Yujuan Choy, MD

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

5 Tips for Treating COVID-Related Anxiety

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

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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: 

Articles

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.

 Thus, it is important to first optimize treatment by ensuring an adequate trial of medication. This may require improving tolerability by initiating treatment at low doses and aggressively managing adverse effects. For treatment-refractory situations, one strategy is to augment treatment with psychotherapy.

Three small open trials have shown that CBT can reduce panic symptoms in patients who are not responding. In the first study, patients (N = 15) who had an incomplete response to pharmacotherapy were given 12 weeks of group CBT treatment.

 These patients reported a decrease in  panic frequency and improved global functioning. There also appeared to be a greater response to CBT in those who received an inadequate trial of medication compared with those who were treatment refractory.

A later study (N = 24) by the same group of researchers confirmed that CBT was an effective strategy in patients who were not responding to medication, but there was no significant difference in response between those who received an adequate trial and those who received an inadequate trial of medication.

 However, there was a greater effect size for those who were adequately treated relative to those who were in the inadequately treated sample. Approximately 60% of the adequately treated sample responded to treatment and had lower PDSS scores compared with 43% of the inadequately treated sample.

In addition, researchers in Brazil found CBT reduced panic symptoms in patients (N = 71) who were resistant to an adequate trial of SSRI, with gains maintained at 1-year follow-up. A little over 80% of patients were panic-free after CBT, and medication use decreased over time. In addition, the presence of baseline comorbid dysthymia, social anxiety disorder, and generalized anxiety disorder predicted worse outcomes.

Most recently, a short-term, panic-focused psychodynamic psychotherapy has been shown to be effective in the treatment of panic disorder.

 Psychodynamic psychotherapy reduced the severity of panic symptoms compared with applied relaxation. The response rate was 73% for psychodynamic therapy versus 39% for applied relaxation in the intent-to-treat group. However, this difference was no longer significant when comparing only the patients who completed treatment. Although there are no augmentation studies with psychodynamic psychotherapy, it may be a good alternative for those who cannot tolerate medication or who do not respond to CBT.

Another strategy for patients who do not respond to pharmacotherapy is to switch to another medication that has proved effective for panic disorder, be it an SSRI, venlafaxine ER, a TCA, a benzodiazepine, or a combination of antidepressant and benzodiazepine. However, these strategies are largely based on clinical practice.

 The efficacy of switching from one antidepressant to another has not been examined in any controlled studies. There are also limited studies on combination pharmacotherapy for patients who are treatment refractory. Although b-blockers are not generally used in panic disorder, one controlled study (N = 25) looked at augmentation with pindolol versus augmentation with placebo in patients who did not respond to fluoxetine.

 Compared with placebo, the addition of pindolol decreased overall anxiety, but the panic-free rates were not reported. Treatment with fluoxetine was also not optimized in this study because 20 mg was the maximum dose. A clinical trial is under way at Massachusetts General Hospital in Boston to determine whether the addition of clonazepam or CBT would benefit patients who did not respond to sertraline (clinicaltrials.gov: NCT00118417).	

In patients who do not respond even after switching to a different medication or the addition of adjunctive treatment, clinicians should consider the presence of comorbid conditions, such as personality disorder, mood disorder, substance abuse, or another anxiety disorder that may complicate the treatment of panic disorder. The 

 presents a suggested treatment algorithm.

Panic disorder is a chronic, debilitating psychiatric illness that should be recognized and adequately treated with CBT, SSRIs, or a combination of both. Combination treatment is effective in the short term but may not confer any additional benefits compared with CBT alone in the long term. Most recently, psychodynamic psychotherapy and venlafaxine ER have also been shown to be effective. During acute treatment, both dosage and duration of medication should be optimized to maximize the chance of recovery. Patients should be given medication for at least 6 months after they have achieved full sustained remission. Relapse is common after medication discontinuation, and measures to decrease the chance of relapse include slow discontinuation of medication and the addition of CBT. Switching medications or adjunctive CBT or SSRI may help with patients who do not respond to monotherapy.	

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Gomez-Caminero A, Blumentals WA, Russo LJ, et al. Does panic disorder increase the risk of coronary heart disease? A cohort study of a national managed care database. 

Zane RD, McAfee AT, Sherburne S, et al. Panic disorder and emergency services utilization. 

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Shear MK, Clark D, Feske U. The road to recovery in panic disorder: response, remission, and relapse. 

Author | Yujuan Choy, MD

Articles

5 Tips for Treating COVID-Related Anxiety

Working With Patients With Heightened Anxiety During COVID-19

Filling Telehealth Gaps in College Mental Health

Treatment Planning for Panic Disorder