Chest pain and panic disorder in the ED: one of the authors responds to Epstein's letter

Letters

CJEM 2003;5(6):380

To the Editor: In our recent article¹ we did not intend to target or blame ANY particular group of physicians for failure to recognize panic disorder (PD).² Our hope was to increase awareness of this problem and to promote better integration of health care services to our community. We agree that, given repeated exposures to their patients, family physicians (FPs) have a greater opportunity than emergency physicians to diagnose PD. It is our belief that FPs are doing an increasingly better job at diagnosing and treating anxiety and mood disorders; however, in these times of outrageous FP shortages, it is a mistake to assume that most or all patients have a family doctor.

There are several reasons why patients with PD end up in the emergency department (ED), and one of them is the difficulty in seeing a family doctor. In addition, panic attacks are dramatic and composed mainly of physical symptoms -- especially cardiovascular symptoms. The role of the ED physician is not only to rule out deadly illness, but to arrive at a comprehensive differential diagnosis and adequate referral. The diagnosis of PD should be included in the diagnostic algorithm of chest pain.

We sympathize with ED physicians: they are overburdened because the rest of the system is. Yet ED doctors are often confronted by patients with PD -- perhaps more often than any other group of physicians. By arriving at a probable diagnosis and arranging appropriate follow-up, they have the opportunity to prevent the evolution of PD from an acute to a chronic condition. While we agree with Dr. Epstein that greater efforts are needed to improve PD detection in family practice, we specifically targeted ED physicians because this study was conducted in the ED. We are flattered that he thinks this paper should be distributed to FPs. Thank you.

Richard Fleet, MD, PhD
Psychologist
Director, Clinical Research
Department of Psychiatry
Resident in Family Medicine
Sacré-Coeur Hospital
Montréal, Que.

References

1. Fleet RP, Lavoie KL, Martel JP, Dupuis G, Marchand A, Beitman BD. Two-year follow-up status of emergency department patients with chest pain: Was it panic disorder? Can J Emerg Med 2003;5(4):247-54.
2. Epstein NL. Chest pain and panic disorder in the ED? [letter]. Can J Emerg Med 2003;5(5):308.