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In this issue of the Canadian Journal of Emergency Medicine, Fleet and colleagues report that up to 25% of emergency department (ED) patients with chest pain meet diagnostic criteria for panic disorder (PD), and that this high prevalence did not decline at follow-up, an average of 2 years later (see page 247). Of note, cardiologists in a specialized chest-pain unit diagnosed PD in only 2% of patients who met Diagnostic and Statistical Manual of Mental Disorders (DSM), 3rd ed, revised (DSM-III-R) criteria for the disorder. This high “miss rate” was replicated by a group of specialty-trained emergency physicians. When PD is identified and treated early, the outlook is favourable: up to 15% of patients experience complete remission and 85% become relatively symptom free. But, left untreated, PD can progress to a chronic disabling disease with hypochondriasis, phobic avoidance and fullblown agoraphobia. Patients with uncontrolled PD are frequent users of ED and health care resources. In a multicentre, population-based study, Klerman and coworkers reported that PD patients were 28 times more likely to use the ED than persons with no psychiatric disorder, while Fleet and colleagues reported a 4-fold increase in ED visits for chest pain. But is it the emergency physician’s job to diagnose PD? From the first day of our residency, we are taught to assume the worst and rule it out. The thought of calling a pulmonary embolism “panic disorder” scares most of us, and emergency physicians often feel their responsibility is limited to “ruling-out” life-threatening disease. At the other end of the spectrum, a recent study demonstrated the feasibility of a protocol in which emergency physicians used a brief screening tool to identify PD patients, then prescribed a month of paroxetine therapy. There are prob-

The buck stops where? What is the role of the emergency physician in managing panic disorder in chest pain patients?