Yujuan Choy, MD

As a result of the coronavirus pandemic (COVID-19), 2020 was a very challenging year. Concerns about contracting the infection, loss of income/employment, disruption of routines, physical 

 from friends and family, restriction of leisure activities, and school and daycare closures caused significant stress for patients and clinicians. Although the stress may not meet the diagnostic criteria for an anxiety disorder, the symptoms can affect quality of life. Tips for addressing stress and anxiety related to the pandemic can be used for other natural disasters and events (

. A major concern for many patients is contracting the virus, and sometimes the fears are based on misinformation. Empower your patients by educating them on COVID-19 transmission and epidemiology and dispelling myths. I have patients who are so fearful of getting infected that they do not want to leave their house, go to the grocery store, or conduct any essential activities. When a patient knows how to protect themselves from infection, they will less anxious. Remind them that certain precautions reduce their risk: staying 6 feet apart, wearing a face covering, keeping hands clean at all times, and not touching hands to face. If they follow these rules, they will feel less stress when leaving their homes. 

Advise patients who are highly anxious to limit screen time and news/media.The media is inundated with information that can increase a patient’s anxiety. Patients should spend the extra time on self-care activities, like taking breaks from work; engaging in physical exercises, 

, and yoga; spending time with their loved ones; listening to music; watching a good show; or reading a novel. Any activities that helps alleviate stress and gives them pleasure is recommended.

Educate patients about normal responses to stress and trauma. Normal responses can include anxiety, apprehension, disbelief, anger, insomnia, concentration problems, fatigue, and irritability. Increases in pain and other physical symptoms are also common. These stress reactions are usually transient and will likely resolve once patients adapt to the pandemic-related changes. If a patient reports stress response symptoms that do not resolve after a few weeks, or that are severe enough to cause significant distress or interfere with daily functioning, then they should be assessed for the development of adjustment disorder with anxiety, acute stress reaction, or new onset generalized anxiety disorder (GAD).

Assess treatments and adjust accordingly. Patients with underlying anxiety disorders, especially GAD, may experience exacerbation of their anxiety. If their symptoms were previously controlled by medication, consider an adjustment.

5 Tips for Treating COVID-Related Anxiety

Cautiously consider the addition of anti-anxiety medications. Patients may present and ask for medications, like 

, but alprazolam or lorazepam should not be prescribed without a thorough assessment. Since PRN benzos can take 30 minutes to an hour to work, PRN dosing is not effective in preventing a panic attack, which usually comes on within 10 minutes. It is preferable to start patients on a selective serotonin reuptake inhibitor. As recurrent panic attacks are often due to an underlying anxiety disorder or depression, it is vital to assess the patient. 

 is past president of the Orange County Psychiatric Society and a distinguished fellow of the American Psychiatric Association. ❒

Articles

Strategies for educating patients on COVID-19 transmission and epidemiology, as well as dispelling myths

Lessons Learned From Treating COVID-Related Anxiety

State medical boards restrict the practice of medicine across state lines. This paper reports on challenges faced by college psychiatrists working with college students who are temporarily out of state. The conclusions highlight the negative outcomes experienced by students from this disruption of care and lend support to a federal bill that would grant college psychiatrists a waiver to treat students in all fifty states. Such a bill would decrease treatment barriers, ensure continuity of care, and reduce poor outcomes.

There is a health crisis on university campuses across the United States. The need for mental health services for college students is staggering. The proportion of students with mental health conditions and the utilization of mental health services on campuses has continuously increased over the past decade.

of college students in the United States in the 2018 to 2019 academic year reported that 36% of students experienced depression, 31% experienced anxiety, 24% reported engaging in self-injury behavior, and 14% had suicidal thoughts.

 This translates to nearly 7 million students nationwide with mental health needs.

Many colleges and universities provide mental health services for their students on campus. However, college students are mobile, and college psychiatrists have long faced difficulties in ensuring continuity of care when students are away from school during summer and holiday breaks. This issue was amplified by the COVID-19 pandemic when students were abruptly sent home in the middle of the Spring 2020 semester. Due to federal and state regulations that mandate physicians to obtain licensure in the state where their patients are located, it has proven exceedingly difficult for college psychiatrists to meet the mental health needs of students who travel to other states. During the pandemic, licensure restrictions in most states were 

temporarily, and a law is being introduced to make licensing accommodations uniform across states.

 However,after the expiration of the temporary easing of regulations due to COVID-19, the longstanding issue of helping the mobile college population will still not be addressed. 

insurance also varies in coverage for the practice of medicine across state lines, adding to the barrier of providing treatment for out-of-state students.

To better understand the specific challenges of treating out-of-state students, an anonymous national survey of college psychiatrists was conducted. We hypothesized that college psychiatrists would face common challenges in ensuring continuity of care, and the survey results would lend support to a federal bill granting college psychiatrists a licensure waiver to treat students across state lines on a permanent basis.

A survey of 11 questions (Q) was initially developed to provide data concerning the introduction of a federal bill to address licensure regulations for college psychiatrists (scroll down for 

). Of the 11 questions, 9 were multiple choice and 2 (#10 and #11) requested respondents to provide a narrative response. Two of the multiple choice questions (#7 and #9) allowed respondents to select more than 1 choice. The survey was created using the free online version of Survey Planet (

). After review of the survey results, the authors decided to publish the results in the hope that they may garner more interest and support for advocacy efforts.

The survey was emailed to a listserv of 467 members of the 

 (APA) Caucus on College Mental Health. Members on the listserv included medical students, residents, fellows, attending-level psychiatrists, nurse practitioners, and physician’s assistants. Only attending-level psychiatrists were asked to respond to the survey. The survey was encouraged to be shared with other attending-level college psychiatrists who may not be members of the Caucus. The authors are attending-level college psychiatrists and completed the survey as well. The survey was sent on May 14th, 2020, and participants were asked to respond by May 20th, 2020. Several respondents completed the survey through May 29th, 2020, and their results were included. No identifying information of the respondents were collected.

The survey was self-determined to be eligible for Institutional Review Board exemption for existing data according to 

 Exemption status was documented and confirmed with completion of the Exempt Self-Determination Tool provided by the 

Results of the multiple choice questions were analyzed by the Survey Planet program. The qualitative data of the 2 narrative responses (#10 and #11) was analyzed by identifying unique negative outcomes or challenges noted by each respondent, and each outcome or challenge was tabulated in a frequency table. Responses that were related to 1 theme were grouped together by consensus of the authors.

A total of 85 responses were received: 82 attending psychiatrists and 3 non-attending psychiatrists. Only the results of the 82 attending psychiatrists are reported.

The majority of psychiatrists reported employment within a counseling center (n = 33, 40.2%). The rest worked with college students at a student health center (n = 24, 29.3%), the university department of psychiatry (n = 10, 12.2%), in group or private practice (n = 8, 9.8%) or other settings (n = 7, 8.5%).

Q 3: Number of states students were dispersed

Once the COVID-19 health emergency was declared, the majority of psychiatrists reported that students were dispersed to between 1 to10 states (n = 44, 53.7%). A smaller number reported that students were dispersed to 11 to 20 states (n = 18, 22%); 21 to 30 states (n = 10, 12.2 %); or more than 30 states (n = 7, 8.5%). Fewer than 4% of psychiatrists reported students were either not dispersed (n = 1) or unknown (n = 2).

In order to comply with current state regulations, the majority of psychiatrists would need to apply for 1 to 10 waivers (n = 46, 56.1%). A smaller number would need to apply for 11 to 20 waivers (n = 12, 14.6%); 21 to 30 waivers (n=6, 7.3%); and 30+ waivers (n = 2, 2.4%). Approximately 2.4% (n = 2) did not know how many waivers they would need, and 17.1% (n = 14) did not need a waiver or did not apply for a waiver because they only worked with students in state, provided limited referral services, or for other reasons.

Q 5: Delay in processing time for waivers

For psychiatrists who did apply for state waivers (n = 25), 28% (n = 7) stated that treatment was delayed due to processing time and 72% (n = 18) reported there was no delay.

During the COVID-19 pandemic, a large majority of psychiatrists (n = 72, 87.8%) reported facing the dilemma of choosing between providing psychiatric care to students across state lines without a waiver versus abandoning students. Approximately 12.2% (n = 10) reported not facing the dilemma.

Q 7: Services provided out of state during the COVID-19 pandemic

Respondents were able to select more than 1 response to this question; therefore, the total n is greater than 82. Only 3 psychiatrists stopped all communications with the students. The rest provided a range of services, and the range of services provided included referrals only (n = 14), referrals plus bridge care (n = 48), full comprehensive psychiatric care via telephone (n = 48) and/or video conferencing (n = 49). A small number (n = 2) provided other services depending on availability of state waivers.

Q 8: Students without psychiatric coverage

Approximately 18.3% (n = 15) of psychiatrists reported that over 51% of their students went without care when students were out of state. Additionally, 19.5% (n = 16) of psychiatrists reported that 26% to 50% of their students went without care, and 50% (n = 41) of psychiatrists reported that 1% to 25% of their students went without care. Approximately 12.2% (n = 10) reported no students went without care.

Q 9: Primary reason students have not received care

Respondents were able to select more than one response to this question; therefore, the total n is greater than 82. The primary reasons given for students going without care when out of state included (in order of decreasing frequency) include lack of availability of care (n = 61); financial and insurance reasons (n = 56); frequent travel preventing establishment of care (n = 41); family/community opposition (n = 38); stigma with receiving care (n = 22); and other reasons (n = 13), including the student being out of the country, lack of initiative or confusion on the part of the student, or the student deciding to stop treatment.

Q 10: Negative outcome as results of interruption of care

Negative outcomes as a result of interruption of care that were commonly cited are summarized in 

. No negative outcome was reported by 13% (n = 11), and in 18% (n = 15), responses were not applicable or unrelated.

Q 11: Challenges in providing care to students during the COVID-19 pandemic

Despite the availability of state waivers, there were many challenges in providing care to students (

). Concerns that were most frequently mentioned were related to licensing and waivers, including difficulties navigating the ever-changing, variable, and complex state requirements. Student-related factors included lack of motivation to engage in treatment, non-adherence or dropping out of treatment, students traveling state to state or out of the country, students not being aware of available resources, unsupportive family environments, and lack of insurance or financial support. 

Concerns less frequently mentioned (by less than 10% of psychiatrists) are summarized in 

 and elaborated here. Access to care issues include lack of resources and limited psychiatrists in certain locations. Barriers in prescribing out of state include difficulty with prescription of controlled substances in other states and COVID-19-related delays in pharmacy services. Obstacles in caring for complex cases out of state include concerns about hospitalizations, delay of referrals to subspecialty services, access to higher levels of care for severely ill patients, and taking care of severely depressed patients. Problems related to telehealth include connecting students to telehealth, privacy issues, and internet connectivity. Approximately 14.6% (n = 12) reported no challenges and in 12.2% (n = 10), responses were not applicable or unrelated.

The results indicate the difficulties faced by college psychiatrists in providing care to students across state lines during the pandemic. Although many states offered waivers for licensing requirements, this did not alleviate the problem. Navigating the complexity of licensing requirements from state to state was one of the most difficult challenges for psychiatrists. Nearly 90% of psychiatrists faced an ethical dilemma: risking their license and practicing without malpractice insurance coverage or abandoning their students. Our survey showed that the vast majority of psychiatrists continued to provide care via phone or video. Many also worked to connect their students to local care.

Of major concern is that 37.8% of psychiatrists reported that 

of their students went without psychiatric care and 18.3% reported that more than 51% of their students went without psychiatric care when not in school pre-COVID-19. This result indicated that continuity of care is not a new issue in college mental health. There are many barriers for students receiving care during breaks when away from school. Reasons endorsed by psychiatrists included lack of availability of care, financial and insurance reasons, frequent travel preventing establishment of care, family and community opposition, and stigma with receiving care. Although not part of the survey questions, gaps in psychiatric care are also an issue when services on campus are closed for the summer months or when campuses face staffing shortages and cannot meet the demand in service. The survey demonstrates that the inconsistency in a student’s treatment throughout college years can result in a myriad of negative consequences, including students dropping out of treatment, worsening of symptoms/relapsing, hospitalization, and experiencing suicidality. Less commonly reported negative outcomes include persistence of symptoms; needing a higher level of care; and negative financial, academic, or work consequences.

"Even though more research can be done, the need for legislative action now is clear. College students deserve continuity of psychiatric care. We need to adjust licensing and malpractice regulations so they can receive that care in the long term, not just during emergency situations."

These poor outcomes should prompt a change of licensing and malpractice regulations for college psychiatrists now that telemedicine is an available and reliable treatment modality. Congress, universities, and governmental agencies need to collaborate to provide a standardized license across state lines for college psychiatrists. There exists a precedent of the federal government intervening to ease regulations on interstate medical care. With the 

 sports medicine providers are allowed to care for their student athletes in states where the provider is not licensed as long as they maintain a license in 1 state. The Clarity Act can serve as a blueprint for future developments in the regulation of interstate treatment for college psychiatrists. Telepsychiatry has shown efficacy in general psychiatry settings and university settings.

 If state licensure restrictions were to be lifted, telepsychiatry has the potential to solve continuity of care challenges.

One limitation of the present study is the pool from which respondents were drawn. It is possible that the responses cannot be generalized to all college psychiatrists. Not all college psychiatrists are on the APA College Mental Health 

listserv. Most respondents were APA members given that this listserv was used. A review of the 3 respondents whose responses were excluded because they were not attending psychiatrists revealed that their concerns were consistent with the other responses. There may also be a selection bias in those who chose to participate in the survey.

Even though more research can be done, the need for legislative action now is clear. College students deserve continuity of psychiatric care. We need to adjust licensing and 

regulations so they can receive that care in the long term, not just during emergency situations.

The survey results highlight the challenges college psychiatrists face in the United States in ensuring continuity of care for students who are away from school. The main challenges reported during the COVID-19 pandemic include the time-consuming process of securing waivers and state licensures, complexities related to state licensure requirements, and ever-changing state laws. College psychiatrists also reported that continuity of care was an issue before the pandemic and led to significant negative outcomes. These concerns will continue to affect the treatment of mental health disorders in college students after the pandemic has abated, just as they did before the pandemic. The challenges and negative outcomes highlighted in this study lend support to a legislative solution which would grant college psychiatrists a permanent waiver to work with college students in the United States when they travel within the country.

is staff psychiatrist, Student Health Center, University of California, Irvine. 

 is chief, Psychiatric Services, Harrison Health Center, St John's College, Annapolis, MD. 

 is staff psychiatrist, Counseling and Psychological Services, and Feinberg School of Medicine, Northwestern University, Evanston, IL. 

 is senior staff psychiatrist the Ohio State University Counseling and Consultation Service, Columbus, OH. The authors report no conflicts of interest concerning the subject matter of this article.

1. Lipson SK, Lattie EG, Eisenberg D. Increased rates of mental health service utilization by U.S. college Students: 10-year population-level trends (2007-2017). 

2. Eisenberg D, Lipson SK. The Healthy Minds Study 2018-2019. 

https://healthymindsnetwork.org/wp-content/uploads/2019/09/HMS_national-2018-19.pdf

3. Federation of State Medical Boards. US States and Territories Modifying Requirements for Telehealth in Response to COVID-19. Accessed October 5, 2020. 

https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

4. Wein EH, Goodman RB, Ferrante TB. COVID-19: States waive in-state licensing, requirements for health care providers. 

https://www.natlawreview.com/article/covid-19-states-waive-state-licensing-requirements-health-care-providers

5. Equal Access to Care Act. October 5, 2020. 

https://www.cruz.senate.gov/files/documents/Bills/2020.06.17%20-%20Equal%20Access%20to%20Care%20Act.pdf

https://www.cchpca.org/telehealth-policy/malpractice

7. Office for Human Research Protections. 

Human subjects regulations decision chart.

 U.S. Department of Health and Human Services.Accessed October 5, 2020. 

https://www.hhs.gov/ohrp/regulations-and-policy/decision-charts/index.html#c5

Sports Medicine Licensure Clarity Act of 2017

https://www.congress.gov/bill/115th-congress/senate-bill/808

9. Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. 

10. Khasanshina EV, Wolfe WL, Emerson EN, Stachura ME. Counseling Center-based Tele-mental for Students at a Rural University. 

APPENDIX. Survey of College Psychiatrists

1. What is your discipline?
a)	Attending psychiatrist (MD/DO)
b)	Resident or fellow physician in training
c)	Nurse practitioner
d)	Physician’s assistant
e)	Psychologist
f)	Other mental health professional

2. In what setting do you see college students?
a)	I am employed within a University or College Counseling Center
b)	I am employed within a University or College Student Health Center
c)	I am employed in a University setting but under the Dept of Psychiatry
d)	I am in a group or private practice seeing college students
e)	I see students as a contracted consultant to a University campus
f)	Other work settings

3. Once COVID-19 health emergency was declared, the students you treated were dispersed to how many states (please approximate)?
a)	All students stayed in state
b)	Between 1-10
c)	Between 11-20
d)	Between 21-30
e)	More than 30
f)	Unknown

4. How many out-of-state temporary licenses or waivers would you need to apply for to be in compliance with current regulations?
a)	None - did not need waiver (only treated students in state)
b)	None - did not apply but provided limited referral services
c)	Would need to apply for 1-10 state waivers
d)	Would need to apply for 11-20 state waivers
e)	Would need to apply for 21-30 state waivers
f)	Would need to apply for 30+ waivers
g)	Other

5. If you applied for a state waiver, was treatment delayed due to processing time?
a)	Yes
b)	No
c)	Not applicable

6. Did you face the dilemma of choosing between providing psychiatric care to students across state lines without a waiver versus abandoning them?
a)	Yes
b)	No

7. What types of services are you providing to students across state lines? (Select all that apply)
a)	No service at all (stop all communication once students leave state)
b)	Limited service - provide referrals
c)	Limited service - provide referrals and bridge care until students connected with local providers
d)	Provide psychiatric services via telephone
e)	Provide telepsychiatry service via video conferencing
f)	Other

8. Prior to COVID-19, what percentage of your students go without psychiatric coverage during the summer months and on breaks while they are not on campus and out of state?
a)	0%
b)	1-25%
c)	26-50%
d)	51-75%
e)	76-100%

9. Prior to COVID-19, what are the primary reasons that your students have not gotten care while in another state? (Select all that apply)
a)	Lack of availability of care
b)	Stigma with receiving care
c)	Financial and insurance reasons
d)	Family/community opposition
e)	Frequent travel preventing establishment of care
f)	Other

10. If there were negative outcomes during those breaks due to lack of care (eg, safety/medical/hospitalization, worsening of symptoms) please describe below the negative outcomes and number of cases you recall. Please do not include any identifying information. [Essay]

11. Did you experience any specific challenges in following-up with students’ care during COVID-19 pandemic despite availability of state waivers? Please do not include any identifying information. [Essay]


The pandemic has brought into focus treatment barriers, disruption in care, and possibly negative outcomes in the mental health of university students. To better understand the specific challenges of out-of-state students, the authors conducted an anonymous national survey of college psychiatrists.

Treatment Challenges for College Psychiatrists and Their Patients

Slideshows

A constellation of factors contributes to heightened anxiety symptoms associated with the pandemic. The author offers simple steps to help patients alleviate stress.

Yujuan Choy, MD, Chief Psychiatrist at UC Irvine Counseling Center, provides tips for working with patients whose anxiety symptoms disrupt their quality of life.

Dr Choy is past president of the Orange County Psychiatric Society and a distinguished fellow of the American Psychiatric Association. Website: 

Filling Telehealth Gaps in College Mental Health

Videos

Working With Patients With Heightened Anxiety During COVID-19

I have been a campus psychiatrist for 14 years. In the pre-COVID-19 era, when a student left campus during breaks or graduated and moved to a different state, I always had time to find local psychiatric resources for the student or connect the student with his or her primary care physician. There was rarely a need to choose between patient safety and my own medical licensure.

In the wake of the COVID-19 pandemic, however, the luxury of time and planning went out the door. Within days, students had scattered from campus to locations around the country, and their psychiatric and mental health care was interrupted at a time when they needed support more than ever.

Our counseling center immediately converted all services to telehealth, so that students could continue to receive treatment remotely. However, since physicians need to hold medical licenses in states where their patients are located, out-of-state students could not and cannot take advantage of telehealth services. Many in my profession must now choose between abandoning patients or practicing illegally across state lines.

Many state medical boards have loosened restrictions so that physicians can practice across state lines in a limited capacity during the COVID-19 health emergency. As of April 15, 2020, 44 states had waived telehealth licensure requirements, and the list grows every day (

However, such decisions are not universal or standardized, making it time-consuming and difficult for physicians to decipher the executive orders and latest regulations of each state. Furthermore, it is not clear if these exceptions apply to routine psychiatric care of college students.

Federal law allows Veterans Administration psychiatrists to work with veterans nationwide without concern about crossing state lines. There should be similar federal and state laws and malpractice insurance to protect campus psychiatrists who provide telehealth services to out-of-state students.

One proposal is to create a special telepsychiatry license allowing campus psychiatrists to work with students enrolled in their universities, regardless of where the students are located. This proposal is worth considering for the following reasons:

 of college students in the 2018-2019 academic year reported that 36% of students experienced depression, 31% experienced anxiety, 24% reported engaging in self-injury behavior, and 14% had suicidal thoughts. This translates to nearly 7 million students nationwide that have significant mental health treatment needs.

• Many students have limited access to psychiatric services in their hometowns. The wait for an appointment at the local mental health clinic can be months, and due to the COVID-19 pandemic, a clinic told one of my students that neither in-person appointments nor telehealth services were available. Other significant barriers to care can include out of pocket costs, insufficient insurance coverage, lack of governmental funding, and a lack of psychiatrists in rural areas. Our college students, however, are seen at no cost because services are covered by school registration fees.

• Students who have suffered from mental illness for many years often wait until they get to college to seek treatment for the first time. They report having delayed treatment due to limited prior healthcare coverage, lack of access to a psychiatrist in their hometown, fear of the stigma of seeking care, and in rare cases, a need to keep treatment from their family. Even as we face the COVID-19 pandemic, colleges should remain places where students feel safe and comfortable seeking mental health care.

• Psychiatrists embedded in a university setting understand the unique needs of the student population. They are familiar with a university’s policies and procedures, and are aware of its resources regarding finances, academics, housing, and disability services. Campus psychiatrists who provide services to students even off-campus can help those students achieve academic success.

• Working with college students often requires family involvement. Receiving a diagnosis of severe mental illness, such as first-onset psychosis or bipolar disorder, can be a traumatic experience for a student and his or her family, and how the family handles the student’s disorder can strongly impact the success of treatment. I have spent countless hours in family meetings over the years, making sure that families understand the ramifications of a student’s diagnosis and how they can support him or her.

Campus psychiatrists are in a unique position to treat mental illness in young adults. I look forward to the day when I can provide treatment without worrying about getting sued for abandonment or for practicing across state lines.

Chief Psychiatrist at the counseling center at the University of California, Irvine, past president of the Orange County Psychiatric Society, and a distinguished fellow of the American Psychiatric Association. Website: 

Within days of the COVID-19 pandemic, students scattered from campus to locations around the country, and their psychiatric care was interrupted at a time when they needed support more than ever.

Panic disorder with or without agoraphobia is a chronic, debilitating psychiatric illness that affects about 4.7% of the general US population.

 report that close to one third of the general population has met criteria for panic disorder within the past year.

 The mean age at onset is in one's 20s, and women are twice as likely as men to present with panic disorder.

Panic disorder is associated with poor quality of life

 and with substantial and moderately severe functional impairment in 45% and 30% of persons, respectively.

 Many patients have at least one other psychiatric diagnosis, most commonly substance use disorder, mood disorder, or another anxiety disorder.

 Panic disorder is associated with a 2-fold increased risk of coronary heart disease

 and frequent use of emergency and medical services.

Despite its chronic nature and severity of illness, many patients do not receive therapy that meets standard treatment guidelines.

 In the primary care setting, only 22% of patients with panic disorder receive adequate medication and only12% receive adequate psychotherapy.

 The purpose of this brief report is to increase the awareness of evidence-based treatments for panic disorder.	

Patients should be thoroughly evaluated to eliminate any conditions that may mimic symptoms of panic disorder, including medical illnesses (eg, cardiac, respiratory, or thyroid diseases) and substance use (eg, marijuana, cocaine, methamphetamines). One of the core symptoms of panic disorder is recurrent, unexpected panic attacks. A full-symptom panic attack requires the abrupt onset of at least 4 physical symptoms (eg, palpitations or dizziness) or cognitive symptoms (eg, fear of going crazy or losing control) that reach a peak within 10 minutes. Another core feature is anticipatory anxiety about future panic attacks or the implications of these attacks. This often leads to agoraphobia in which the person avoids situations where escape or help is not readily available if a panic attack occurs. Thus, expected, or cued, panic attacks can be triggered by the anticipation or presence of a phobic situation.

Panic attacks and phobic avoidance are also present in other anxiety disorders, and examining the focus of the patient's fear helps in the differential diagnosis. According to the cognitive model of panic disorder, panic attacks are the result of catastrophic misappraisals of bodily sensations.

 The focus of fear is the perceived harmful consequence of panicking (eg, losing control, going crazy, and so forth) and the associated physical sensations (eg, having a heart attack or stroke)

 In other anxiety disorders, the fear is not of the panic attacks themselves. In generalized anxiety disorder, for example, panic attacks are the exacerbation of persistent worries and anxiety about daily life events and the anticipation of future bad events. Panic attacks in social anxiety disorder are limited to the anticipation or presence of social or performance situations caused by fear of embarrassment or humiliation. Panic attacks in posttraumatic stress disorder are triggered by reminders of the traumatic event. In specific phobia, the focus of fear is often the perceived danger of the object or situation.

Cognitive-behavioral therapy (CBT) and pharmacotherapy are among the empirically supported treatments for panic disorder.

Defining treatment response and remission

Treatment response is usually defined by a "panic-free" status that is the absence of full-symptom panic attacks. Other measures include clinician's ratings of overall improvement and severity on the Clinical Global Impression (CGI) scale

 and changes in panic symptoms in the Panic Disorder Severity Scale (PDSS).

 Remission has been defined in one of several ways. The international consensus group considers remission as the complete resolution of symptoms for at least 3 months.

 However, most pharmacotherapy studies have defined remission by using a combination of panic-free status and improved CGI and/or PDSS scores. CBT trials have focused on rates of "clinically significant improvement," such as achieving high end-state functioning

 or meeting the criteria developed by Jacobson and colleagues.

Treatment components of CBT include education, breathing retraining, cognitive restructuring, interoceptive exposure, and in vivoexposure.

 Education helps establish treatment alliance and teach key concepts, including the course of panic disorder, the nature of panic attacks, behaviors that maintain the panic cycle, the cognitive model, and the treatment rationale. Breathing retraining was initially thought to reduce physical symptoms of panic, but it was later conceptualized as a way to demonstrate how hyperventilation can exacerbate physical symptoms.

The goal of cognitive restructuring is to identify and challenge anxious thoughts regarding a panic attack. In interoceptive exposure, patients perform various exercises (eg, hyperventilation, spinning in a chair) in a controlled setting in order to repeatedly confront anxiety-provoking physical symptoms. With exposure, patients learn that symptoms are not as dangerous as originally perceived. In vivo exposure traditionally has been used in the treatment of agoraphobia. During in vivo exposure, patients confront the actual phobic situation, such as traveling alone or being in an airplane or elevator. These treatment components are based on 2 CBT approaches to panic disorder: panic control treatment (PCT) developed by Barlow and colleagues,

 which introduced interoceptive exposure as a key element; and the cognitive therapy (CT) program  developed by Clark,

 which emphasized cognitive restructuring.

In the first controlled trial of PCT (N = 56), 3 active treatments-PCT, muscle relaxation, and PCT plus muscle relaxation-were compared with wait-list controls.

 PCT outperformed the other treatment conditions. Approximately 87% of patients in the PCT groups, 60% of patients who received muscle relaxation, and 36% of controls were panic-free at the end of their respective treatments. There was a greater distinction when patients who had dropped out were included in the analysis: 74% to 79% of PCT patients, 40% of patients who received muscle relaxation, and 33% of controls were panic-free. However, only 46% of patients who were treated with PCT achieved high-end functioning, despite the high panic-free status associated with this group. This suggests that many patients were still symptomatic at the end of treatment.

A controlled study of 2 versions of CT (N = 42) showed favorable results. A full 12-session and a brief 5-session course of CT were compared with wait-list controls.

 A greater proportion of patients who received CT had panic-free status relative to controls; 79% in the 12-session CT group, 71% in the 5-session CT group, and 8% in the control group had panic-free status. Thus, the investigators concluded that brief intervention was as effective as full 12-session treatment.

Other randomized controlled studies have confirmed the efficacy of CBT for panic disorder, with findings of panic-free status achieved in approximately 70% to 90% of patients.

 Rates of clinically significant improvement were found to be  38% to 79%, depending on the criteria used.

Dismantling studies have attempted to determine which treatment component is the "active" ingredient or  the most effective intervention. With the exception of breathing retraining, which was not shown to be helpful and may possibly increase the risk of relapse,

 the other 3 main interventions-cognitive restructuring, interoceptive exposure, and in vivoexposure-have been shown to be equally effective.

Several classes of psychotropics have been shown to be effective and have comparable efficacy in the treatment of panic disorder, including tricyclic antidepressants (TCAs), benzodiazepines, and SSRIs.

 SSRIs are now considered first-line pharmacotherapy because of a more favorable adverse-effect profile than with TCAs

 and less concern for withdrawal and dependence than with benzodiazepines.

 Based on clinical practice, SSRIs are generally started at one half to one third of the typical starting dose for depression to limit the adverse effects of jitteriness and anxiety.

 Benzodiazepines are better tolerated than antidepressants and may help with adverse effects.

 presents common adverse effects and suggested dosages.

On average, 55% to 60% of patients treated with pharmacotherapy achieve panic-free status.

 Efficacy data are most extensive for imipramine, fluvoxamine, paroxetine, and alprazolam. There is relatively less controlled data for monoamine oxidase inhibitors, the newer SSRI escitalopram, and the serotonin-norepinephrine reuptake inhibitor venlafaxine. Studies have shown either minimal or modest efficacy for the newer drugs.

A recent placebo-controlled trial compared the efficacy of venlafaxine extended release (ER) with that of paroxetine.

 Venlafaxine ER and paroxetine achieved a greater panic-free status compared with placebo (70%, 58%, and 48%, respectively). Venlafaxine ER also resulted in greater improvement than paroxetine in the PDSS scale. Based on CGI-improvement responders, active treatments resulted in a response rate of 80% to 85%, compared with a placebo response of 60%.

In addition to monotherapy, there is some evidence that combining an antidepressant with a benzodiazepine may facilitate early treatment response. For example, one study randomized patients (N = 50) to clonazepam or placebo during the initial 4 weeks of treatment with sertraline.

 Compared with sertraline alone, combination treatment resulted in a greater reduction of panic symptoms. Treatment gains were maintained even after clonazepam was discontinued.

Remission rates in pharmacotherapy trials are infrequently reported. A retrospective analysis of paroxetine studies found a rate of 24.6% to 35.5%, depending on the definition of remission.

 Remission was achieved in 50% of patients treated with venlafaxine ER based on CGI severity score.

 These rates are probably an overestimation of true remission, because the more stringent definition proposed by the international consensus group was not used.

A large (N = 312) randomized, placebo-controlled, head-to-head comparison trial examined the efficacy of monotherapy (CBT alone or imipramine alone) with combination treatment (CBT and imipramine).

 All active treatments were superior to placebo during the acute treatment phase, but imipramine produced a higher quality of response than CBT. During maintenance, combination treatment fared better than monotherapy. However, imipramine appeared to decrease the long-term efficacy of CBT.

Once treatment was discontinued, patients treated with medication (alone or with CBT) were more vulnerable to relapse than those treated with CBT alone. One possible reason may be that medication was discontinued too rapidly (over 1 to 2 weeks). Based on this study, all 3 treatment modalities are effective for acute stabilization. Medication is helpful if a more potent response is desired, but the long-term effects of medication are limited. Discontinuation of medication over a longer period may reduce the chance of relapse. CBT alone is better tolerated and has a more lasting effect. 

In addition to treatment efficacy, other factors should be considered when recommending treatment, including patient preference, treatment history, severity of illness, and presence of comorbid disorders. 

 summarizes the advantages and disadvantages of the different treatment modalities.

Acute treatment with medication should be at least 8 to 12 weeks' duration to ensure optimal response. CBT treatment can range from 8 to 12 weekly sessions. Most maintenance studies lasting 6 months to 1 year have largely found that gains achieved during acute treatment with CBT or pharmacotherapy are either sustained or improved during the maintenance phase.

 However, one naturalistic long-term, follow-up study reported that survival probability decreased over time even with continued treatment, from 87% at 1 year to 64% at 4 years following a 3-year maintenance period.

Relapse is common on medication discontinuation, with the highest rates (up to 88%) reported for benzodiaz-epines

 and the lowest rates (15% to 30%) for SSRIs.

 The American Psychiatric Association guidelines recommend that treatment be maintained for at least 1 year,

 and the international consensus group recommends 1 to 2 years.

 Subsequent to these guidelines, a series of controlled discontinuation studies suggest that the length of maintenance treatment is not predictive of relapse. For example, the relapse rate (37%) within 1 year of medication discontinuation was the same after 6 months or 18 months of maintenance with imipramine.

 In an SSRI discontinuation study, relapse rates within 1 year of discontinuation did not differ between those who received treatment over 1 or 2 years with paroxetine (18% vs 15%).

 Similarly, another study found a high relapse rate (46% within 1 year of discontinuation) even after 3 years of maintenance treatment in a select group of moderately healthy patients.

Given that a longer length of maintenance treatment does not seem to protect against relapse, medication discontinuation can be considered 6 months after full and sustained remission is obtained. Discontinuation should be conducted slowly over 2 to 6 months.

 Clinicians should prepare patients for what to expect following discontinuation so that treatment can be reinstituted promptly should relapse occur. Patients should also be advised to consider adjunctive CBT to optimize their chance of maintaining improvement after medication discontinuation. There is extensive evidence that CBT reduces the chance of relapse after medication discontinuation.

 One study also showed that brief psychodynamic psychotherapy reduces the incidence of relapse.

 Treatment should be continued in patients with significant residual anxiety or depressive symptoms, because premature medication discontinuation in these patients is less successful.

 Treatment should also be continued in patients with a history of relapse after discontinuation, in those with significant comorbidities, and in those with current severe life stressors.

A substantial number of patients do not completely recover from panic disorder with either CBT or pharmaco-therapy; in fact, only 25% to 45% of treated patients are considered to be in remission.

The reasons for failure to respond to CBT have not been adequately studied.

 In a group of patients who received in vivo exposure, those who were treatment resistant (n = 21) were younger, more likely to be male and unmarried, and had a longer duration of illness, greater baseline depression, and poorer adherence to exposure homework than those who were successfully treated (n = 81).

A limited number of studies suggest that the addition of medication or prolonged treatment with CBT may help patients who do not respond to CBT. An early, small study (N = 18) found that augmentation with clomipramine resulted in significant but modest improvement in patients who failed exposure therapy.

In a later study with SSRIs, patients who did not adequately respond to CBT (n = 43) were given additional CBT with or without paroxetine.

 Adjunctive paroxetine improved 3 of 7 outcome measures, including agoraphobic symptoms and anxiety discomfort. A greater proportion of patients in the CBT plus paroxetine group were panic-free compared with the CBT alone group (74% vs 47%), but this finding was not statistically significant. On the other hand, one study of 21 patients who were treatment-resistant suggested that prolonged (at least an additional 8 weeks) exposure to treatment alone can achieve a greater chance of panic-free status than augmentation with either imipramine or cognitive therapy.

 However, imipramine was not given a fair trial since many of the patients (6 of the 14) could not tolerate imipramine, and the medication had to be discontinued prematurely.

One of the most common reasons for drug treatment failures is inadequate dose and/or duration of treatment. True treatment resistance is found in only 24% of adequate medication trials.