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Am Fam Physician. 2002;65(9):1932-1934

Patients with panic disorder commonly come to emergency departments with a variety of symptoms, including chest pain. Identification and management of these patients in the emergency department would be useful. Wulsin and associates used a randomized, controlled trial to test the one- and three-month outcomes of a protocol to identify patients with panic disorder in the emergency department and initiate treatment.

Patients admitted to a university hospital chest pain center in the emergency department were screened for panic disorder by the research assistant using the five-question Panic Syndrome Checklist taken from the panic disorder section of the Prime-MD Patient Health Questionnaire. Participants whose results were positive for panic disorder completed the Panic Disorder Module of the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). SCID is a five-question interview designed to help clinicians diagnose panic disorder. The Panic Disorder Severity Scale (PDSS), a seven-item structured interview that measures panic symptoms and provides a score to identify persons with panic disorder, was also used. Patients with panic disorder confirmed by these three diagnostic tests were randomly assigned to either usual care or the intervention group.

Usual care consisted of reassurance that the patient had no cardiac disease causing the chest pain and, if necessary, referral to a physician. The intervention group received education about panic disorder, initiation of treatment with a one-month supply of paroxetine tablets in a dosage of 20 mg, once daily, and a specific referral to a psychiatrist or physician within the next month to be confirmed by the research assistant with a telephone call.

All 25 patients randomized to the intervention group began taking paroxetine within three days of their emergency department visit. In the usual-care group, six (24 percent) patients reported taking an antipanic medication during the first month after their emergency visit. The number of patients still taking antipanic medications declined at the two-month follow-up and was even lower after three months. The intervention group's PDSS scores were lower than those of the usual-care group after three months, but this difference was not statistically different.

The authors conclude that patients with panic disorder who present to the emergency department complaining of chest pain can be accurately diagnosed in five to 10 minutes using a brief screening strategy followed by a guided interview. When patients are given medical treatment and provided with minimal education about panic disorder, function, and symptoms at three-month follow-up are improved, although the change is not statistically significant.

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