Panic disorder ranks among one of the most debilitating and costly anxiety disorders in the country and is accompanied by a host of distressing physical and psychological symptoms. Consequences of panic include medication and substance abuse/dependence, social and emotional dysfunction, vocational problems, and increased social withdrawal. Research indicates that many U.S. military personnel returning from Iraq and Afghanistan do not seek treatment because of time and financial constraints, inability to access immediate care (particularly those living in rural areas), and stigma associated with mental illness. Unfortunately, standard psychosocial treatments for anxiety disorders require multiple appointments and usually occur during the week when most people are in school or at work, which further contributes to the underutilization of services.
The current project examined the feasibility of implementing an intensive treatment for returning service members with panic disorder in three rural outpatient clinics. The specific aims were to (1) conduct focus groups with stakeholders to identify potential barriers associated with offering the treatment at each clinic; (2) Adapt the treatment to fit within existing program structures based on information obtained; and (3) pilot the adapted treatment by offering it over a single weekend at each of the three sites.
Three focus groups were conducted with administrators, providers, and patients at three community based outpatient clinics that serve Veterans living in rural areas. The interviews focused on gathering information regarding the feasibility of offering an intensive two-day treatment at their facilities, which were used to adapt the existing treatment protocol. The brief evidence-based intervention consisted of two, 6-hour days of treatment and was offered once at each site. A total of 12 Veterans were enrolled across the three sites, consisting of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with a current diagnosis of panic disorder. Persons with substance dependence, psychosis, bipolar disorder and severe depression were excluded from the study. Assessments were conducted over the telephone one-week before and after treatment, and included a 3-month follow-up. Effect sizes for the primary outcome variables (frequency and fear of panic attacks) and secondary outcomes (depression, anxiety) are reported. Treatment satisfaction was also evaluated.
Data obtained from the focus groups indicated strong enthusiasm for a brief but intensive treatment to help Veterans with panic disorder. From the perspective of administrators and providers, the primary barrier to delivering this type of treatment at community based outpatient clinics (CBOCs) was the ability to reserve a group room large enough in which to conduct the treatment. Also, due to concerns about patient safety and logistics, the treatment was not delivered over a weekend, but over two week days, when clerical staff and security were present. Veterans from the focus groups were excited to learn about a new behavioral treatment that could help them with their anxiety. They particularly liked the intensive format, stating that it was similar to military training exercises, such as weekend drills. Veterans were also very receptive to the idea of attending a workshop with a small group of their peers.
A total of 12 returning (OEF/OIF) Veterans were enrolled in this study across the three CBOCs. Of these, 9 initiated treatment and 6 completed the program. The 3 individuals who dropped out of the treatment were unable to attend the second day because 2 reported transportation issues and one Veteran indicated he had a family emergency. All three of these individuals expressed a desire to attend this program at a future date. Given the small sample size of treatment completers, Cohen's d effect sizes are reported for primary and secondary outcomes. The primary outcome variable was panic frequency and fear. A medium effect size (d=0.47) was found for panic frequency from pre-treatment to a 1-week post-treatment, with the average number of panic attacks decreasing from 6.3 at pre-treatment to 3.8 at post-treatment. These results maintained at a 3-month follow-up. A large effect size (d=1.31) was found for fear of panic before and after treatment, with fear ratings decreasing from 6.88 to 4.23, respectively. Moderate-to-large effect sizes were found on secondary outcomes measures of general depression (d=0.63) and anxiety (d=2.15). Follow-up data indicated that general anxiety increased close to pre-treatment levels, but general depression remained improved.
Veterans reported strong satisfaction with the intensive treatment format, reporting an average score of 29.5 (scores on this measure range from 8 - 32) on the Client Satisfaction Questionnaire, a brief measure that assesses participant satisfaction with a treatment program. Higher scores on this measure indicate greater treatment satisfaction. Veterans also indicated that they found the intensive treatment program to be highly acceptable, reporting an average score of 36.4 (out of a possible score of 45) on the Treatment Evaluation Inventory, a measure of general acceptability and satisfaction with treatment received.
This study explored an innovative method of delivering cognitive-behavioral treatment for recently returning Veterans who have panic disorder and live in rural communities. The potential impact of this study is high, as a brief and intensive weekend intervention for anxiety overcomes many help-seeking barriers inherent in conventional psychosocial treatment approaches currently offered in most VA settings. A highly concentrated intensive two-day intervention directly addresses the geographical, temporal, financial, and cultural dimensions of access to care. Based on preliminary findings, Veterans not only benefited from the treatment, but reported high levels of satisfaction with the intervention. Implications of findings from this study show that this type of treatment delivery method can potentially benefit the health care delivery system. Providing evidence-based treatments in a brief group format maximizes health-service resources.
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Grant Number: I01HX000353-01
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