Three-year medication prophylaxis in panic disorder: to continue or discontinue? A naturalistic study
Introduction
Panic disorder is a common psychiatric illness with a lifetime prevalence of 4.7% in the United States [1]. It is characterized by a chronic, fluctuant course and is highly comorbid with other psychiatric disorders, including substance abuse and dependence [2], mood disorders [3], [4], other anxiety disorders [5], and personality disorders [6]. Panic disorder is increasingly recognized as a major mental health problem with a high degree of functional impairment [7], [8], [9], poor quality of life [10], [11], [12], and increased risk of suicide [13], [14], [15].
Panic disorder responds well to tricyclic antidepressants (TCAs), serotonin-reuptake inhibitors, or combination treatment with benzodiazepines [16]. After successful treatment, how long do patients need to remain on medication? The American Psychiatric Association (APA) practice guideline recommends at least 1 year of maintenance after 12 weeks of acute stabilization [16], but this recommendation is based on limited empirical data. Controlled discontinuation studies have found a wide range of relapse rates, from 30% with sertraline [17] to more than 70% with alprazolam [18]. Patients from these studies may not be representative of individuals in the community because they were participants in a research treatment protocol before the discontinuation phrase. Available naturalistic studies have generally used retrospective data obtained from a one-time follow-up visit many years after the acute treatment period [19], limiting their ability to characterize treatment course over time. In this context, the optimal duration of maintenance therapy after acute stabilization remains unclear.
The purpose of this study was to compare the treatment outcome of patients who were continued on versus those successfully discontinued from medication after 3 years of panic-free remission. Although previous studies have noted a lower survival probability in patients who discontinued medication [17], [20], we did not expect any difference in survival probabilities in our patients because we hypothesized that 3 years of maintenance treatment—a period that is significantly longer than that of previous studies—would be sufficient prophylaxis against relapse. To our knowledge, this is the only naturalistic, longitudinal study to date in which medication discontinuation was systematically attempted after 3 years of maintenance treatment, and patients were followed for an additional 4 to 8 years in clinical practice.
Section snippets
Study patients
Patients (N = 217) in the study were receiving routine clinical care at Freedom from Fear. Freedom from Fear (Staten Island, NY) is a mental illness advocacy organization and an urban community clinic that specializes in the treatment of anxiety disorders. Patients met Diagnostic and Statistical Manual of Mental Disorders, Third Edition, (DSM-III) diagnosis of panic disorder with or without agoraphobia. Diagnosis was determined by consensus from 2 clinicians as part of routine assessment during
Assignment, demographics, baseline symptoms, and treatment profiles
Of the 217 participants, 168 choose to remain on medication (the continued group), 37 successfully completed medication taper (the discontinued group), and 12 failed to discontinue medication because of severe anxiety during the taper period. A total of 30 patients were lost to follow-up (14.6%): 2 from the discontinued group and 28 from the continued group. These patients were included in the analysis and categorized as terminated well based on their last visit.
There was no significant
Discussion
The main finding in our study was that patients who successfully discontinued from medication had a poorer treatment outcome compared with those who remained on medication. The median survival time of patients who discontinued medication was only one fifth of that enjoyed by patients continued on medication, and their risk of relapse was significantly higher at 4 years follow-up (85% vs 36%). Although these results were unexpected as we had hoped that 3 years of maintenance treatment would be
Acknowledgments
The authors thank Freedom from Fear, a mental illness advocacy organization for their support with this project. Many thanks to the staff at the Freedom from Fear for their assistance in the administrative aspects of the study. We also greatly appreciate the following physicians for their help in data collection: Sunil Khushalani, MD; Wieslawa Tomaszewska, MD; Michael Z. Sobel, MD; Alexandria Hallin, MD; R. Sandlin Lowe, MD; R. Todd Lafargue MD; Gita Vaid, MD. We are very grateful to Carole
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This study was not supported by any outside grant or sponsored by any pharmaceutical companies. Study was completed at the Freedom from Fear, 308 Seaview Avenue, Staten Island, NY 10305.