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Investigating Relations Between the Symptoms of Panic, Agoraphobia, and Suicidal Ideation: The Significance of Comorbid Depressive Symptoms in Veterans with Panic Disorder

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Abstract

Although panic disorder has been frequently associated with increased suicidal ideation and behaviors, there are multiple explanations for this association in the literature. For example, some research has demonstrated panic disorder symptoms to mediate agoraphobia and suicidal ideation, while other researchers have hypothesized that comorbid depression symptoms contribute to suicidal ideation across anxiety disorders. Of note, none of these studies were completed in veterans, a population at higher risk for suicide relative to civilian samples. The present study investigated relations between the symptoms of panic, agoraphobia, depression, and suicidal ideation in 58 veterans diagnosed with panic disorder via correlations, hierarchical regression, and exploratory path analyses. Multiple models were investigated based on prior research. The final path model demonstrated that symptoms of panic disorder predicted agoraphobia symptoms, with agoraphobia predicting symptoms of depression. Symptoms of depression, then, predicted suicidal ideation. Discussion of the findings related to comorbid depressive symptoms highlight considerations for the assessment and treatment practices for panic disorder, with a particular focus on veterans receiving care within Veterans Affairs Healthcare System.

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Data Availability

The data that support the findings of this study are available from the corresponding author, [DG], upon reasonable request.

References

  • Allan, N. P., Gorka, S. M., Saulnier, K. G., & Bryan, C. J. (2023). Anxiety sensitivity and intolerance of uncertainty: Transdiagnostic risk factors for anxiety as targets to reduce risk of suicide. Current Psychiatry Reports, 25, 139–147.

    Article  PubMed  PubMed Central  Google Scholar 

  • Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gorman, J. M., & Woods, S. W. (2010). Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with treatment outcome. Journal of Psychopathology and Behavioral Assessment,32(2), 185–192.

    Article  PubMed  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association.

    Book  Google Scholar 

  • Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression anxiety stress Scales in clinical groups and a community sample. Psychological Assessment,10(2), 176.

    Article  Google Scholar 

  • Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., & Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry,74, 875–884.

    Article  PubMed  PubMed Central  Google Scholar 

  • Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & May, J. T. E. (2010). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. Oxford University Press.

    Book  Google Scholar 

  • Barrera, T. L., Graham, D. P., Dunn, N. J., & Teng, E. J. (2013). Influence of trauma history on panic and posttraumatic stress disorder in returning veterans. Psychological Services,10(2), 168.

    Article  PubMed  Google Scholar 

  • Barrera, T. L., Hiatt, E. L., Dunn, N. J., & Teng, E. J. (2013b). Impact of panic disorder on quality of life among veterans in a primary care pilot study. Comprehensive psychiatry, 54(3), 256–261.

    Article  PubMed  Google Scholar 

  • Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological Bulletin,107, 238–246.

    Article  PubMed  Google Scholar 

  • Beuke, C. J., Fischer, R., & McDowall, J. (2003). Anxiety and depression: Why and how to measure their separate effects. Clinical Psychology Review,23, 831–848.

    Article  PubMed  Google Scholar 

  • Blais, R. K., & Geiser, C. (2019). Depression and PTSD-related anhedonia mediate the association of military sexual trauma and suicidal ideation in female service members/veterans. Psychiatry Research,279, 148–154.

    Article  PubMed  Google Scholar 

  • Bolton, J. M., Pagura, J., Enns, M. W., Grant, B., & Sareen, J. (2010). A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder. Journal of Psychiatric Research,44, 817–882.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brown, T. A. (2014). Anxiety and related disorders interview schedule for DSM-5RG (ADIS-5)-Adult and lifetime version: Clinician manual. Oxford University Press.

    Google Scholar 

  • Brown, T. A., White, K. S., & Barlow, D. H. (2005). A psychometric reanalysis of the Albany panic and phobia questionnaire. Behaviour Research and Therapy,43(3), 337–355.

    Article  PubMed  Google Scholar 

  • Bystritsky, A., Kerwin, L., Niv, N., Natoli, J. L., Abrahami, N., Klap, R., & Young, A. S. (2010). Clinical and subthreshold panic disorder. Depression and Anxiety,27(4), 381–389.

    Article  PubMed  PubMed Central  Google Scholar 

  • Capron, D. W., Norr, A. M., Macatee, R. J., & Schmidt, N. B. (2013). Distress tolerance and anxiety sensitivity cognitive concerns: Testing the incremental contributions of affect dysregulation constructs on suicidal ideation and suicide attempt. Behavior Therapy,44, 349–358.

    Article  PubMed  Google Scholar 

  • Clauss, K., Houtsma, C., Shapiro, M. O., McDermott, M. J., Macia, K. S., Franklin, C. L., & Raines, A. M. (2023). Anxiety sensitivity and intolerance of uncertainty among veterans with subthreshold versus threshold PTSD. Traumatology Advance Online Publication. https://doi.org/10.1037/trm0000437

    Article  Google Scholar 

  • Coyne, A. E., & Gros, D. F. (2022). Comorbidity as a moderator of the differential efficacy of transdiagnostic behavior therapy and behavioral activation for affective disorders. Psychotherapy Research, 32, 886–897.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ennis, C. R., Raines, A. M., Aldea, M. A., Shapiro, M. O., Crowe, C. M., & Franklin, C. L. (2023). Addressing barriers in access to mental health care within the Veterans Health Administration: Evidence-based psychotherapies for anxiety and related disorders. Administration and Policy in Mental Health and Mental Health Services Research,50, 173–176.

    Article  Google Scholar 

  • Gros, D. F. (2014). Development and initial evaluation of Transdiagnostic Behavior Therapy (TBT) for veterans with affective disorders. Psychiatry Research,220(1–2), 275–282.

    Article  PubMed  Google Scholar 

  • Gros, D. F., & Allan, N. P. (2019). A randomized controlled trial comparing Transdiagnostic Behavior Therapy (TBT) and behavioral activation in veterans with affective disorders. Psychiatry Research,281, 112541.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gros, D. F., Frueh, B. C., & Magruder, K. M. (2011). Prevalence and features of panic disorder and comparison to posttraumatic stress disorder in VA primary care. General Hospital Psychiatry,33(5), 482–488.

    Article  PubMed  Google Scholar 

  • Gros, D. F., Keller, S., Allan, N. P., & Szafranski, D. D. (2023). Application of Transdiagnostic Behavior Therapy (TBT) for diagnostic comorbidity. Psychiatry Research Case Reports,2, 100102.

    Article  Google Scholar 

  • Gros, D. F., Merrifield, C., Rowa, K., Szafranski, D. D., Young, L., & McCabe, R. E. (2019). A naturalistic comparison of group Transdiagnostic Behaviour Therapy (TBT) and disorder-specific cognitive behavioural therapy groups for the affective disorders. Behavioural and Cognitive Psychotherapy,47(1), 39–51.

    Article  PubMed  Google Scholar 

  • Hendriks, S. M., Spijker, J., Licht, C. M., Beekman, A. T., Hardeveld, F., de Graaf, R., & Penninx, B. W. (2014). Disability in anxiety disorders. Journal of Affective Disorders,166, 227–233.

    Article  PubMed  Google Scholar 

  • Hill, R. M., Busto, D., Buitron, C. T., & Pettit, J. W. (2018). Depressive symptoms and perceived burdensomeness mediate the association between anxiety and suicidal ideation in adolescents. Archives of Suicide Research,22, 555–568.

    Article  Google Scholar 

  • Horenstein, A., & Heimberg, R. G. (2020). Anxiety disorders and healthcare utilization: A systematic review. Clinical Psychology Review,81, 101894.

    Article  PubMed  Google Scholar 

  • Houck, P. R., Spiegel, D. A., Shear, M. K., & Rucci, P. (2002). Reliability of the self-report version of the panic disorder severity scale. Depression and Anxiety,15(4), 183–185.

    Article  PubMed  Google Scholar 

  • Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling,6, 1–55.

    Article  Google Scholar 

  • Huang, M. F., Yen, C. F., & Lung, F. W. (2010). Moderators and mediators among panic, agoraphobia symptoms, and suicidal ideation in patients with panic disorder. Comprehensive Psychiatry,51, 243–249.

    Article  PubMed  Google Scholar 

  • Hunt, C., Krauss, A., Hiatt, E., & Teng, E. J. (2022). Predictors of symptom reduction following intensive weekend treatment for panic disorder: An exploratory study of veterans. Journal of Affective Disorders,308, 298–304.

    Article  PubMed  Google Scholar 

  • Jobes, D. A., Haddock, L. A., & Olivares, M. R. (2019). Military and veteran suicide prevention. Veteran Psychiatry in the US (pp. 51–71). Springer.

  • Kaplan, M. S., Huguet, N., McFarland, B. H., & Newsom, J. T. (2007). Suicide among male veterans: A prospective population-based study. Journal of Epidemiology & Community Health,61(7), 619–624.

    Article  Google Scholar 

  • Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. American Psychologist,69, 19–33.

    Article  PubMed  Google Scholar 

  • Katz, I., Barry, C. N., Cooper, S. A., Kasprow, W. J., & Hoff, R. A. (2020). Use of the Columbia-Suicide severity rating scale (C‐SSRS) in a large sample of Veterans receiving mental health services in the Veterans Health Administration. Suicide and Life‐Threatening Behavior,50, 111–121.

    Article  PubMed  Google Scholar 

  • Keefe, J. R., Chambless, D. L., Barber, J. P., & Milrod, B. L. (2019). Treatment of anxiety and mood comorbidities in cognitive-behavioral and psychodynamic therapies for panic disorder. Journal of Psychiatric Research,114, 34–40.

    Article  PubMed  Google Scholar 

  • Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry,62, 617–627.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine,16(9), 606–613.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine,146(5), 317–325.

    Article  PubMed  Google Scholar 

  • Louzon, S. A., Bossarte, R., McCarthy, J. F., & Katz, I. R. (2016). Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatric Services,67(5), 517–522.

    Article  PubMed  Google Scholar 

  • Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression anxiety stress scales (2nd ed.). Psychology Foundation of Australia.

  • McNally, R. J. (2002). Anxiety sensitivity and panic disorder. Biological Psychiatry,52, 938–946.

    Article  PubMed  Google Scholar 

  • Miller, M., Barber, C., Young, M., Azrael, D., Mukamal, K., & Lawler, E. (2012). Veterans and suicide: A reexamination of the national death index–linked national health interview survey. American Journal of Public Health,102(S1), S154–S159.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nepon, J., Belik, S. L., Bolton, J., & Sareen, J. (2010). The relationship between anxiety disorders and suicide attempts: Findings from the national epidemiologic survey on Alcohol and related conditions. Depression and Anxiety,27(9), 791–798.

    Article  PubMed  PubMed Central  Google Scholar 

  • Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity and the anxiety disorders: A meta-analytic review and synthesis. Psychological Bulletin,135, 974–999.

    Article  PubMed  Google Scholar 

  • Price, M., Gros, D. F., Strachan, M., Ruggiero, K. J., & Acierno, R. (2013). The role of social support in exposure therapy for Operation Iraqi Freedom/Operation Enduring Freedom veterans: A preliminary investigation. Psychological Trauma: Theory Research Practice and Policy,5(1), 93.

    Article  PubMed  Google Scholar 

  • Raines, A. M., Chambliss, J. L., Norr, A. M., Sanders, N., Smith, S., Walton, J. L., & Schmidt, N. B. (2023). Acceptability, feasibility, and utility of a safety aid reduction treatment in underserved veterans: A pilot investigation. Cognitive Behaviour Therapy,52, 1–17.

    Article  PubMed  Google Scholar 

  • Rapee, R. M., Craske, M. G., & Barlow, D. H. (1994/1995). Assessment instrument for panic disorder that includes fear of sensation-producing activities: The Albany panic and phobia questionnaire. Anxiety, 1(3), 114–122.

  • Rosseel, Y. (2012). Lavaan: An R package for structural equation modeling. Journal of Statistical Software,48, 1–36.

    Article  Google Scholar 

  • Rubin, H. C., Rapaport, M. H., Levine, B., Gladsjo, J. K., Rabin, A., Auerbach, M., & Kaplan, R. (2000). Quality of well being in panic disorder: The assessment of psychiatric and general disability. Journal of Affective Disorders,57(1–3), 217–221.

    Article  PubMed  Google Scholar 

  • Scheer, V., Blanco, C., Olfson, M., Lemogne, C., Airagnes, G., Peyre, H., & Hoertel, N. (2020). A comprehensive model of predictors of suicide attempt in individuals with panic disorder: Results from a national 3-year prospective study. General Hospital Psychiatry,67, 127–135.

    Article  PubMed  Google Scholar 

  • Schmidt, N. B., Woolaway-Bickel, K., & Bates, M. (2001). Evaluating panic-specific factors in the relationship between suicide and panic disorder. Behaviour Research and Therapy,39(6), 635–649.

    Article  PubMed  Google Scholar 

  • Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., & Papp, L. A. (1997). Multicenter collaborative panic disorder severity scale. American Journal of Psychiatry,154(11), 1571–1575.

    Article  PubMed  Google Scholar 

  • Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science & Medicine,32(6), 705–714.

    Article  Google Scholar 

  • Stanley, I. H., Boffa, J. W., Rogers, M. L., Hom, M. A., Albanese, B. J., Chu, C., & Joiner, T. E. (2018). Anxiety sensitivity and suicidal ideation/suicide risk: A meta-analysis. Journal of Consulting and Clinical Psychology,86, 946–960.

    Article  PubMed  PubMed Central  Google Scholar 

  • Steiger, J. H. (1998). A note on multiple sample extensions of the RMSEA fit index. Structural Equation Modeling,5, 411–419.

    Article  Google Scholar 

  • Stevens, E. R., Mazumdar, M., Caniglia, E. C., Khan, M. R., Young, K. E., Edelman, E. J., & Braithwaite, R. S. (2020). Insights provided by depression screening regarding pain, anxiety, and substance use in a veteran population. Journal of Primary Care & Community Health,11, 2150132720949123.

    Article  Google Scholar 

  • Tietbohl-Santos, B., Chiamenti, P., Librenza-Garcia, D., Cassidy, R., Zimerman, A., Manfro, G. G., & Passos, I. C. (2019). Risk factors for suicidality in patients with panic disorder: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews,105, 34–38.

    Article  Google Scholar 

  • Tsai, J., Snitkin, M., Trevisan, L., Kraus, S. W., & Pietrzak, R. H. (2020). Awareness of suicide prevention programs among US military veterans. Administration and Policy in Mental Health and Mental Health Services Research,47, 115–125.

    Article  PubMed  Google Scholar 

  • U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. (2022). National veteran suicide prevention annual report. 2022. Retrieved January 31, 2023, from https://www.mentalhealth.va.gov/suicide_prevention/data.asp

  • Van Beek, M. H. C. T., Voshaar, O., Beek, R. C., Van Zijderveld, A. M., Visser, G. A., Speckens, S., & Van Balkom, A. E. M. (2013). A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: A 24‐week randomized controlled trial. Depression and Anxiety,30(7), 670–678.

    Article  PubMed  Google Scholar 

  • Van Buuren, S., & Groothuis-Oudshoorn, K. (2011). Mice: Multivariate imputation by chained equations in R. Journal of Statistical Software,45, 1–67.

    Article  Google Scholar 

  • Weber, M. C., Pavlacic, J. M., Gawlik, E. A., Schulenberg, S. E., & Buchanan, E. M. (2020). Modeling resilience, meaning in life, posttraumatic growth, and disaster preparedness with two samples of tornado survivors. Traumatology,26(3), 266–277.

    Article  Google Scholar 

  • Wiebenga, J. X., Dickhoff, J., Mérelle, S. Y., Eikelenboom, M., Heering, H. D., Gilissen, R., & Penninx, B. W. (2021). Prevalence, course, and determinants of suicide ideation and attempts in patients with a depressive and/or anxiety disorder: A review of NESDA findings. Journal of Affective Disorders,283, 267–277.

    Article  PubMed  Google Scholar 

  • Zhang, Y., Wang, J., Xiong, X., Jian, Q., Zhang, L., Xiang, M., & Zou, Z. (2021). Suicidality in patients with primary diagnosis of panic disorder: A single-rate meta-analysis and systematic review. Journal of Affective Disorders,300, 27–33.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Mental Health Service, Ralph H. Johnson VA Healthcare System, 109 Bee Street, 29401, Charleston, SC, USA

    Daniel F. Gros, Jeffrey M. Pavlacic & Jennifer M. Wray

  2. Department of Psychology & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA

    Daniel F. Gros, Jeffrey M. Pavlacic & Jennifer M. Wray

  3. Orlando VA Healthcare System, Orlando, FL, USA

    Derek D. Szafranski

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  1. Daniel F. Gros
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Correspondence to Daniel F. Gros.

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The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Daniel F. Gros, Jeffrey M. Pavlacic, Jennifer M. Wray, and Derek D. Szafranski have no conflicts of interest to disclose.

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This study is supported by the Department of Veterans Affairs Office of Research and Development, CSR&D grant# I01 CX001846 (PI: Gros).

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Gros, D.F., Pavlacic, J.M., Wray, J.M. et al. Investigating Relations Between the Symptoms of Panic, Agoraphobia, and Suicidal Ideation: The Significance of Comorbid Depressive Symptoms in Veterans with Panic Disorder. J Psychopathol Behav Assess 45, 1154–1162 (2023). https://doi.org/10.1007/s10862-023-10082-4

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