Where Do Panic Attack Sufferers Seek Care? David A. Katerndahl, MD, MA, and Janet P. Realini, MD, MPH Sun Antonio, Texas Background. Although 40% of people with panic attacks 26% of subjects used mental health settings. The family never seek care for their attacks, those who do may use physician’s office was the most frequent site of presenta­ medical settings or mental health settings, or both. The tion (35%), followed by a hospital emergency depart­ purpose of this study was to examine where people seek ment (32%). Only 13% of subjects sought care from a care for their panic attacks within and outside the health site outside the health care system. Variables predicting care system, and to determine what variables predict the presentation to specific health care sites varied. Subject choice of a given site. demographics, panic characteristics, and symptom per­ ceptions were generally significant factors in care-seek­ Methods. The Panic Attack Care-Seeking Threshold ing. Illness behaviors, readiness for sick role, health lo­ (PACT) study is a community-based survey of 97 sub­ cus of control, and family measures failed to predict the jects meeting the Diagnostic and Statistical Manual of seeking of care specific to any particular site. Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for panic attacks. A structured interview was Conclusions. When subjects with panic attacks seek care, used to collect information about panic attacks, family they most commonly present to a general or family phy­ characteristics, psychiatric comorbidity, health care ac­ sician’s office or a hospital emergency department. cess and utilization, illness attitudes and behaviors, qual­ Key words. Panic disorder; delivery of health care; health ity of life, and symptom perceptions. care utilization; family practice; primary health care; Results. Forty-nine percent of the subjects seeking care emergency medical services; emergency service, hospital; for panic attacks presented to medical settings, whereas care-seeking. ( / Fam Pract 1995; 40:237-243) Panic attacks are common among the general population The National Institute of Mental Health (NIMH) and can be interpreted as either medical or psychological recently implemented the Panic Disorder Education Pro­ events by those experiencing them.1’2 Even when attacks gram to inform the public about panic disorder, to en­ occur less frequently than required for the diagnosis of courage panic sufferers to seek treatment, and to educate panic disorder (four times in 4 weeks),3 they are associ­ health care providers about the disorder.9 This campaign ated with disabling complications: depression,4 suicide,5 may substantially increase the frequency with which peo­ substance abuse,6 and agoraphobia.4 Although about ple seek care for panic attacks as well as improve physician 40% of people who experience panic attacks never seek recognition of the presenting symptoms of panic disor­ health care for this problem,7-8 when they do seek care, it der. A better understanding of where people seek care for may be from medical settings or mental health settings, or their panic attacks is important to the anticipation of the both. Panic sufferers also may seek care from sources out­ current and future demand for services and the prepara­ side the conventional health care system, such as from the tion of providers working in relevant settings to accurately clergy or a folk healer. recognize and effectively treat this problem. Most of the information concerning how people who have panic attacks use the health care system comes Submitted, revised, November 15, 1994. from studies that ask about seeking care for broad reasons, trm the Department o f Family Practice, University o f Texas Health Science Center ie, for “emotional problems” or for “any reason.”10-11 ut San Antonio. Requests for replants should be addressed to David A. Katerndahl, Little is known about where people seek care specifically blD, Department of Family Practice, University of Texas Health Science Center, 1703 Floyd Curl Dr, San Antonio, TX 78284-7795. for panic symptoms. Even less is known about factors that 6 1995 Appleton & Lange ISSN 0094-3509 The Journal of Family Practice, Vol. 40, No. 3(Mar), 1995 237 Where Do Panic Attack Sufferers Seek Care? Katerndahl and Realhi might influence the choice of sites within the health care Control21; Ways of Coping Checklist22; Appraisal Dimen­ system. Such factors might include symptom type and sions Scale23; Cuellar Acculturation Scale24; Family In- j severity of attacks, perceptions and interpretations of ventory of Life Events and Changes25; Family Adaptabil­ symptoms, attitudes about illness, coexisting mental dis­ ity and Cohesion Evaluation Scales26; and Duke Social orders, family functioning, access to health care, and de­ Support and Stress Scale.27 mographic characteristics. An understanding of the char­ The interview instruments identified where and how acteristics that predict the specific sites from which panic often subjects presented for care. Additional instruments; sufferers seek care can help us understand the process of assessed potential factors in the person’s decision-makin; choosing a care site. Delineating the factors that influence process, including symptom perceptions, quality of life the decision about where to seek care also can improve the psychiatric comorbidity, personality, panic characteristics, ability of providers in specific settings to recognize pa­ and access to care. tients who present to them with panic attacks. Symptom severity was measured on a scale based on j The purpose of this study was to examine where the Acute Panic Inventory. Total attack severity was the people seek care for their panic attacks within and outside summation of the individual symptom severity.15 Individ­ the health care system, and to determine the number of uals’ perceptions of the significance of each symptom ! different sites used and the factors predicting a particular were rated on a 0- to 7-point scale. Twelve panic-related j choice among the various sites. The data used were col­ symptoms (eg, chest pain) and 12 randomly selected non­ lected in the Panic Attack Care-Seeking Threshold panic symptoms (eg, sore throat) were rated in five areas: (PACT) study,7 which investigated determinants of care­ the degree to which the symptom (1) needs treatment,. seeking behavior among a community-based sample of (2) is life-threatening, (3) is considered severe, (4) is em- I adults who had experienced panic attacks. barrassing, and (5) interferes with functioning.17 The nonpanic symptoms were included to assess subjects’ per ception of symptoms in general, in addition to their per­ Methods ceptions of the panic-related symptoms. The responses | concerning these 12 nonpanic symptom perceptions were The PACT study was conducted in San Antonio, Texas, combined and analyzed to reflect subjects’ general symp-1 from August 1989 to April 1990. The sampling proce­ tom perceptions. dure has been described in detail previously.12 House­ Subjects were considered to have sought care from holds from 18 census tracts were selected at intervals of the health care system if they reported seeking care for | eight beginning from a randomly selected intersection. their panic attacks from either medical settings (hospital Within each household, an adult >18 years old was ran­ emergency department, minor emergency center, medical domly selected by the Kish method13 and screened for clinic, physician’s office, or ambulance) or mental health I panic attacks using the Structured Clinical Interview of settings (psychiatrist, psychologist, social worker, thera­ the DSM-III.14 pist, or mental health clinic). It was also determined Individuals who met the criteria for any occurrence whether subjects had sought care from sources outside of panic attacks (spontaneous attacks with at least four the conventional health care system, including the useol panic-related symptoms peaking within 10 minutes of a telephone help line, chiropractor, folk healer, or clergy. onset) completed an in-depth structured interview that Statistical analysis required a significance level of .05. | was conducted by using the following instruments: the Based on a medium effect size, the statistical power was j Structured Clinical Interview of the DSM-III (sections on 68% to 84%, depending upon the test used. UnivariaR major depressive episode, substance abuse, obsessive- analyses by chi-square and t test identified variables thai compulsive disorder, simple phobia, social phobia, and were significant in the choice of specific care sites. These generalized anxiety disorder)14; Acute Panic Inventory significant variables were then included in stepwise logis­ (modified)15; Symptom Checklist-9016; Quality of Life tic regressions modeling predictors for seeking care for Questionnaire*; Health Care Access and Utilization the purpose of identifying independent predictors. Questionnaire*; Symptom Perception Scales (modi­ fied)17; Illness Behavior Questionnaire18; Illness Attitude Scales19; Readiness for Sick Role Index20; Health Locus of Results O f the 1683 persons contacted, 1266 (75%) agreed to b. *The Qiiality of Life Questionnaire and the Health Care Access and Utilization screened. Panic attacks occurred in 119 (9%); 97 (82' Questionnaire were developed for the Panic Attack Care-Seeking Threshold study, reported on in 1993. agreed to the in-depth interview. 238 The Journal of Family Practice, Vol. 40, No. 3(Mar), 1$ Where Do Panic Attack Sufferers