Anxiety Disorders: University of Washington

Moore SA. · University of Washington, Department of Psychology and VA Puget Sound Healthcare System, Seattle, WA 98108, USA. · Curr Opin Psychiatry. · Pubmed #19122530 No free full text.

Abstract: PURPOSE OF REVIEW: The current review aims to describe and evaluate research on cognitive difficulties associated with posttraumatic stress disorder (PTSD) published between January 2007 and June 2008. RECENT FINDINGS: The reviewed studies provide additional evidence that negative appraisals and decrements on verbal and autobiographical memory tasks are exhibited by individuals with PTSD relative to controls and may represent preexisting risk factors for PTSD rather than a result or concomitant of PTSD symptoms. In addition, the reviewed findings provide further evidence for source monitoring difficulties and attentional biases toward trauma-relevant information in PTSD. Recent research also provides evidence that, although memories of traumatic events differ in PTSD relative to other types of memories and memories of depressed individuals, they are likely on the same continuum as nontraumatic memories rather than qualitatively different. SUMMARY: Individuals with PTSD experience cognitive alterations ranging from impairments in overall memory functioning to difficulties specific to trauma-related cues. These cognitive difficulties appear to be importantly related to the development and/or maintenance of the disorder. At this point, it is unclear whether common mechanisms may account for these diverse cognitive difficulties and whether cognitive impairments are attributable to comorbid depression.

Kross EK, Gries CJ, Curtis JR. · Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, School of Medicine, University of Washington, Seattle, WA 98104-2499, USA. · Crit Care Clin. · Pubmed #18929945 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) is a common psychiatric condition that can occur after a traumatic event. Individuals exposed to traumatic events are at risk for PTSD and other psychologic morbidity, such as depression, panic disorder, generalized anxiety disorder, and substance abuse. The burden of PTSD can be high, with inability to work or return to prior levels of functioning. Emerging literature suggests a significantly increased risk for symptoms of PTSD among survivors of critical illness and the families of patients who survive or die after critical illness. This review summarizes these studies and provides suggestions for current clinical implications and for future research.

Luks AM. · Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington 98104, USA. · High Alt Med Biol. · Pubmed #18800955 No free full text.

Abstract: Given the well-established problems with sleep at high altitude, it is not uncommon for people planning trips to the mountains to seek advice from clinicians regarding pharmacologic options for improving sleep during their trip. This review article considers the various medications that have been studied for this purpose at high altitude with an emphasis on both their efficacy and safety. The available data support the use of either acetazolamide, temazepam, zolpidem or zaleplon in this environment. Other agents commonly used at sea-level such as eszopiclone and diphenhydramine have not been studied at high altitude but are likely safe to use given their mechanism of action and known side effects. Limited evidence suggests diazepam may cause hypoventilation at high altitude and its use in this environment should be discouraged. Insufficient data exist to determine which agent is most effective at altitude nor do we know whether combination therapy with acetazolamide and a hypnotic agent offers any benefits over monotherapy.

Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ. · Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington School of Medicine, Box 356896, Seattle, WA 98104, USA. · Gen Hosp Psychiatry. · Pubmed #18774425 No free full text.

Abstract: OBJECTIVE: Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD and the impact of post-ICU PTSD on health-related quality of life (HRQOL). METHODS: We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO and a hand-search of 13 journals. RESULTS: Fifteen studies were eligible. The median point prevalence of questionnaire-ascertained "clinically significant" PTSD symptoms was 22% (n=1,104), and the median point prevalence of clinician-diagnosed PTSD was 19% (n=93). Consistent predictors of post-ICU PTSD included prior psychopathology, greater ICU benzodiazepine administration and post-ICU memories of in-ICU frightening and/or psychotic experiences. Female sex and younger age were less consistent predictors, and severity of critical illness was consistently not a predictor. Post-ICU PTSD was associated with substantially lower HRQOL. CONCLUSIONS: The prevalence of PTSD in ICU survivors is high and negatively impacts survivors' HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives) and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients' needs for early intervention.

Yard SS, DuHamel KN, Galynker II. · Beth Israel Medical Center, New York, New York, USA. · Int J Clin Exp Hypn. · Pubmed #18569143 No free full text.

Abstract: The authors review the literature relating hypnotizability and posttraumatic stress. Sixty-seven abstracts containing the key terms ASD, acute stress, trauma, traumatic, or PTSD in combination with either hypnotic susceptibility or hypnotizability were reviewed. Six articles were found containing data on hypnotizability and posttraumatic stress symptoms. Each of the studies showed some relation between hypnotizability and posttraumatic stress, but, in all of them, hypnotizability was measured after the potentially traumatizing event. High hypnotizability might be a risk factor for both acute and chronic posttraumatic symptoms. However, this cannot be determined until prospective studies measure hypnotizability in individuals before and after a potentially traumatizing event, perhaps by targeting populations that are at risk for experiencing trauma.

Davydow DS, Desai SV, Needham DM, Bienvenu OJ. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. · Psychosom Med. · Pubmed #18434495 No free full text.

Abstract: OBJECTIVE: Acute lung injury (ALI), including its more severe subcategory, acute respiratory distress syndrome (ARDS), is a critical illness associated with considerable morbidity and mortality. Our objective was to summarize data on the prevalence of depressive, posttraumatic stress disorder (PTSD), and other anxiety syndromes amongst survivors of ALI/ARDS, potential risk factors for these syndromes, and their relationships to quality of life. METHODS: We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, and PsycINFO. Eligible studies reported data on psychiatric morbidity at least once after intensive care treatment of ALI/ARDS. RESULTS: Ten observational studies met inclusion criteria (total n = 331). Using questionnaires, the point prevalence of "clinically significant" symptoms of depression ranged from 17% to 43% (4 studies); PTSD, 21% to 35% (4 studies); and nonspecific anxiety, 23% to 48% (3 studies). Studies varied in terms of instruments used, thresholds for clinical significance, baseline psychiatric history exclusions, and timing of assessments (range = 1 month to 8 years). Psychiatrist-diagnosed PTSD prevalence at hospital discharge, 5 years, and 8 years were 44%, 25%, and 24%, respectively. Three studies prospectively assessed risk factors for post-ALI/ARDS PTSD and depressive symptoms; significant predictors included longer durations of mechanical ventilation, intensive care unit stay, and sedation. All four studies that examined relationships between psychiatric symptoms and quality of life found significant negative associations. CONCLUSIONS: The prevalence of psychiatric morbidity in patients surviving ARDS seems high. Future research should incorporate more in-depth diagnostic and risk factor assessments for prevention and monitoring purposes.

Roy-Byrne PP, Davidson KW, Kessler RC, Asmundson GJ, Goodwin RD, Kubzansky L, Lydiard RB, Massie MJ, Katon W, Laden SK, Stein MB. · University of Washington School of Medicine, Seattle, WA 98195, USA. · Gen Hosp Psychiatry. · Pubmed #18433653 No free full text.

Abstract: OBJECTIVE: To provide an overview of the role of anxiety disorders in medical illness. METHOD: The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed. RESULTS: A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care. CONCLUSIONS: Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

Rosen GM, Lilienfeld SO. · University of Washington, Seattle, Washington, USA. · Clin Psychol Rev. · Pubmed #18329146 No free full text.

Abstract: The diagnosis of posttraumatic stress disorder (PTSD) rests on several core assumptions, particularly the premise that a distinct class of traumatic events is linked to a distinct clinical syndrome. This core assumption of specific etiology ostensibly distinguishes the PTSD diagnosis from virtually all other psychiatric disorders. Additional attempts to distinguish PTSD from extant conditions have included searches for distinctive markers (e.g., biological and laboratory findings) and hypothesized underlying mechanisms (e.g., fragmentation of traumatic memory). We review the literature on PTSD's core assumptions and various attempts to validate the construct within a nomological network of distinctive correlates. We find that virtually all core assumptions and hypothesized mechanisms lack compelling or consistent empirical support. We consider the implications of these findings for conceptualizing PTSD in the forthcoming edition of the American Psychiatric Association's diagnostic manual.

Woods NF, Alexander JL, Dennerstein L, Richardson G. · University of Washington, School of Nursing, Seattle, WA, USA. · Expert Rev Neurother. · Pubmed #18039065 No free full text.

Abstract: Culture, individual health beliefs and distressing symptoms frequently determine women's perceptions of their menopausal transitions. Women's perceptions of mental health problems and the acceptability of different interventions greatly affect if and what a woman is willing to try as a treatment option and whether or not she will accept the possibility that her menopausal symptoms represent a comorbidity with a diagnosis, such as depression or anxiety. These perceptions have a significant impact on women's choices with regard to health practices, as well as on whether or not they will seek out medical care for their distressing symptom(s). Working with a woman's beliefs, sharing decision making, and empowering her through health education are all critical aspects of the treatment of the patient with comorbid perimenopausal symptoms, regardless of their etiology.

Zatzick DF, Galea S. · Department of Psychiatry & Behavioral Sciences, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104-2499, USA. · J Trauma Stress. · Pubmed #17721951 No free full text.

Abstract: Early, trauma-focused intervention development has emphasized unidirectional trajectories that begin with basic research and efficacy trials followed later by effectiveness and dissemination studies. In this article, the authors present methods derived from social and clinical epidemiology that constitute foundational research in the development of early trauma-focused intervention. They also describe how population-based practice research may serve to feed back and inform what has been conceptualized as earlier stages of intervention development such as efficacy trials. Examples of relevant epidemiologic research methods are presented to illustrate these points. The authors posit that the continued application of population-based methods may produce treatments that can be feasibly applied to the unique patient, provider, organizational, and community contexts relevant to early interventions for survivors of trauma.

Katon W, Lin EH, Kroenke K. · Department of Psychiatry, University of Washington School of Medicine, Seattle, WA 98195-6560, USA. · Gen Hosp Psychiatry. · Pubmed #17336664 No free full text.

Abstract: BACKGROUND: Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses. METHODS: MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes. RESULTS: Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures. CONCLUSIONS: Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.

Giardino ND, Friedman SD, Dager SR. · Department of Radiology, University of Washington School of Medicine, Seattle, WA 98105, USA. · Compr Psychiatry. · Pubmed #17292699 links to  free full text

Abstract: Brain functional imaging methods, such as fMRI, are sensitive to changes in cerebral blood flow (CBF) that are normally associated with changes in regional neural activation. However, other endogenous and exogenous factors can alter CBF independently of brain neural activity, thus complicating the interpretation of functional imaging data. The presence of an anxiety disorder, as well as change in state anxiety, is often accompanied by respiratory alterations that affect arterial CO(2) tensions and produce significant changes in CBF that are independent of task-related neural activation. Therefore, the effects of trait and state anxiety need to be given close consideration in interpreting functional imaging findings. In this paper, we review the dependence of most brain functional imaging methods on localized changes in CBF and the potentially confounding effects of anxiety-related alterations of respiration on interpreting patterns of functional activation. Approaches for addressing these effects are discussed.

McCurry SM, Logsdon RG, Teri L, Vitiello MV. · Department of Psychosocial and Community Health, School of Nursing, University of Washington, 9709 3rd Avenue, NE, Ste. 507 Seattle, WA 98115-2053, USA. · Sleep Med Rev. · Pubmed #17287134 links to  free full text

Abstract: Estimates suggest that there are more than 10 million adult caregivers of persons with dementia, two-thirds of who experience some form of sleep disturbance during the course of their caregiving career. Health care professionals are in the best position to detect and address this significant public health problem. Three major contributors to caregiver sleep disturbance are discussed in this paper: (1) the presence of caregiver disrupted sleep routines; (2) caregiver burden and depression; and, (3) the caregiver's physical health status. Successful treatment of a caregiver's sleep disturbance requires careful consideration of each of these contributors. We review and analyze the scientific literature concerning the multiple complex factors associated with the development and maintenance of sleep disturbances in caregivers. We provide a clinical vignette that illustrates the interplay of these contributing factors, and close by providing recommendations for clinicians and researchers treating and investigating the development and maintenance of sleep problems in family caregivers.

Rosen GM, Taylor S. · University of Washington, USA. · J Anxiety Disord. · Pubmed #17084063 No free full text.

Abstract: Pseudo-posttraumatic stress disorder (pseudo-PTSD) refers to cases in which a patient's presentation is but a simulation of the actual clinical syndrome. The problem of pseudo-PTSD has been neglected by many clinicians and researchers, who often rely on the assumption that a patient's reported symptoms can be accepted as valid. The purpose of this article is to (a) consider the diverse causes of pseudo-PTSD, (b) emphasize the importance of the DSM-IV's guideline to rule out malingering, and (c) discuss the implications that pseudo-PTSD has for research and clinical practice.

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.

Carter GT, Han JJ, Mayadev A, Weiss MD. · Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington, USA. · Am J Hosp Palliat Care. · Pubmed #17060310 No free full text.

Abstract: Charcot-Marie-Tooth disease, the most common hereditary motor and sensory neuropathy, is a slowly progressive disorder characterized by diffuse muscle weakness and prominent distal atrophy that predominantly involves the intrinsic muscles of the feet and the peroneal muscles. It results in marked reduction in functional aerobic capacity during exercise and fatigue is commonly reported. To date, no pharmacologic treatment has been shown to be effective for treating fatigue in Charcot-Marie-Tooth. Modafinil is used to treat the symptoms of fatigue and excessive daytime sleepiness in narcolepsy. However, fatigue and subsequent excessive daytime sleepiness secondary to fatigue are common symptoms in many neurologic disorders. Prior reports on patients with myotonic muscular dystrophy, multiple sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis, have shown beneficial effects of modafinil in treating fatigue. We report 4 patients with genetically confirmed Charcot-Marie-Tooth disease who had significant fatigue that was almost completely relieved by modafinil.

Roy-Byrne PP, Craske MG, Stein MB. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine at Harborview Medical Center, Seattle, WA 98104-2499, USA. · Lancet. · Pubmed #16980119 No free full text.

Abstract: Panic disorder is a common mental disorder that affects up to 5% of the population at some point in life. It is often disabling, especially when complicated by agoraphobia, and is associated with substantial functional morbidity and reduced quality of life. The disorder is also costly for individuals and society, as shown by increased use of health care, absenteeism, and reduced workplace productivity. Some physical illnesses (eg, asthma) commonly occur with panic disorder, and certain lifestyle factors (eg, smoking) increase the risk for the disorder, but causal pathways are still unclear. Genetic and early experiential susceptibility factors also exist, but their exact nature and pathophysiological mechanisms remain unknown. Despite an imprecise, although increased, understanding of cause, strong evidence supports the use of several effective treatments (eg, pharmacological, cognitive-behavioural). The adaptation and dissemination of these treatments to the frontlines of medical-care delivery should be urgent goals for the public-health community.

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.

Levy RL, Olden KW, Naliboff BD, Bradley LA, Francisconi C, Drossman DA, Creed F. · University of Washington, Seattle, Washington 98105, USA. · Gastroenterology. · Pubmed #16678558 No free full text.

Abstract: This report reviews recent research on the psychosocial aspects of the functional gastrointestinal disorders (FGIDs). A review and evaluation of existing literature was conducted by a multidisciplinary committee of experts in this field. This report is a synopsis of a chapter published in the Rome III book. The committee reached consensus in finding considerable evidence supporting the association between psychological distress, childhood trauma and recent environmental stress, and several of the FGIDs but noted that this association is not specific to FGIDs. There is also considerable evidence that psychosocial variables are important determinants of the outcomes of global well-being, health-related quality of life, and health care seeking. In line with these descriptive findings, there is now increasing evidence that a number of psychological treatments and antidepressants are helpful in reducing symptoms and other consequences of the FGIDs in children and adults. The FGIDs are a result of complex interactions between biological, psychological, and social factors, and they can only be treated satisfactorily when all these factors are considered and addressed. Therefore, knowledge about the psychosocial aspects of FGIDs is fundamental and critical to the understanding, assessment, and treatment of these disorders. More extensive physician training is needed if these aspects of treatment are to be used effectively and widely in clinical practice.

Sullivan MD, Robinson JP. · Department of Psychiatry, University of Washington, 1959 Pacific Street, Box 356560, Seattle, WA 98195, USA. · Phys Med Rehabil Clin N Am. · Pubmed #16616273 No free full text.

Abstract: Antidepressants and anticonvulsants have been shown to be efficacious in the treatment of neuropathic pain, chronic headache, and other chronic pain conditions. They may be useful in the treatment of disorders in which central nervous system hypersensitivity con-tributes to pain. They provide valuable alternatives or adjuncts to the use of opioid medications in the treatment of chronic pain. Antidepressants have several potential roles in the treatment of chronic pain in addition to their analgesic effects. Specifically, they effectively address the sleep disturbance, depression, and anxiety that are common in patients with chronic pain.

Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. · Department of Rehabilitation Medicine, University of Washington, Seattle, USA. · Am J Phys Med Rehabil. · Pubmed #16554686 No free full text.

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Schraufnagel TJ, Wagner AW, Miranda J, Roy-Byrne PP. · Department of Psychiatry and Behavioral Sciences, University of Washington, Harborview Medical Center, Seattle, 98104, USA. · Gen Hosp Psychiatry. · Pubmed #16377362 No free full text.

Abstract: OBJECTIVE: The purpose of this study is to examine the current state of knowledge regarding treating ethnic/racial minority patients with mood and anxiety disorders, emphasizing data-based studies whenever possible. METHOD: This article reviews the evidence on poorer access and quality of care for minorities, the biological and cultural differences between minority and majority populations that may impact care and outcomes, and recent studies that address minority treatment response and outcomes both alone and in comparison to majority groups. RESULTS: Numerous impediments to appropriately treating anxious and depressed minority patients remain. Underutilization and poor quality of mental health care in minorities is due to less-than-favorable illness and treatment beliefs that affect adherence and outcome, stigma, clinician failure to engage the patient, poor patient activation and biological differences that may impact pharmacotherapy choice. However, though limited in number, some studies do indicate that when appropriate treatment is well-delivered to minorities, results are comparable to those seen among Caucasian patients. CONCLUSIONS: The clinician treating members of minority groups must consider differential personal elements, from the biological to the cultural, to achieve treatment success. The limited available data do suggest that minority patients can be successfully treated with available interventions. Of primary importance is for researchers to increase the number of carefully designed intervention studies that allow for ethnic/racial minority-specific analyses.

Mitchell ES, Neumaier JF. · University of Washington, Box 359911, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA. · Pharmacol Ther. · Pubmed #16005519 No free full text.

Abstract: Over the past decade, there has been increasing interest in the role of serotonin 6 (5-HT6) receptors in higher cognitive processes such as memory. Polymorphisms of the 5-HT6 receptor have been implicated in syndromes that affect cognition, such as schizophrenia and dementia. Manipulation of 5-HT6 receptor activity alters the transmission of several neurotransmitters important in memory: acetylcholine and glutamate, as well as dopamine, ã-aminobutyric acid (GABA), epinephrine (E), and norepinephrine (NE). Several 5-HT6 antagonists have been developed, advancing the understanding of the relationship between 5-HT6 blockade and memory consolidation in diverse learning paradigms. There is also evidence that 5-HT6 receptor activity affects anxiety behaviors and may be involved in the pathophysiology of schizophrenia. Several clinically useful atypical antipsychotics and antidepressants have 5-HT6 affinity, but recently developed selective 5-HT6 receptor antagonists may present attractive, new therapeutic options for several types of disease states.

Aisenberg E, Ell K. · School of Social Work, University of Washington, USA. · J Interpers Violence. · Pubmed #15914706 No free full text.

Abstract: This article presents an integrated conceptual framework that contextualizes exposure to community violence and the interpersonal and interdependent processes of parent and child response to community violence. This model posits that parental distress, including post-traumatic stress disorder (PTSD) and depression, is a significant mediator of child distress symptomatology and behavior problems. The model advances understanding of the impact of community violence in the lives of parents and children through various mechanisms, including social capital. This article underscores the need for a fundamental shift in the study of community violence, in the delivery of mental health services, and in prevention efforts from focusing on the individual child to concentrating on the parent, family, and community-level factors and processes. This article highlights important areas to address in future research, including investigation and specification of the mechanisms and processes by which neighborhoods affect and influence human development outcomes.

Roy-Byrne PP, Wagner AW, Schraufnagel TJ. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Harborview Medical Center, Seattle, USA. · J Clin Psychiatry. · Pubmed #15842183 No free full text.

Abstract: According to studies, the median prevalence of panic disorder in the primary care setting is 4%. Rates are higher among certain patient populations, such as those with cardiac (20% to 50%) or gastrointestinal presentations (28% to 40%). Consequently, patients with panic disorder are high utilizers of medical services and are heavily represented among patients classified as high health care utilizers, compared with other psychiatric or non-psychiatric groups. Despite its frequency in the primary care setting, panic disorder is significantly under-recognized by medical providers. Corresponding with inadequate recognition is the substantial proportion of these patients who fail to receive appropriate treatment (pharmacotherapy and psychotherapy). Most experts have concluded that panic disorder is poorly managed in the primary care setting because of the process of care and patient engagement. In terms of process of care, primary care practice still operates on an acute disease model (leaving no time for initial patient education or follow-up), which is a poor fit for the management of chronic diseases. Insufficient patient engagement in treatment (i.e., being involved in the treatment process, "buying into" rationale for treatment, and being willing to collaborate with clinician and adhere to recommendations) is the second important contributor to inadequate treatment. Use of a chronic disease self-management approach would enhance treatment of panic disorder. This model requires that patients, in collaboration with the health care provider/system, take day-to-day responsibility for managing their illness by doing 3 things: adhering to recommended medical management, adopting improved health habits/coping skills, and assisting in ongoing monitoring of illness status/change. Future approaches to treating panic disorder in primary care would be enhanced by including assessments of patient beliefs and preferences, spending more time in preparing the patient for treatment, utilizing a simple pharmacotherapy algorithm, utilizing simple rating scales to monitor outcomes, and training providers in brief CBT interventions.