Are Benzodiazepines Still the Medication of Choice for Patients With Panic Disorder With or Without Agoraphobia
Bruce SB, Vasile RG, Goisman RM, Salzman C, Spencer M, Machan JT and Keller MB;
Commented by , 29 Aug 2003
Aim of the study
For the pharmacological treatment of panic disorder with or without agoraphobia, current treatment guidelines emphasize prescription of antidepressants, especially selective serotonine reuptake inhibitors (SSRIs), over treatment with benzodiazepines.
In this article, the authors report on the changes that have occured in the use of the two types of drugs over the past 10 years.
The authors report on patients with panic disorder with or without agoraphobia included in the Harvard/Brown Anxiety Research Project, a prospective longitudinal study of anxiety disorders.
Patients were included from 1989 on and were assessed subsequently once or twice a year regarding the presence of specific symptom criteria, psychiatric comorbidity, psychosocial functioning and pharmacological treatment. The analyses of the present study were restricted to 443 patients who had at least 6 months of follow-up.
Use of benzodiazepines declined slightly over the 10 years of follow-up, although over one-half of the patients still reported use of a benzodiazepine during each of the follow-up years. Use of SSRIs showed a moderate increase, from 13.3% at intake to 32.9% at the 10-year follow-up.
Of the patients taking an SSRI, approximately two-thirds were also taking a benzodiazepine in combination during each of the follow-up intervals. Patients with a comorbid major depressive disorder were 3.5 times more likely to take an SSRI than those who did not have a major depressive disorder.
No significant differences in the use of medication were found with regard to the presence or absence of agoraphobia.
The authors acknowledge having been surprised by the results of their study i.e. by the fact that pharmacological treatment patterns for panic disorder with or without agoraphobia had remained relatively stable over the past 10 years.
They discuss several factors that may have impeded a more radical change. Among others, they discuss the possibility that clinicians, especially more experienced clinicians, may oppose following guidelines for fear of loss of autonomy and clinical judgement.
They also discuss the potential influence of adverse side effects, especially sexual dysfunction, on the compliance of patients taking an SSRI. Finally, the rapid onset of action of the benzodiazepines may be seen as an advantage – both by the patients and the prescribing physician - in comparison with the delayed onset of action following treatment with an SSRI.
Although the authors do mention that cognitive behavior therapy (CBT) is an empirically supported treatment for panic disorder and agoraphobia, they do not discuss if and to what extent CBT may influence the prescription, use and compliance of pharmacological treatment.
This article raises important questions concerning the influence of practice guidelines on the prescription and delivery of care in everyday practice.
Although treatment guidelines are developed by specialists on the basis of the best empiral evidence available, there is obviously a need to more closely examine the factors that may be involved in promoting or inhibiting the implementation of practice guidelines in the real world.