1. Are Benzodiazepines Still the Medication of Choice for Patients With Panic Disorder With or Without Agoraphobia? By : s.bruce, PhD et al (Am J Psychiatry 2003; 160:1432-1438)

2. Introduction Panic disorder (PD): Is a disabling psychiatric condition associated with significant impairment in psychosocial & occupational functioning, the lifetime prevalence rate (2-4%).

3. Introduction Drugs used: T C A. M A O I s. Benzodiazepines.

4. Introduction 1- Currently, (SSRIs) indicated as the first line treatment for (PD). 2-The APA ’ s Practice Guidelines for Treatment of Patients With Panic Disorder states that SSRIs are likely to have the most favorable balance of efficacy and adverse effects.

5. Introduction - (SSRIs) have an advantage over other treatment agents in that they are safer in overdose & their ability to effectively treat comorbid disorders (e.g. MDD,OCD & social anxiety disorder).

6. Objective To examine how the use of psychotropic drugs has shifted over the course of 10 years to determine if prescribing patterns have changed to reflect these revised treatment guidelines.

7. Method The harvard\brown anxiety research project(naturalistic,longtudinal,multicenter study of adults w current or past hx of anxiety dis.) Number of subjects = 711, 30 clinicians’ practice Inclusion criteria ??

8. Method Exclusion criteria : - Organic brain syndrome. - History of schizophrenia or current psychosis at intake. Insufficient for inclusion, but frequently seen as comorbid conditions, were diagnoses of simple phobia, PTSD, OCD, anxiety dis not otherwise specified.

9. Method A total of (443) patients at intake met the criteria for (PD) w or w/o agoraphobia. The present data derive from structured diagnostic interview administrated at intake (1989-1991) & subsequent semiannual & annual follow up interviews over 10 y (1991-2001).

10. Method The initial comprehensive evaluation assessed lifetime history with: # Structured Clinical Interview for DSMIII-R Non-Affective Disorders. # The Research Diagnostic Criteria (RDC) # Schedule for Affective Disorders &Schizophrenia-Lifetime Version (SADS-L). # follow up ??

12. Method A participant was considered to have remitted panic dis if he/she experience 8 consecutive wk of psychiatric status rating of 2 or fewer. Pts were judge to have relapsed if their psychiatric status rating increased to a score of 5 or 6 for two consecutive weeks.

13. Method The evaluation gathered weekly information about the presence of specific symptom criteria, psychiatric comorbidity & psychosocial functioning. Information regarding pharmacological treatment form the pt was collected every 6- 12 months, retrospectively, including medications type, average daily dose, whether pts were taking it as needed.

15. Results an additional (44) subjects had a new onset of (PD) w or w/o agoraphobia were included in these f/u analysis. * Demographic characteristics: -89% Caucasian. -68% Female. -38% Had a college education or higher.

16. Results No significant differences regarding demographic characteristics between patients w or w/o agoraphobia or between patients with (PD) Age at onset bet. PD with agoraphobia and without ??

19. Use of pharmacological agents over follow-up The results indicated : Slight decline in benzo. use across the follow-up interval. Moderate increase in SSRIs use. However, of the pts taking an SSRI, about 2/3 were also taking a benzo. in combination.

20. Use of pharmacological agents over follow-up Comparisons of the patients who were having panic attacks at f/u with the patients who were in remission ?? The patients with PD & comorbid MDD were 3.5 times more likely to use an SSRI than those without MDD.

21. Use of pharmacological agents over follow-up Previous use of benzodiazepines & SSRIs in the F\U ??. Other comorbid conditions such as alcohol/substance use disorders & additional comorbid anxiety disorders V V SSRIs & the F \ U ??

22. Pharmacological treatment & clinical course The patients whose disorder remitted BEFORE REMITION ??

23. Discussion The result from this study indicate: Use of SSRIs & gudidelines ? Benzodiazepine being the most common class of drugs used to treat PD. The effect of comorbid MDD on medication treatment patterns in patients with PD was found to be a significant predictor of greater use of SSRI.

24. Discussion These results are consistent with those of ( Uhlenhuth & colleagues ) who reported a negligible decrease in overall frequency of expert recommendations for benzodiazepine as a first-line treatment of PD over a 5 years interval in the 1990s.

25. Discussion although physicians` self-reports indicated a change in the way in which they practice, actual behavior had change little. *** Why would a high percentage of these patient`s physicians not prescribe SSRIs for PD despite treatment guidelines endorsing SSRIs as a first- choice ?

26. Discussion ( Dugan & cohen ) suggested that “before physician view guidelines as precise tool to use in the construction of optimal patient care, they must be convinced that guidelines contain clear, evidence- based recommendations, and that there is a distinct advantage to them in changing practice styles to follow guidelines”

27. Discussion rapid onset of action of the benzo. make their use more favorable than newer SSRIs. non-compliance SSRIs found in some studies because of unwanted sexual side effects. ( Otto &colleagues ) found no evidence to support the hypothesis that SSRIs are more effective than older antidepressants for the treatment of PD !!!!.

28. Limitations This study did not include data from patients’ treating physicians, it is impossible to determine whether SSRIs were not being prescribed to the patients or…….. Lack of patients education about : side effects \ The onset of action

29. Limitations Since the pts were recruited from (1989-1991), most SSRIs had not yet become available. Therefore, the finding from this study may not be indicative of individuals who are newly diagnosed with PD & seeking treatment for the first time.

30. Conclusion gap between pharmacological treatment guidelines and actual delivery of care Future studied should address this apparent gap, including whether or not the clinical guidelines to use SSRIs as first-line treatment is premature.

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