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Brief Report   |    
Treatment of Panic Attack and Risk of Major Depressive Disorder in the Community
Renée Goodwin, Ph.D.; Mark Olfson, M.D., M.P.H.
Am J Psychiatry 2001;158:1146-1148. doi:10.1176/appi.ajp.158.7.1146

Abstract

OBJECTIVE: The authors’ goal was to determine whether treatment of panic attacks has a protective effect on the risk of major depression in the community. METHOD: Data were drawn from the National Comorbidity Survey, a community-based household sample representative of the U.S. adult population. A Cox proportional hazard model was used to estimate the association between risk of first-onset major depression and panic among subjects who had or had not received treatment for panic. RESULTS: A significantly smaller proportion of individuals who received treatment for panic (19%) than those who did not receive treatment (45%) developed major depression. This difference remained significant in a Cox proportional hazard analysis adjusted for age at onset of panic and differences in demographic characteristics. CONCLUSIONS: Detection and treatment of panic may reduce the risk of developing major depression.

Abstract Teaser
Figures in this Article

Data from several epidemiologic studies show that a majority of individuals who experience a panic attack will also have an episode of major depression during their lifetime (13). The likelihood of this co-occurrence is even stronger among those who meet the full criteria for panic disorder (1). A substantial minority of individuals who experience an episode of major depression also experience panic attacks (1, 2). The functional disability and risk of suicidal behavior associated with comorbid panic and depression far exceed those associated with either disorder alone (4).

Most clinical and epidemiologic data suggest that the onset of anxiety usually precedes the onset of depression (1, 2). In the National Comorbidity Survey, a majority of respondents with lifetime panic-depression comorbidity (43.4%) experienced their first panic attack before the first onset of major depression (1). Wittchen et al. (5) found that anxiety preceded onset of depression in a majority of subjects with comorbid anxiety and depression in clinical and epidemiologic samples.

Despite the availability of efficacious treatments (6), panic is often undiagnosed and untreated (7). Delay in diagnosis and treatment of several chronic medical conditions is clearly associated with a greater risk of subsequent associated morbidity (e.g., untreated hypertension is associated with greater risk of coronary disease [8]). Similarly, a longer length of time from onset of panic to first treatment is associated with higher rates of comorbidity at first psychiatric treatment contact and less favorable treatment outcomes among panic disorder patients in psychiatric settings (9). It is not known, however, whether treatment of panic attack reduces the risk of developing major depression.

The purpose of the current study was to investigate the effects of treatment of panic attack on the subsequent risk of first onset of major depression. We hypothesized that treatment of a panic attack will have a protective effect on the risk of major depression.

The National Comorbidity Survey (N=8,098) is based on a national probability sample of individuals 15 to 54 years old in the noninstitutionalized population. There was an 82.4% response rate. Weights are described in detail elsewhere (10, 11).

The group under study consisted of the respondents who endorsed having a panic attack (lifetime prevalence) (N=425). Panic attack and panic disorder are collapsed because there is no meaningful cutoff point in epidemiologic and clinical data that distinguishes panic attack from panic disorder in terms of panic attack symptoms or associated social morbidity (12). Diagnoses were generated from a modified version of the World Health Organization Composite International Diagnostic Interview (13), a structured interview designed for use by lay interviewers.

At the end of the diagnostic sections for each of five types of disorders, respondents were asked whether they ever told a medical doctor other than a psychiatrist (M.D., D.O., or a student in training to become an M.D. or D.O.), a mental health specialist (a psychiatrist, psychologist, or social worker), or any other professional (a nurse, minister, priest, rabbi, or counselor) about the problems discussed in that section of the interview. Positive responses were followed by probes for the age when the respondent first told each type of professional. Age at first treatment was quantified by the variable documenting earliest age at which the respondent told a professional about a panic attack.

We used Pearson’s chi-square tests to determine sociodemographic differences between respondents who were or were not treated for panic among those who experienced onset of panic attack before the onset of major depressive disorder (lifetime) and those who experienced panic attacks without experiencing lifetime major depressive disorder. A Cox proportional hazard model was then used to calculate unadjusted and adjusted hazards ratios (with 95% confidence intervals [CIs]) estimating the effect of treatment of panic attacks on the risk of developing major depressive disorder.

Compared with respondents who experienced panic attacks and did not receive treatment, those who were treated were older, more likely to be married, and less likely never to have married (t1).

Approximately one in five (19.2%) of those who were treated for panic developed major depression. By contrast, nearly half (44.7%) of those who had not been treated developed major depression (χ2=11.5, df=1, p=0.001). Consistent with these results, Cox proportional hazard analyses produced unadjusted and adjusted hazards ratios showing that individuals who were treated for panic were at lower risk for major depression; the unadjusted hazards ratio was 0.43 (95% CI=0.27–0.69), and the adjusted hazards ratio was 0.47 (95% CI=0.28–0.78). Similar results were produced when the model was rerun to estimate the risk of major depression only among individuals who met full criteria for panic disorder: the unadjusted hazards ratio was 0.52 (95% CI=0.30–0.91), and the adjusted hazards ratio was 0.58 (95% CI=0.32–1.00).

Treatment of panic attack may be a roadblock or a detour on the pathway from panic symptoms to major depression. In this regard, it is interesting to note that panic and major depression share a recommended first-line psychopharmacological treatment, i.e., selective serotonin reuptake inhibitors (6). Alternatively, professional help-seeking may reflect unmeasured individual characteristics that protect against the development of major depression (14). For example, telling a health care professional about panic attacks may indicate a capacity for accurate cognitive self-appraisal that helps decrease the risk of future psychiatric comorbidity (1517). It is also possible that a tendency to develop depression independently reduces the likelihood of seeking treatment.

These results are preliminary and need to be interpreted within the context of several limitations. First, retrospective reports of age at onset of disorder and first treatment are subject to recall bias, although there is no reason to suspect that this would differ by group. Second, the measure of treatment for panic attacks is limited to self-report of having spoken with a health care professional about panic attacks. No information is available on the nature or effectiveness of the services provided. Third, variations in services that individuals in these groups went on to receive or had previously received could contribute to observed differences. Fourth, the crude estimates of percentages of those who developed major depression in the treated and untreated groups are unadjusted for time effects or other confounders. Finally, some of the covariates (education, marital status, and income) are time-dependent and may not be the same at the time of the onset or treatment of the disorder.

This study provides evidence for a prophylactic effect of treatment of panic attacks on the risk of major depression in the community. The findings reveal a possible pathway for prevention of depression through treatment of panic. Since we have no data on the nature or effectiveness of the treatments provided, the mechanism through which this occurs remains unknown. These data should encourage clinicians, policy makers, and health care administrators to increase efforts aimed at the detection and treatment of panic.

 

Received July 20, 2000; revision received Nov. 8, 2000; accepted Feb. 1, 2000. From the Department of Psychiatry, College of Physicians and Surgeons of Columbia University; New York State Psychiatric Institute, New York; and the Division of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University. Address reprint requests to Dr. Goodwin, Department of Psychiatry, Columbia University, 1051 Riverside Dr., Unit 43, New York, NY 10032; rdg66@columbia.edu (e-mail). Supported in part by NIMH grants MH/DA-46376 and MH-49098, a National Institute of Drug Abuse supplement to grant MH/DA-46376, and W.T. Grant Foundation grant 90135190.

Kessler RC, Stang PE, Wittchen HU, Ustun TB, Roy-Byrne PP, Walters EE: Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry  1998; 55:801-808
[PubMed]
[CrossRef]
 
Andrade L, Eaton WW, Chilcoat HD: Lifetime comorbidity of panic attacks and major depression in a population-based study: age of onset. Psychol Med  1996; 26:991-996
[PubMed]
[CrossRef]
 
Reed V, Wittchen H-U: DSM-IV panic attacks and panic disorder in a community sample of adolescents and young adults: how specific are panic attacks? J Psychiatr Res  1998; 32:335-345
[PubMed]
[CrossRef]
 
Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL: Quality of life in panic disorder. Arch Gen Psychiatry  1989; 46:984-992
[PubMed]
 
Wittchen H-U, Essau CA, Krieg J-C: Anxiety disorders: similarities and differences of comorbidity in treated and untreated groups. Br J Psychiatry  1991; 159:21-33
 
American Psychiatric Association: Practice Guideline for the Treatment of Patients With Panic Disorder. Am J Psychiatry 1998; 155(May suppl)
 
Narrow WE, Regier DA, Rae DS, Manderscheid RW, Locke BZ: Use of services by persons with mental and addictive disorders: findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Arch Gen Psychiatry  1993; 50:95-107
[PubMed]
 
Kannel WB: CHD risk factors: a Framingham Study update. Hosp Pract  1990; 25:93-104
 
Shinoda N, Kodama K, Sakamoto T, Yamanouchi N, Takahashi T, Okada S, Noda S, Komatsu N, Sato T: Predictors of 1-year outcome for patients with panic disorder. Compr Psychiatry  1999; 40:39-43
[PubMed]
[CrossRef]
 
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H-U, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry  1994; 51:8-19
[PubMed]
 
Kessler RC, Little RJA, Groves RM: Advances in strategies for minimizing and adjusting for survey nonresponse. Epidemiol Rev  1995; 17:192-204
[PubMed]
 
Leon AC, Klerman GL, Weissman MM, Fyer AJ, Johnson J: Evaluating the diagnostic criteria for panic disorder: measures of social morbidity as criteria. Soc Psychiatry Psychiatr Epidemiol  1992; 27:180-184
[PubMed]
[CrossRef]
 
Wittchen H-U: Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res  1994; 28:57-84
[PubMed]
[CrossRef]
 
Parker GB, Brown LB: Coping behaviors that mediate between life events and depression. Arch Gen Psychiatry 1982; 39:1386-  1391
 
Breier A, Charney DS, Heninger GR: Agoraphobia with panic attacks: development, diagnostic stability, and course of illness. Arch Gen Psychiatry 1986; 43:1029-  1036
 
Klein DF: Anxiety reconceptualized, in Anxiety: New Research and Changing Concepts. Edited by Klein DF, Rabkin J. New York, Raven Press, 1981, pp 235-263
 
Weekes C: Simple effective treatment of agoraphobia. Am J Psychother  1978; 32:357-369
[PubMed]
 
+

References

Kessler RC, Stang PE, Wittchen HU, Ustun TB, Roy-Byrne PP, Walters EE: Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry  1998; 55:801-808
[PubMed]
[CrossRef]
 
Andrade L, Eaton WW, Chilcoat HD: Lifetime comorbidity of panic attacks and major depression in a population-based study: age of onset. Psychol Med  1996; 26:991-996
[PubMed]
[CrossRef]
 
Reed V, Wittchen H-U: DSM-IV panic attacks and panic disorder in a community sample of adolescents and young adults: how specific are panic attacks? J Psychiatr Res  1998; 32:335-345
[PubMed]
[CrossRef]
 
Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL: Quality of life in panic disorder. Arch Gen Psychiatry  1989; 46:984-992
[PubMed]
 
Wittchen H-U, Essau CA, Krieg J-C: Anxiety disorders: similarities and differences of comorbidity in treated and untreated groups. Br J Psychiatry  1991; 159:21-33
 
American Psychiatric Association: Practice Guideline for the Treatment of Patients With Panic Disorder. Am J Psychiatry 1998; 155(May suppl)
 
Narrow WE, Regier DA, Rae DS, Manderscheid RW, Locke BZ: Use of services by persons with mental and addictive disorders: findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Arch Gen Psychiatry  1993; 50:95-107
[PubMed]
 
Kannel WB: CHD risk factors: a Framingham Study update. Hosp Pract  1990; 25:93-104
 
Shinoda N, Kodama K, Sakamoto T, Yamanouchi N, Takahashi T, Okada S, Noda S, Komatsu N, Sato T: Predictors of 1-year outcome for patients with panic disorder. Compr Psychiatry  1999; 40:39-43
[PubMed]
[CrossRef]
 
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H-U, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry  1994; 51:8-19
[PubMed]
 
Kessler RC, Little RJA, Groves RM: Advances in strategies for minimizing and adjusting for survey nonresponse. Epidemiol Rev  1995; 17:192-204
[PubMed]
 
Leon AC, Klerman GL, Weissman MM, Fyer AJ, Johnson J: Evaluating the diagnostic criteria for panic disorder: measures of social morbidity as criteria. Soc Psychiatry Psychiatr Epidemiol  1992; 27:180-184
[PubMed]
[CrossRef]
 
Wittchen H-U: Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res  1994; 28:57-84
[PubMed]
[CrossRef]
 
Parker GB, Brown LB: Coping behaviors that mediate between life events and depression. Arch Gen Psychiatry 1982; 39:1386-  1391
 
Breier A, Charney DS, Heninger GR: Agoraphobia with panic attacks: development, diagnostic stability, and course of illness. Arch Gen Psychiatry 1986; 43:1029-  1036
 
Klein DF: Anxiety reconceptualized, in Anxiety: New Research and Changing Concepts. Edited by Klein DF, Rabkin J. New York, Raven Press, 1981, pp 235-263
 
Weekes C: Simple effective treatment of agoraphobia. Am J Psychother  1978; 32:357-369
[PubMed]
 
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