Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method.

BACKGROUND: Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered. METHODS: We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted. RESULTS: The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia. CONCLUSIONS: Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.

[How to Motivate Medical Students to Practice in Rural Areas]. / Wege aufs Land ­ Wie Medizinstudierende für die Tätigkeit im ländlichen Raum gewonnen werden.

BACKGROUND: The excellent project "LandArztMacher" is an attempt to work against the predicted shortage of rural doctors in Germany with diverse approaches. METHOD: "LandArztMacher" is a clinical traineeship with four weeks of practical training in general practices and clinics in the Bavarian countryside, accompanied by joint professional teaching. Participants were asked before and after the internship about the topics "importance of an internship in rural areas"; "attractiveness of rural areas" (scale: 0/no agreement to 10/full agreement). Ideas about the tasks of a general practitioner were assessed (scale: 0/no idea at all to 100/exact idea). The present study is a repeated cross-sectional study. The median is reported as the location measure and the interquartile range as the dispersion measure. RESULTS: Participants (n=363, 74% female, n=267, age: range 19-46 years, mean: 23.2 years, SD: 2.41 years) from the clinical section of the medical studies considered an internship in the rural area before and after the internship very important (median: 8 and 9, respectively) and could well imagine working in the countryside (median: 7 and 8, respectively). Their attitude towards the cultural offerings or the infrastructure did not change (median: 6 in each case). After the internship, the students had a more precise idea of what a general practitioner tasks are (median: 65 and 90, respectively). SUMMARY: A well-structured four-week rural internship can enhance the appeal of future rural employment through individual supervision and collaborative training.

Validation of the German Version of the P4 Suicidality Tool.

For general practitioners (GPs), it may be challenging to assess suicidal ideation (SI) in patients. Although promising instruments exist for the use in primary care, only a few have been validated in German. The objectives of this study were to examine the validity of the brief P4 screener for assessing SI in a cross-sectional study including outpatients. Inclusion criteria were a PHQ-9 score ≥ 10 or an affirmative answer to its SI item. Construct validity of the P4 was examined by comparison with the four-item Suicide Behaviors Questionnaire-Revised (SBQ-R), the PHQ-9 (convergent), and the positive mental health (PMH) scale (divergent). The study sample included 223 patients (mean age 47.61 ± 15 years; 61.9% women) from 20 primary care practices (104 patients) and 10 psychiatric/psychotherapeutic clinics (119 patients). The first three items of the P4 correlate positively with most of the four items of the reference standard SBQ-R (convergent validity); the fourth item of the P4 (preventive factors) correlates significantly with the PMH scale. The most common preventive factor (67%) is family or friends. The German P4 screener can be used to assess SI in outpatient care. It explores preventive or protective factors of suicide, which may support the GP's decision on treatment. We recommend a further clinical interview for patients flagged by P4 assessment in order to more formally assess suicidal risk.

CBT-Intervention for panic disorder in primary care: 5 years follow-up of a cRCT during the Covid-19 pandemic.

A practice team-based exercise programme with elements of cognitive behavioural therapy (CBT) and case management for patients with panic disorder with or without agoraphobia in primary care showed significant positive effects. Here, we analyse the long-term effects (>5 years) of this intervention in the stressful context of the Covid-19 pandemic. All participants of the original PARADIES cluster randomized controlled trial (cRCT; 2012-2016) were invited to participate in a follow-up during the Covid-19 pandemic. Clinical outcomes were anxiety symptoms, number and severity of panic attacks, agoraphobic avoidance behaviour, Covid-specific anxiety symptom severity, depression, and patient assessment of chronic illness care. Data were analysed cross-sectionally for group differences (intervention, control) and longitudinally (T0: baseline, T1: 6 months and TCorona: >60 months). Of the original 419 participants, 100 participated in the 60 months follow-up (October 2020-May 2021). In the cross-sectional analysis, the anxiety symptom severity in the intervention group was lower than in the control group (p = .011, Cohen's d = .517). In the longitudinal analysis, both groups showed an increase of anxiety and depression symptoms compared to pre-pandemic level. The intervention may have had a lasting impact regarding anxiety severity despite the challenging context of the Covid-19 pandemic. However, we cannot say to what extend the intervention still played a role in participants' lives; other factors may also have helped with coping. The increase of anxiety and depression symptoms in both groups over time could be attributed to external circumstances.

Psychometric evaluation and Rasch analyses of the German Overall Anxiety Severity and Impairment Scale (OASIS-D).

The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that captures symptoms of anxiety and associated functional impairments. This study evaluates a German version (OASIS-D) that was administered to a convenience sample of 1398 primary care patients of whom 419 were diagnosed with panic disorder with/without agoraphobia. Psychometric properties were analyzed using classical test theory as well as probabilistic test theory. Factor analyses suggested a unitary (latent) factor structure. The internal consistency was good to excellent. Convergent as well as discriminant validity with other self-report measures was found. A sum score (range 0-20) of ≥ 8 emerged as optimal cut-score for screening purposes. A difference score of ≥ 5 was indicative of reliable individual change. A Rasch analysis of local item independence suggested response dependency between the first two items. Rasch analyses of measurement invariance detected noninvariant subgroups associated with age and gender. Analyses of validity and optimal cut-off score were solely based on self-report measures, which may have introduced method effects. In sum, the findings support the transcultural validity of the OASIS and indicate its applicability to naturalistic primary care settings. Caution is warranted when using the scale to compare groups that differ in age or gender.

The Association of Social Connectivity and Body Weight With the Onset of Type 2 Diabetes: Findings From the Population-Based Prospective MONICA/KORA Cohort.

OBJECTIVE: Low levels of social connectivity are related to the onset of type 2 diabetes mellitus (T2D), and this study investigates the role of body weight in this association. METHODS: In a sample of 9448 participants followed for a mean of 15.3 years (186,158.5 person-years) from the Monitoring of Trends and Determinants in Cardiovascular Disease Augsburg/Cooperative Health Research in the Region of Augsburg population-based cohort conducted in Germany, we investigated the association of social connectivity, measured by the Social Network Index, and body mass index (BMI) with the risk of clinically validated T2D incidence using stratified Cox proportional hazards regression models adjusted for sociodemographic, life-style, cardiometabolic, and psychosocial risk factors. RESULTS: During a mean follow-up of 14.1 years (186,158.5 person-years), 975 (10.3%) participants developed T2D. Participants with low social connectivity developed T2D at a higher rate than socially connected participants (10.0 versus 8.0 cases/10,000 person-years); however, BMI played a significant role in the association of social connectivity with T2D ( p < .001). In comparison to their socially connected counterparts, low social connectivity was associated with a higher rate of T2D incidence in normal-weight (6.0 versus 2.0 cases/10,000 person-years), but not overweight (13.0 versus 13.0 cases/10,000 person-years) or obese participants (32.0 versus 30.0 cases/10,000 person-years). Correspondingly, Cox regression analysis showed that 5-unit increments in BMI increased the risk of T2D in socially connected participants (hazard ratio = 3.03, 95% confidence interval = 2.48-3.79, p < .001) at a substantially higher rate than in low socially connected participants (hazard ratio = 1.77, 95% confidence interval = 1.45-2.16, p < .001). CONCLUSION: The detrimental link between low social connectivity and increased risk of T2D is substantially stronger in participants with a lower BMI.

Patient characteristics and changes in anxiety symptoms in patients with panic disorder: Post-hoc analysis of the PARADIES cluster randomised trial.

Anxiety disorders are among the most common mental health problems in primary care. The PARADIES (Patient Activation foR Anxiety DIsordErS) intervention combined elements of cognitive behavioural therapy with case management and has demonstrated efficacy. Our aim was to explore patient characteristics, which may influence the course of anxiety symptoms over a 12 months period. Multiple linear regression was used to quantify associations of baseline characteristics (demographics, clinical parameters, medication use) with changes in anxiety symptoms as measured by the Beck anxiety inventory. Treatment modalities (e.g. adherence to appointment schedules) were considered as confounders. We examined univariate associations between dependent and independent variables before considering all independent variables in a multivariate final model. To find the best model to explain BAI score changes, we performed step-wise selection of independent variables based on Akaike information criteria. We tested for interaction terms between treatment allocation (intervention vs control) and independent variables using the multivariate model. We repeated these analyses in control vs intervention groups separately. From the original trial (N = 419), 236 patients (56.3%) were included. In the multivariate model, receiving the intervention (p<0.001), higher anxiety symptom severity (p<0.001) and longer illness duration at baseline (p = 0.033) were significantly associated with changes in anxiety symptom severity to the better while depression severity at baseline (p<0.001) was significantly associated with changes in anxiety symptoms to the worse. In stratified analyses, the control group showed significant associations between depression symptom severity and illness duration with anxiety symptom changes while baseline severity of anxiety symptoms remained significantly associated with anxiety symptom changes in both groups. A brief primary-care-based exposure training combined with case management is effective in a broad range of patients with panic disorder with/without agoraphobia, including those with longer illness duration and co-existing symptoms of depression at baseline.

[Long-term course of heart disease: How can psychosocial care be improved?] / Herzerkrankungen im Langzeitverlauf: Wie kann die psychosoziale Versorgung verbessert werden?

Cardiovascular diseases, which primarily include coronary artery disease (CAD), heart failure (HF) and cardiac arrhythmias, are the leading causes of death in the European Union and responsible for most of the serious courses of coronary disease. Acute events are usually the focus of clinical attention. In contrast, there are hardly any structured care and therapy concepts for the long-term course of these diseases. Based on a literature review, this article provides an overview of the long-term consequences and long-term care of heart diseases. Deficits in the psychosocial care of patients and possible solutions are discussed.Patients with CAD often experience problems with medication adherence and compliance to behavioural recommendations due to inadequate long-term psychosocial care. Psychological comorbidities reduce the quality of life and are a driver for health-damaging behaviour. Patients with cardiac arrhythmias often get into a vicious circle of recurrent physical complaints interacting with anxiety and panic attacks and the associated use of outpatient, emergency, or inpatient care facilities. In the course of heart failure, a clinically significant growing number of patients are treated with antidepressants, the benefit of which is rather doubtful.The apparent deficits in long-term psychosocial care of cardiovascular disease and the quality of life of patients could be improved through the increased use of systematic collaborative care models by specialised care facilities with the involvement of general practitioners.

[Structured Individual Mentoring as Part of Continuing Education in Family Medicine in Bavaria - a Multicenter Evaluation]. / Strukturiertes Einzelmentoring im Rahmen der Weiterbildung Allgemeinmedizin in Bayern ­ eine multizentrische Evaluation.

Background: Since 2019, the competence center for specialist training in family medicine Bavaria (KWAB) offers an individual mentoring program to accompany specialist training in family medicine. The mentors are confidants for matters of specialist training, private practice, career development and compatibility of work and family life. The training takes place after registration via an online portal. Methods: The evaluation was conducted 24 months after the start of KWAB mentoring (06/30/2021-08/01/2021). All active participants were interviewed via online survey. In each case, separate questionnaires were developed, which inquire on the one hand about the content-related aspects of the mentoring, such as topics discussed, and on the other hand about the individual mentoring relationship, such as the interpersonal relationship. The mentees received 39 questions (34 closed, 5 open) and the mentors received 26 questions (21 closed, 5 open), which were subsequently analyzed using descriptive statistics. Results: N = 30 mentors and N = 72 mentees were invited to participate in the evaluation (25 (83 %) mentors and 32 (44 %) mentees participated). More than half of the participants met each other at least twice. The main methods of communication were telephone, face-to-face meetings, and email contacts. The individual time commitment in each case was judged to be appropriate. According to the mentors, the mentees showed interest in the content of the program and demonstrated availability and commitment. All respondents indicated a high level of satisfaction with one-on-one mentoring and would recommend it to others. Conclusions: Mentors and mentees in family medicine residency reported a great benefit from the one-on-one mentoring offered and a will to continue their mentoring relationships even after the project period.

Shared Decision Making - A Key Competence of All Health Care Professionals. Evaluation and Adaptation of a Digitally Enhanced Learning and Teaching Unit.

The Covid-19 pandemic induced a radical shift towards digitally enhanced learning and teaching (DELT). Success of this adaptation depended on how much DELT had been provided before. The Bavarian Virtual University (BVU) is a university network to fund, promote and support DELT. The Ludwig-Maximilians-University Munich as a part of this network implemented the DELT course "Shared decision making (SDM) - a part of evidence-based medicine" in 2015. Based on regular evaluations and due to the latest developments, a media-didactic and content-related adaptation will be conducted now. Clinical cases will be embedded in a framework structure of SDM. Videos, podcasts and literature of doctor-patient interaction will be provided. To enable different health care professions to have a positive learning experience, the course will be linguistically adapted. The interaction between students and teacher will be enhanced by a transparent distribution of tasks and an issue-specific chat forum. SDM is an interdisciplinary general concept. With regard to the academization of different health care professions, the demand for DELT will increase. However, medical competencies can`t be taught fully online, since face-to-face patient interaction is mandatory. Communication skills can be practiced theoretically but have to be applied in reality.

[Short screener for suicidal behaviour in primary care - a systematic review]. / Kurze Screener für Suizidalität in der Allgemeinmedizin : Eine systematische Übersichtsarbeit.

BACKGROUND: We summarize the available studies reporting diagnostic accuracy of brief instruments for suicidal behaviour in primary care. METHOD: Databases MEDLINE, EMBASE, PsychINFO, PSYNDEX, and Cochrane Library were searched without any time constraints. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool. The certainty of evidence was rated via GRADEpro. We included studies on primary care patients or participants from the general population. Suicidal behaviour was the defined target condition. With respect to the applicability in a primary care setting we included only studies assessing brief screening instruments; a brief instrument was defined as having no more than 12 items. We assessed sensitivity, specificity, and positive and negative predictive value. RESULTS: A total of 12,460 studies were identified; of those, n = 7 fulfilled all strong criteria and were included. The range of sensitivity was 0.26-1.00, specificity was 0.64-0.99, positive predictive value 0.06-0.91, negative predictive value 0.83-1.00. Risk of bias was rated moderate and concerns regarding applicability acceptable. A required sensitivity of at least 0.80 and specificity of 0.50 with a moderate to high GRADE rating was achieved by 8 of 11 index tests. CONCLUSIONS: Brief screening instruments can support ruling-out suicidality, but are less suitable for ruling-in. They may support general practitioners in an initial assessment, but in case of a positive test result, a valid diagnostic assessment should be done by a structured clinical interview.

A metabolome-wide association study in the general population reveals decreased levels of serum laurylcarnitine in people with depression.

Depression constitutes a leading cause of disability worldwide. Despite extensive research on its interaction with psychobiological factors, associated pathways are far from being elucidated. Metabolomics, assessing the final products of complex biochemical reactions, has emerged as a valuable tool for exploring molecular pathways. We conducted a metabolome-wide association analysis to investigate the link between the serum metabolome and depressed mood (DM) in 1411 participants of the KORA (Cooperative Health Research in the Augsburg Region) F4 study (discovery cohort). Serum metabolomics data comprised 353 unique metabolites measured by Metabolon. We identified 72 (5.1%) KORA participants with DM. Linear regression tests were conducted modeling each metabolite value by DM status, adjusted for age, sex, body-mass index, antihypertensive, cardiovascular, antidiabetic, and thyroid gland hormone drugs, corticoids and antidepressants. Sensitivity analyses were performed in subcohorts stratified for sex, suicidal ideation, and use of antidepressants. We replicated our results in an independent sample of 968 participants of the SHIP-Trend (Study of Health in Pomerania) study including 52 (5.4%) individuals with DM (replication cohort). We found significantly lower laurylcarnitine levels in KORA F4 participants with DM after multiple testing correction according to Benjamini/Hochberg. This finding was replicated in the independent SHIP-Trend study. Laurylcarnitine remained significantly associated (p value < 0.05) with depression in samples stratified for sex, suicidal ideation, and antidepressant medication. Decreased blood laurylcarnitine levels in depressed individuals may point to impaired fatty acid oxidation and/or mitochondrial function in depressive disorders, possibly representing a novel therapeutic target.

[Health Assistants Perspectives on Team-Led Program for Patients with Panic Disorder in General Practice - A Qualitative Study]. / Perspektiven von Medizinischen Fachangestellten zu teambasierter Behandlung von Patienten mit Panikstörung in der Hausarztpraxis ­ Eine qualitative Studie.

AIM OF THE STUDY: Investigation of the perspective of medical assistants (MA) regarding their participation in behaviour-therapy oriented interventions in family practice. METHOD: 15 MA (w, 39.5 years old), case managers in a general practitioner supported exercise programme for patients with panic disorder (ICD-10: F41.0), were interviewed using semi-structured interview guidelines on the recruitment and interaction of/with patients, communication of the exercises and implementation in everyday practice. The interviews (n = 14) were documented, transcribed and qualitatively analysed according to Mayring. RESULTS: MA perceived their contribution to the intervention regarding recruitment and monitoring of patients through telephone contacts as positive. CONCLUSION: Strengthening the role of MAs' can help to provide targeted support for patients with mental health problems in GP care as part of a low-threshold intervention and relieve the workload on the GP.

Cost-effectiveness of Practice Team-Supported Exposure Training for Panic Disorder and Agoraphobia in Primary Care: a Cluster-Randomized Trial.

BACKGROUND: Primary care is the main treatment setting for panic disorder and should be supplemented by collaborative care programs. However, shortage of mental health professionals prevents collaborative care programs from being effectively implemented. The PARADISE study showed the efficacy of a self-managed, cognitive-behavioural therapy (CBT)-oriented exposure training for patients with panic disorder with or without agoraphobia in primary care delivered by the family practice team. OBJECTIVE: To assess the cost-effectiveness of the PARADISE intervention. DESIGN: Cost-effectiveness analysis from the societal perspective based on data from a cluster-randomized controlled trial over a time horizon of 12 months. PARTICIPANTS: Four hundred nineteen adult panic disorder patients with or without agoraphobia. INTERVENTIONS: A self-managed, CBT-oriented exposure training for patients with panic disorder with or without agoraphobia in primary care delivered by the primary care practice team in comparison to routine care. MAIN MEASURES: Total costs from the societal perspective. Direct costs and disease-specific costs. Quality-adjusted life years based on the EQ-5D-3L. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. KEY RESULTS: Patients in the intervention group caused lower costs (mean, €1017; 95% confidence interval [-€3306; €1272]; p = 0.38) and gained on average more QALY (mean, 0.034 QALY (95% confidence interval [0.005; 0.062]; p = 0.02). Therefore, the intervention dominated the control treatment. The probability of cost-effectiveness of the intervention at a willingness-to-pay margin of €50,000 per QALY was 96%. Results from supplementary analyses considering direct or disease-specific costs instead of total costs showed comparable results. CONCLUSION: The PARADISE intervention is cost effective. This conclusion is valid for total costs, generic health care (direct) costs, disease-specific health care costs. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00004386 Current Controlled Trials: ISRCTN64669297.

Impact of meteorological parameters on suicide mortality rates: A case-crossover analysis in Southern Germany (1990-2006).

BACKGROUND: There is evidence for a seasonal pattern of suicides with peaks in spring and early summer; however, only a limited number of studies has investigated whether daily changes in meteorological variables may trigger suicides. METHODS: Daily fatal suicide (N = 10,595) and meteorological data were available for four Bavarian cities and ten counties (Germany) for 1990-2006. City/county-specific immediate, delayed and cumulative effects of air temperature, sunshine duration, and cloud cover on suicides were analyzed using a time-stratified case-crossover approach; city/county-specific effects were then combined using random effects meta-analysis. Potential effect modifiers were specific weather conditions, personal or regional characteristics, and season. RESULTS: A 5 °C increase in air temperature on the day before a suicide compared to the control days was associated with a 5.7% (95% confidence interval (CI): 0.6; 11.0) higher suicide risk. Further, the suicide risk was 6.5% (95% CI: 0.2; 13.3) higher on days with low/medium cloud cover (0-6 oktas) compared to days with high cloud cover (7-8 oktas). While daily changes in temperature were not associated with suicides in spring, we found a higher suicide risk in summer, autumn, and winter in association with temperature increases. The effects of cloud cover were strongest in summer and autumn and on days with temperature above the median (>8.8 °C). Sunshine duration was not associated with suicides. CONCLUSION: We found a higher risk for suicides in association with short-term increases in air temperature on the day before the event compared to the control days and on days with low to medium cloud cover. This may highlight times when people are more likely to commit suicide.

eHealth-supported case management for patients with panic disorder or depression in primary care: Study protocol for a cRCT (PREMA).

BACKGROUND: Panic disorder (PD), frequently occurring with agoraphobia (AG), and depression are common mental disorders in primary care and associated with considerable individual and societal costs. Early detection and effective treatment of depression and PD/AG are of major importance. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety and depressive symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study aims at evaluating the effects and cost-effectiveness of a primary care team-based intervention using behavioural therapy elements and case management supported by eHealth components in patients with PD/AG or depression compared to treatment as usual. METHODS/DESIGN: This is a two-arm cluster-randomized, controlled trial (cRCT). General practices represent the units of randomisation. General practitioners recruit adult patients with depression and PD ± AG according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. Practice teams and patients are supported by eHealth components. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after 6 months (T1), and at follow-up after 12 months (T2). The primary outcome is the mental health status of patients as measured by the Mental Health Index (MHI-5). Effect sizes of 0.2 standard deviation (SD) are regarded as relevant. Assuming a drop-out rate of 20% of practices and patients each, we aim at recruiting 1844 patients in 148 primary care practices. This corresponds to 12.5 patients on average per primary care practice. Secondary outcomes include depression and anxiety-related clinical parameters and health-economic costs. DISCUSSION: If the intervention is more effective than treatment as usual, the three-component (cognitive behaviour therapy, case-management, eHealth) primary care-based intervention for patients suffering from PD/AG or depression could be a valuable low-threshold option that benefits patients and primary care practice teams. TRIAL REGISTRATION: German clinical trials register, DRKS00016622. Registered on February 22nd, 2019.

Symptom trajectories in patients with panic disorder in a primary care intervention: Results from a randomized controlled trial (PARADISE).

This analysis aims to identify and characterize symptom trajectories in primary care patients with panic disorder with/without agoraphobia (PD/AG) who participated in a primary care team based training involving elements of cognitive behavioural therapy (CBT). Growth Mixture Modeling was used to identify different latent classes of change in patients with PD/AG (N = 176) who underwent treatment including CBT elements. We identified three patient classes with distinct similar trajectories. Class 1 (n = 58, mean age: 46.2 years ± 13.4 years, 81% women) consisted of patients with an initially high symptom burden, but symptoms declined constantly over the intervention period. Symptoms of patients in class 2 (n = 89, mean age: 44.2 years ± 14.5 years, 67.4% women) declined rapidly at the beginning, then patients went into a plateau-phase. The third class (n = 29, mean age: 47.0 years ± 12.4 years, 65.5% women) was characterized by an unstable course and had the worse outcome. Our findings show that only a minority did not respond to the treatment. To identify this minority and refer to a specialist would help patients to get intensive care in time.

Panic Disorder in Primary Care.

BACKGROUND: We evaluated a team-based program of exercises for patients with panic disorder with or without agoraphobia (PDA) in primary care. METHODS: 419 patients with PDA (mean age 46.2 years, standard deviation 14.4 years; 74% female) were included in this cluster-randomized, controlled intervention trial. The patients were blinded with respect to their group assignment at baseline. Patients in the intervention group (36 primary-care practices, 230 patients) underwent a 23-week exercise program combined with case management, while patients in the control group (37 practices, 189 patients) received standard care. Symptoms of anxiety (according to the Beck Anxiety Inventory, BAI) at six months were the primary endpoint. Patients were followed up at six months (n = 338, 81%) and at twelve months (n = 318, 76%). The analysis was by intention to treat. RESULTS: Symptoms of anxiety improved to a significantly greater extent in the intervention group (p = 0.008). The intergroup dif- ference in the reduction of the BAI score (range: 0-63) was 3.0 points (95% confidence interval [-5.8; -0.2]) at six months and 4.0 points [-6.9; -1.2] at twelve months. In the intervention group, there was a significantly greater reduction in the frequency of panic attacks (p = 0.019), in avoidant behavior (p = 0.016), and in depressiveness (p<0.001), as well as a greater improvement of the quality of treatment (p<0.001). CONCLUSION: In primary-care patients who have panic disorder with or without agoraphobia, a team-based exercise program combined with case management can improve symptoms to a greater extent than standard primary-care treatment.