SINGAPORE: Elizabeth (not her real name) was a top performer at her job and regular gym attender. One night she woke up with sudden chest pain and felt her heart racing. Gasping for breath, she tried desperately to understand what was happening to her.
She woke her husband who tried to calm her down, but she soon started feeling dizzy and was worried she might faint. They rushed to the nearest emergency department (ED) where Elizabeth was evaluated for signs of a heart attack. Tests, however, were negative and she was discharged with a follow-up appointment to see a cardiologist.
Over the next few weeks, she continued to experience almost daily episodes of chest pain and breathlessness. She became fearful of going out without her husband, took multiple medical certificates (MCs), and stopped exercising as a precaution. But her cardiology evaluation also found no physical cause for her symptoms.
What Elizabeth experienced was a panic attack. Panic attacks are not rare – world mental health surveys suggest that between 13 and 30 per cent of people will experience panic attacks at some point in their lives. Many of them will visit EDs at the onset of a panic attack, but it often results in extensive, repeated and unnecessary investigations without a proper diagnosis.
AN UNDER-DIAGNOSED CONDITION
Patients like Elizabeth come to the ED for good reason. They experience symptoms such as chest pain, shortness of breath, heart palpitations and dizziness, which can be very frightening, as these can be signs of a heart attack, stroke, or other life-threatening conditions. There is much less public awareness that these symptoms can also be related to stress or anxiety.
From 2013 to 2018, a team from Singapore General Hospital and Duke-NUS Medical School conducted studies at local hospitals to screen patients visiting an ED for panic attacks and a more severe condition called panic disorder.
We found that 24 per cent of ED patients with symptoms like chest pain, giddiness, shortness of breath, or heart palpitations met the diagnostic criteria for a panic attack and another 23 per cent met the criteria for panic disorder.
However, fewer than 1 per cent of them were discharged from ED with a diagnosis of panic-related anxiety or referral for treatment. Our local findings were nearly identical to studies conducted overseas that consistently show a lack of detection and early intervention for panic attacks at EDs.
After ruling out heart attack, stroke and other life-threatening conditions, most patients who present at ED with panic attack symptoms are discharged with a symptom-based diagnosis like “chest pain”, “palpitations”, or “dizziness and giddiness” and are referred to cardiologists or other specialists for additional tests.
Without appropriate mental health help, we have seen otherwise healthy adults like Elizabeth exit the workforce or significantly limit their usual activities due to panic disorder. Many also develop depression or suicidal thoughts.
Undiagnosed panic-related anxiety exerts a burden on the healthcare system. A recent local study by members of our team found that depression and anxiety disorders like panic disorder are associated with over S$600 million in healthcare costs, including medication, in-person visits and diagnostic tests.
Nearly half of the participants who reported anxiety symptoms had never been formally diagnosed. Over the previous year, 13 per cent had at least one visit to the ED, 9 per cent had at least one hospital admission, 7 per cent underwent an electrocardiogram (ECG) test and 6 per cent underwent a magnetic resonance imaging (MRI) scan.