کاربرد پزشکی و هزینه ها در اختلال هراس: مقایسه با هراس اجتماعی

There is considerable evidence that people with panic disorder utilise the physical health care system more frequently than people in the general community and so incur for themselves, and impose on the public health care system, considerably greater costs. Although this is probably because of specific characteristics to do with panic disorder, it may also be a function of having any anxiety disorder where panic is prominent. This study represents one of the few comparisons of medical utilisation and costs incurred by people with panic disorder to those incurred by people with another anxiety disorder, in this case, social phobia. Before treatment, 41 people with panic disorder, 15 with social phobia and 43 nonanxious controls were interviewed about their use of the medical care system over the previous 12 months. As expected, people with panic disorder had significantly higher utilisation rates than either the nonanxious controls or the socially phobic subjects, and incurred substantially higher costs. Adequate screening for panic disorder at the primary medical care level together with appropriate treatment referral therefore have the potential to substantially reduce the personal and community costs incurred by people with panic disorder. “A 38 year old Puerto-Rican woman admitted to the emergency department reported chest pain, dizziness, shortness of breath, and the fear that she was dying. The electrocardiogram showed no abnormalities. She had no cardiac risk factors” (Tommasini & Federici, 1992, p.319). This example is one of many similar presentations in which panic disorder often remains unidentified because of the presumed presence of an underlying medical condition. For people with panic disorder, the experience of heightened anxiety symptoms usually occurs without the person being able to identify any obvious cause. As a result, the origins of the symptoms experienced are unclear, particularly during the initial panic attack. The frightening symptoms of palpitations, tachycardia and chest pain for example, result in many sufferers seeking treatment at emergency departments because they fear they are experiencing a heart attack. Compared to people with other psychological disorders, those with panic disorder may have the highest use of emergency departments for problems with an emotional origin (Weissman, 1991). Indeed, Katon, Vitaliano, Russo, Jones, and Anderson (1987) stated that people with panic disorder frequently seek medical care services for a wide variety of complaints which includes visits to multiple medical practitioners and the frequent use of emergency rooms, clinics and hospitals. This is consistent with the National Ambulatory Medical Care Survey which gathered information on approximately 90,000 patient visits to a sample of physicians from nine medical specialty groups in the United States and found that anxiety accounted for 11% of all visits (Schurman, Kramer, & Mitchell, 1985). However, despite a large number of visits to primary care physicians and associated specialists, the search for an explanation for the symptoms of panic typically results in frustrating and costly misdiagnoses. In one study of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program, which was the first major epidemiological study to incorporate the DSM-III criteria for panic disorder, Boyd (1986) reported that in comparison with other mental disorders, panic disorder was associated with the highest number of physical and mental health visits. Panic disordered patients were also found to receive about three times more mental health treatment than those with specific phobias, alcohol dependence and drug dependence. More recently, Siegel, Jones, and Wilson (1990) found that people with panic disorder had on average seven times the number of medical visits expected for the general population. Not surprisingly, such high utilisation rates are associated with greatly increased expenditures on medical services. For example, Sheehan, Ballenger, and Jacobsen (1980) reported that in the United States 100 million dollars were spent in 1980 on health care costs and related employment losses for people with panic disorder. More recently, in the United states it has been estimated that 33 million dollars per year is spent on medical care utilisation in individuals with panic disorder (Katon, 1992) because as observed earlier by Sheehan (1982), referral to psychiatrists or other mental health professionals typically occurs late in the course of the disorder as patients remain preoccupied with their somatic symptoms which tend to override its emotional component. Delays in proper diagnosis are therefore costly both for the individual and for the health care delivery system. Siegel et al. (1990) suggested that a conservative estimate of annual charges for physician visits for people with panic disorder was $1,068 in 1990, which contrasted to $403 for physician expenditures in the general population. Support for these estimates came from Simon, Ormel, VonKorff, and Barlow (1995) who found that primary care patients with DSM-III-R anxiety or depressive disorders have health care costs which are one and a half to twice as high as for those people without a DSM-III-R diagnosis. These large cost differences were found after adjustment for medical morbidity. Salvador-Carulla, Segui, Fernandez-Cano, and Canet (1995) assessed the costs associated with panic disorder before diagnosis and after the provision of effective treatment. They included 61 people with a primary diagnosis of panic disorder who were assessed over a 24-month period. Significant improvements were found in the patients’ quality of life as indicated by a decrease in the number of panic attacks, the number of symptoms related to panic disorder, and the level of restriction due to agoraphobia. They also reported a 94% reduction in the use of nonpsychiatric health services following the provision of appropriate psychiatric or psychological care, which therefore adds weight to the case for appropriate mental health treatment for people with panic disorder as a way of reducing overall health care costs associated with this problem. Most studies have compared health care use in panic disorder with the general population rather than conducting comparisons with other anxiety disorders (e.g., Katon 1992 and Siegel et al. 1990). An exception is a recent report by Kennedy and Schwab (1997) who found that people with generalised anxiety disorder and obsessive compulsive disorder were high utilisers of primary care physicians and medical specialists, although not to the same degree as their sample of people with panic disorder. It appears therefore, that a sizeable proportion of the high medical utilisation and costs associated with panic disorder are a function of specific characteristics of this disorder itself, but it is not clear whether this is a result of the frequent experience of panic or the way in which it is interpreted. An ideal comparison condition for panic disorder is social phobia because both conditions usually involve significant experiences of panic but they are interpreted differently. For example, individuals with panic disorder are more likely to attribute their somatic symptoms to an underlying medical problem rather than anxiety as the symptoms often appear to come out of nowhere. By contrast, panic attacks experienced in the context of social phobia usually have a clearer causal pathway because they are more easily explained as a result of the social context and are therefore less likely to be misinterpreted as a medical problem. Consequently, it is likely that people with panic disorder will incur higher medical costs than people with social phobia due to basic differences in how their symptoms are interpreted. Although this makes intuitive sense, there is a paucity of studies comparing these two anxiety disordered groups in their use of the health care system. The main aim of this study was to compare the medical utilisation rates and costs for individuals with panic disorder to those of people with social phobia so as to clarify whether the high utilisation rates by panic sufferers are more likely to be related to the frequent experience of panic or to its interpretation. As well, because data on medical utilisation and costs for panic disorder have been predominantly gathered on American samples, studies are lacking which provide information about such utilisation and costs in other parts of the world. This study aimed therefore to collect Australian data bearing on this issue. The specific hypothesis tested was that people with panic disorder will report higher rates of medical utilisation and associated costs than people with social phobia.