Anxiety Disorders: Katon WJ

Katon WJ, Unützer J, Simon G. · No affiliation provided · Med Care. · Pubmed #15550794 No free full text.

This publication has no abstract.

Katon WJ, Zatzick D, Bond G, Williams J. · Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195-6560, USA. · J Trauma Stress. · Pubmed #17075915 No free full text.

Abstract: Randomized controlled trials have established the efficacy of psychotherapy and medication treatments for posttraumatic stress disorder (PTSD). Despite these advancements, many individuals do not receive guideline-concordant PTSD care. In an effort to advance dissemination of evidence-based PTSD treatments, the authors review several examples of dissemination efforts of mental health interventions. The first examples describe the dissemination of multifaceted collaborative care interventions for patients with depressive disorders and evidence-based interventions for patients with severe mental illness. The final example explores evolving efforts to adapt and disseminate interventions to acutely injured trauma survivors. For each example, the authors describe the problem with prior clinical approaches, the program to be disseminated, the barriers and levers to implementation and the progress in overcoming these barriers.

Katon WJ. · Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA. edu · N Engl J Med. · Pubmed #16738272 No free full text.

This publication has no abstract.

Roy-Byrne PP, Russo J, Cowley DS, Katon WJ. · Department of Psychiatry & Behavioral Science, University of Washington, Seattle, USA. · J Clin Psychiatry. · Pubmed #12716237 No free full text.

Abstract: BACKGROUND: To complement existing data on predictors of treatment response in groups of "pure" panic disorder patients studied in clinical trials or in poorly controlled naturalistic follow-up, we sought to elucidate predictors of treatment response over 1 year in a diagnostically heterogeneous and comorbidly ill group of primary care patients with panic disorder participating in a randomized effectiveness study. METHOD: Patients with DSM-IV panic disorder (N = 115), mostly without agoraphobia, were recruited from 3 primary care clinics in Seattle, Wash., and randomly assigned to an on-site collaborative care intervention (N = 57), in which psychiatrists provided education, 2 visits, follow-up phone calls, and paroxetine, or to usual care by their primary care physician (N = 58). Predictors of response at 3-month intervals over 1 year were determined using logistic regression analysis. RESULTS: Patients with consistent response over the year (response at the majority of available timepoints) were significantly (p <.05) more likely to be white, employed, in higher income strata, and in the intervention group and had less medical comorbidity and phobia severity, fewer recent hospitalizations and emergency room visits, and higher reported Medical Outcomes Study 36-Item Short Form physical and role functioning. The final regression model indicated that responders were more likely to be in the intervention group, be employed, and lack a recent emergency room visit. CONCLUSION: While some of the univariate findings partially replicate previous results linking greater illness severity with poorer response, univariate findings linking medical comorbidity and low socioeconomic status with poor response, as well as multivariate findings that unemployment and recent emergency room use are the most potent predictors of poor response, have not been previously reported.

Roy-Byrne PP, Russo J, Cowley DS, Katon WJ. · Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington 98104-2499, USA. · Depress Anxiety. · Pubmed #12621592 No free full text.

Abstract: The prevalence of anxiety disorders is increased among low-income individuals, who are more likely to seek mental health care in medical as opposed to specialty settings because of limited insurance access and restricted availability of public sector mental health resources. However, little is known about the clinical characteristics and illness severity of anxiety disorders in this setting. We studied the clinical characteristics of low-income compared with middle-income primary care panic patients. Clinical, functional, and service use measures obtained at baseline interview in 39 panic disorder patients seen in one public sector medical clinic were compared with 76 patients seen in two middle-income clinics. All patients were participants in a randomized effectiveness pharmacotherapy trial [Roy Byrne et al., Arch Gen Psychiatry 2001;58:869-876]. Public sector patients were more often older, male, single, unemployed, of lower income, and non-Caucasian ethnicity. They had more severe clinical symptoms, more medical comorbidity, worse physical and role health status, and more emergency room visits. Low income and unemployment accounted for most of the differences in non-anxiety-related measures. However, type of clinic still contributed independently to the greater severity of specific measures of panic/anxiety (Panic Disorder Severity Scale and Marks Fear Scale scores), suggesting that the increased stress and limited social resources associated with low-income and disadvantaged status may have more specific effects on anxiety than other aspects of psychopathology.

Katon WJ, Roy-Byrne P, Russo J, Cowley D. · Department of Psychiatry and Behavioral Sciences, Campus Box 356560, University of Washington Medical School, 1959 NE Pacific St, Seattle, WA 98195-6560, USA. · Arch Gen Psychiatry. · Pubmed #12470125 links to  free full text

Abstract: BACKGROUND: A collaborative care (CC) intervention for patients with panic disorder that provided increased patient education and integrated a psychiatrist into primary care was associated with improved symptomatic and functional outcomes. This report evaluates the incremental cost-effectiveness and potential cost offset of a CC treatment program for primary care patients with panic disorder from the perspective of the payer. METHODS: We randomly assigned 115 primary care patients with panic disorder to a CC intervention that included systematic patient education and approximately 2 visits with an on-site consulting psychiatrist, compared with usual primary care. Telephone assessments of clinical outcomes were performed at 3, 6, 9, and 12 months. Use of health care services and costs were assessed using administrative data from the primary care clinics and self-report data. RESULTS: Patients receiving CC experienced a mean of 74.2 more anxiety-free days during the 12-month intervention (95% confidence interval [CI], 15.8-122.0). The incremental mental health cost of the CC intervention was $205 (95% CI, -$135 to $501), with the additional mental health costs of the intervention explained by expenditures for antidepressant medication and outpatient mental health visits. Total outpatient cost was $325 (95% CI, -$1460 to $448) less for the CC than for the usual care group. The incremental cost-effectiveness ratio for total ambulatory cost was -$4 (95% CI, -$23 to $14) per anxiety-free day. Results of a bootstrap analysis suggested a 0.70 probability that the CC intervention was dominant (eg, lower costs and greater effectiveness). CONCLUSION: A CC intervention for patients with panic disorder was associated with significantly more anxiety-free days, no significant differences in total outpatient costs, and a distribution of the cost-effectiveness ratio based on total outpatient costs that suggests a 70% probability that the intervention was dominant, compared with usual care.

Unützer J, Rubenstein L, Katon WJ, Tang L, Duan N, Lagomasino IT, Wells KB. · Center for Health Services Research, Neuropsychiatric Institute, University of California, Los Angeles, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA 90024, USA. · Arch Gen Psychiatry. · Pubmed #11576031 links to  free full text

Abstract: BACKGROUND: Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression. METHODS: A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists. RESULTS: Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group. CONCLUSIONS: Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.

Walker EA, Katon WJ, Russo J, Von Korff M, Lin E, Simon G, Bush T, Ludman E, Unützer J. · Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Seattle, Wash. 98195, USA. · J Gen Intern Med. · Pubmed #11119182 links to  free full text

Abstract: OBJECTIVE: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response. DESIGN: Randomized trial of a stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician. MEASUREMENTS AND MAIN RESULTS: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months. CONCLUSIONS: Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.

Rockhill CM, Russo JE, McCauley E, Katon WJ, Richardson LP, Lozano P. · Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington 98195, USA. · J Nerv Ment Dis. · Pubmed #18000451 No free full text.

Abstract: This study examined parent-child agreement regarding anxiety and depressive disorders in youth with asthma and evaluated key demographic and health differences associated with parent-child agreement. Of 756 outpatient youth with asthma, 122 (16.0%) were diagnosed with a DSM-IV anxiety or depression disorder using the Diagnostic Interview Schedule for Children (C-DISC). Parents reported on internalizing symptoms using the Child Behavior Checklist (CBCL). Logistic regression analyses were used to examine factors related to parent- and child-reported symptom agreement. Low rates of agreement (48.9%) between youth and parents regarding diagnosis of a DSM-IV anxiety or depressive disorder were found among youth with asthma. Increased agreement was associated with higher externalizing behavior score on the CBCL and more anxiety and depressive symptoms on the C-DISC. Children without behavioral problems and with less severe anxiety and depression were recognized significantly less often by their parents.

Kinder LS, Bradley KA, Katon WJ, Ludman E, McDonell MB, Bryson CL. · Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA. · Psychosom Med. · Pubmed #17991816 No free full text.

Abstract: OBJECTIVE: To determine whether a history of depression and/or posttraumatic stress disorder (PTSD) is associated with all-cause mortality in primary care patients over an average of 2 years. METHODS: Patients from seven Department of Veterans Affairs medical centers completed mailed questionnaires. Depression and PTSD status were determined from patient self-report of a prior diagnosis and/or electronic administrative data. Date of death was ascertained from Veterans Health Information Systems and Technology Architecture and the Department of Veterans Affairs' Beneficiary Identification and Records Locator System. RESULTS: Among 35,715 primary care patients, those with a history of depression without a history of PTSD (n = 6876) were at increased risk of death over an average of 2 years compared with patients with neither depression nor PTSD after adjustment for demographic variables, health behaviors, and medical comorbidity (hazard ratio (HR) = 1.17; 95% Confidence Interval (CI) = 1.06-1.28). However, patients with a history of PTSD without a history of depression (n = 748) were not at increased risk of death compared with patients with neither depression nor PTSD (HR = 0.84; 95% CI = 0.63-1.13). Patients with a history of both (n = 3762) were at increased risk of death after adjustment for demographic factors, although not after additional adjustment for health behaviors and medical comorbidity (HR = 0.90; 95% CI = 0.78-1.04). CONCLUSIONS: In a large sample of veterans, a prior diagnosis of depression, but not PTSD, was associated with an increased risk of death over an average of 2 years after adjusting for age, demographic variables, health behaviors, and medical comorbidity.

Katon WJ, Richardson L, Russo J, Lozano P, McCauley E. · Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195-6560, USA. · Med Care. · Pubmed #17122709 No free full text.

Abstract: OBJECTIVES: Youth with asthma have a high rate of anxiety and depressive disorders, and these comorbid disorders are associated with increased asthma symptom burden and functional impairment. This study examined the rates and predictors of recognition of anxiety and depressive disorders among youth (ages 11 to 17) with asthma who are seen in primary care settings as well as the quality of mental health care provided to those with comorbid anxiety and depression over a 12-month period. METHODS: This study used automated utilization and pharmacy data from a health maintenance organization to describe the rate of recognition of Diagnostic and Statistical Manual of Mental Disorders, edition IV, anxiety and depressive disorders and the quality of mental health care provided for the 17% of youth with asthma and comorbid anxiety and/or depression during the 12-month period prior to diagnosis. Psychiatric diagnoses were based on a telephone version of the Computerized Diagnostic Interview Schedule for Children (Version 4.0). RESULTS: Approximately 35% of youth with 1 or more anxiety and depressive disorders and 43% of those with major depression were recognized by the medical system during a 12-month period. Greater functional impairment (odds ratio [OR] 3.32, 95% confidence interval [CI] 1.25-8.79), higher severity on parent-rated anxiety and depressive symptoms (OR 2.49, 95% CI 1.04-6.00), and a greater number of primary care visits (OR 1.26, 95% CI 1.10-1.44) were associated with significantly higher recognition rates while having Medicaid or Washington state medical insurance was associated with lower rates of recognition (OR 0.27, 95% CI 0.08-0.92). Only approximately 1 in 5 youths with comorbid major depression received an adequate dosage and duration of antidepressant medication, and only 1 in 6 received a minimally adequate number of psychotherapy sessions (> or =4 visits). CONCLUSION: Rates of recognition of comorbid anxiety and depressive disorders are low in youth with asthma and few youth with asthma and comorbid anxiety and depression receive guideline-level mental health treatment.

Garrison MM, Katon WJ, Richardson LP. · Child Health Institute, University of Washington, Box 354920, Seattle Washington 98195-4920, USA. · Diabetes Care. · Pubmed #16123482 links to  free full text

Abstract: OBJECTIVE: Comorbid psychiatric disorders have been associated with poorer disease outcomes in diabetic youth. Less is known, however, about the relationship between psychiatric disorders and repeat hospitalizations for youth with diabetes. RESEARCH DESIGN AND METHODS: We performed a retrospective cohort study using data from the Pediatric Health Information System, which included detailed discharge data from 37 non-competing children's hospitals in the U.S. Using logistic regression, we examined whether the presence of coded diagnoses for internalizing or externalizing disorders at an index hospitalization for diabetes was associated with increased risk for rehospitalization during follow-up (duration of follow-up ranged from 3 to 24 months). The analysis was stratified by age-groups, and we controlled for potential confounders including sex, age, race/ethnicity, type 1 versus type 2 diabetes, Medicaid status, intensive care unit utilization, length of stay during index admission, and duration of follow-up. RESULTS: Among adolescents aged 13-18, internalizing disorders were associated with significantly increased odds of rehospitalization (odds ratio 1.79 [95% CI 1.27-2.52]); the point estimate for externalizing disorders was similar, but the finding was not statistically significant at the alpha = 0.05 level (1.74 [0.96-3.15]). No significant association between psychiatric diagnoses and odds of repeat hospitalization was observed in diabetic children aged 5-12 years. CONCLUSIONS: Internalizing disorders are associated with increases in repeat hospitalizations for diabetes among adolescents. Future research is needed to explore the reasons for this finding, such as degree to which treatment nonadherence mediates this relationship and whether appropriate treatment of internalizing disorders results in improved diabetes outcomes and decreased readmissions.

Ciechanowski PS, Walker EA, Russo JE, Newman E, Katon WJ. · Department of Psychiatry and Behavioral Sciences, University of Washington, Box 356560, Seattle, WA 98195-6560, USA. · Gen Hosp Psychiatry. · Pubmed #15234820 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) is associated with high numbers of self-reported physical symptoms and functional disability in clinical samples, but little is known about the magnitude of these associations in population samples and using actual physician-coded diagnoses. We administered a 22-page survey to 1225 female HMO enrollees randomly selected from the current membership of a large, staff model HMO in Seattle, Washington. Using the PTSD Checklist (internally validated against a subset of clinical interviews) we compared women with low, moderate, and high scores with respect to differences in self-reported physical health status, functional disability (36-item short form health survey), numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. Compared to women with low PTSD symptom severity, those with moderate or high severity reported significantly higher functional disability (P<.001), rates of abuse and neglect (P<.01 to P<.001), health risk behavior scores (P<0.05), as well as higher mean numbers of common physical symptoms (P<.05). Compared to women with low PTSD symptom severity those with moderate or high severity had significantly higher adjusted odds ratios for aversive physical symptoms (range, 1.7-10.1). The mean number of physician-coded ICD-9 diagnoses was also significantly higher in the both the moderate and high severity groups. Among female HMO members, PTSD symptoms are associated with a wide range of both self-reported and physician-coded adverse physical health outcomes.

Katon WJ, Richardson L, Lozano P, McCauley E. · Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington 98195-6560, USA. · Psychosom Med. · Pubmed #15184694 links to  free full text

Abstract: OBJECTIVE: This article reviewed the child and adult medical literature on the prevalence of comorbid anxiety disorders in patients with asthma. Theoretical ideas regarding the relatively high comorbidity rates are presented along with a model describing putative interactions between anxiety disorders and asthma. METHOD: A search of the literature from the last 2 decades using MEDLINE by pairing the word, "asthma," with the following words: "anxiety," "depression," "panic," and "psychological disorders." We located additional research by screening the bibliographies of articles retrieved in the MEDLINE search. RESULTS: Both adult and child/adolescent populations with asthma appear to have a high prevalence of anxiety disorders. In child/adolescent populations with asthma, up to one third may meet criteria for comorbid anxiety disorders. In adult populations with asthma, the estimated rate of panic disorder ranges from 6.5% to 24%. However, most studies are limited by small samples, nonrepresentative populations, self-reported asthma status, and lack of controlling for important potential confounders such as smoking and asthma medications. There are also limited data on the impact of anxiety comorbidity in patients with asthma on symptom burden, self-care regimens (such as monitoring peak expiratory flow, taking medication, and quitting smoking), functional status, and medical costs. CONCLUSIONS: There appears to be a high comorbidity of anxiety disorders in patients with asthma. The prevalence and longitudinal impact of anxiety comorbidity needs to be examined in a large population-based sample of children, adolescents, and adults with asthma. If a high prevalence of comorbid anxiety disorder is documented and if this comorbidity adversely affects the self-efficacy and self-care, symptom burden, and functioning in persons with asthma, then it will be important to develop treatment trials.

Mauksch LB, Tucker SM, Katon WJ, Russo J, Cameron J, Walker E, Spitzer R. · Department of Family Medicine, University of Washington School of Medicine, Seattle, USA. · J Fam Pract. · Pubmed #11195480 No free full text.

Abstract: OBJECTIVE: Our goal was to compare the prevalence of mental illness and its impact on functional status in an indigent uninsured primary care population with a general primary care sample. We also hoped to assess patient preferences about mental health and medical service integration. STUDY DESIGN: We compared a survey of consecutive primary care adults in April and May 1999 with a 1997-98 survey of 3000 general population primary care patients. Both studies used the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and the 20-question Medical Outcomes Study Short Form. POPULATION: The patients were from a private nonprofit primary care clinic in Grand Junction, Colorado, that served only low-income uninsured people. We approached a total of 589 consecutive patients and enrolled 500 of them. MAIN OUTCOME MEASURE: The main outcomes were the prevalence of psychiatric illnesses and the relationship with functional impairment. We compared our findings with a more generalizable primary care population. RESULTS: This low-income uninsured population had a higher prevalence of 1 or more psychiatric disorders (51% vs 28%): mood disorders (33% vs 16%), anxiety disorders (36% vs 11%), probable alcohol abuse (17% vs 7%), and eating disorders (10% vs 7%). Having psychiatric disorders was associated with lower functional status and more disability days compared with not having mental illness. Patients indicated a preference for mental health providers and medical providers to communicate about their care. CONCLUSIONS: This low-income uninsured primary care population has an extremely high prevalence of mental disorders with impaired function. It may be important in low-income primary care settings to include collaborative care designs to effectively treat common mental disorders, improve functional status, and enhance patient self-care.

Roy-Byrne PP, Stein MB, Russo J, Mercier E, Thomas R, McQuaid J, Katon WJ, Craske MG, Bystritsky A, Sherbourne CD. · Department of Psychiatry, University of Washington, Seattle, USA. · J Clin Psychiatry. · Pubmed #10453807 No free full text.

Abstract: BACKGROUND: Increased medical service utilization in patients with panic disorder has been described in epidemiologic studies, although service use in primary care panic patients relative to other primary care patients is less well characterized. Inadequate recognition of panic has been shown in several primary care studies, although the nature of usual care for panic in this setting has not been well documented. This study aimed to document increased service use in panic patients relative to other primary care patients and to characterize the nature of their usual care for panic and their outcome. METHOD: Using a waiting room screening questionnaire and follow-up telephone interview with the Composite International Diagnostic Interview, we identified a convenience sample of 81 patients with panic disorder (DSM-IV) and a control group of 183 psychiatrically healthy patients in 3 primary care settings on the West Coast and determined psychiatric diagnostic comorbidity, panic characteristics, disability, and medical and mental health service use, including medications. A subsample (N = 41) of panic patients was reinterviewed 4-10 months later to determine the persistence of panic and the adequacy of intervening treatment received using the Harvard/Brown Anxiety Disorders Research Program study criteria for cognitive-behavioral therapy (CBT) and an algorithm developed by the authors for medications. RESULTS: Seventy percent of panic patients had a comorbid psychiatric diagnosis. Patients had more disability in the last month (days missed or cut down activities) (p < .01), more utilization of emergency room and medical provider visits (p < .01), and more mental health visits (p < .05). Despite the latter, only 42% received psychotropic medication, 36% psychotherapy, and 64% any treatment. On follow-up, 85% still met diagnostic criteria for panic, and only 22% had received adequate medication (type and/or dose) and 12% adequate (i.e., CBT) psychotherapy. CONCLUSION: These findings suggest a need for improved treatment interventions for panic disorder in the primary care setting to decrease disability and potentially inappropriate medical service utilization.