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An APA practice guideline for the treatment of patients with panic disorder is a reality following a lengthy development that included review by more than 900 persons and a final approval from the APA Board of Trustees at its December meeting.
The "Practice Guideline for the Treatment of Patients with Panic Disorder" joins eight other APA guidelines in the practicing psychiatrist’s armamentarium. It was approved by the Assembly in November.
The guideline is a product of the Steering Committee on Practice Guidelines chaired by former APA president John S. McIntyre, M.D., and the Work Group on Panic Disorder, chaired by Jack Gorman, M.D., and Katherine Shear, M.D.
Of the various treatment modalities evaluated in the guideline, panic-focused cognitive behavioral therapy (CBT) received the highest rating of clinical confidence for a psychotherapeutic approach and was supported by extensive and high-quality data. CBT encompasses a range of treatments including psychoeducation, continuous panic monitoring, development of anxiety management skills, cognitive restructuring, and in vivo exposure. Other psychosocial treatments, including other forms of psychotherapy, may be considered and are widely employed on the basis of clinical consensus, in conjunction with psychiatric management and medication.
Medications are also reviewed in the guideline, and four classes of drugs are found to have proven efficacy in the treatment of panic disorder: selective serotonin reuptake inhibitors, tricyclic antidepressants, benzodiazepines, and monoamine oxidase inhibitors. The choice of medication, according to the guideline, is guided by consideration of adverse effects and the patient’s personal preferences because all four classes were found to have comparable efficacy.
APA develops practice guidelines as a set of patient care strategies to improve patient care by assisting physicians in clinical decision making. The guidelines are peer reviewed and "evidence based" after a review of an extensive literature search, supplemented by clinical consensus in those areas where research is viewed as inadequate. In the course of development of the panic disorder guideline, some 1,800 articles were reviewed.
McIntyre, speaking to the APA Board of Trustees, said that the use of clinical consensus in the guideline, while criticized by some, was appropriate.
"We will accept this criticism because we feel strongly that evidence, not just in our field but throughout medicine, should include both research data and clinical consensus or clinical wisdom," said McIntyre. "How to tap into that clinical wisdom is a challenge. . .and we hope that the [Practice Research Network] will help in that regard, as does the very process of guideline development involving a very large number of our members."
Because the developers concluded that there is no convincing evidence that either psychotherapy or medication is superior in all patients, the guideline recommends that treatment decisions be based on an individualized assessment of efficacy, the benefits and risks of each modality, and patient preferences. "Psychiatric management" should be the foundation of all treatment of persons with panic disorder, the guideline says, which includes these components:
"While there are some things I would still like to see different, I’m convinced that the guidelines are the best we can do given the various considerations that have to be reconciled," remarked Area 4 Trustee Norman Clemens, M.D., who participated in the ad hoc committee that reviewed early drafts. Clemens also chairs APA’s Commission on Psychotherapy by Psychiatrists.
The final draft was "much more reflective of what is considered to be prevailing practice, and one of the striking things is it shows psychotherapy to be effective without medication," he observed. It is important that APA "never forget the necessity of grounding guidelines in scientific literature tempered by clinical consensus."
Gorman, the cochair of the guideline development work group, lauded approval of the guideline: "Panic disorder has become one of the most gratifying disorders for the psychiatrist to treat. Patients usually respond to treatment, and modern treatments are increasingly well tolerated in addition to being effective. Still, there are many treatment options available, and the new practice guideline represents an attempt to sort through the available scientific literature and common clinical practice in order to offer recommendations for clinicians. These guidelines also highlight some of the deficiencies in our knowledge, such as the optimal forms of maintenance therapy for panic disorder patients, and therefore call attention to areas in which more research is clearly needed."
APA’s practice guidelines are developed in an iterative process in which multiple drafts are reviewed by an increasing number of experts and clinicians. The guidelines are intended to assist psychiatrists in caring for patients, not to serve as a standard of medical care. A statement of intent in the panic disorder guideline specifies that adherence to the guideline does not ensure a successful outcome of treatment in every case, nor should the guideline be construed as including all proper methods of care aimed at the same results.
"The ultimate judgment regarding a particular clinical procedure must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available," states the guideline.
The guideline will be published in the American Journal of Psychiatry at a later date.