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.This issue has been addressed as ‘‘clinical significance’’ in DSM-IV, but has been poorly operationalized in surveys.The ICD uncouplesdisability from disease and uses the International Classification ofFunctioning, Disability and Health (ICF) to measure and classify associated disability.Such independent assessment of disease symptoms and functional limitations provides a good scientific approach to study thecontribution of each component (i.e.disease and disability) separately inthe resulting outcome: the need for treatment [4].The final question is one of policy: what can be done to change thecurrent practice? We should gather evidence in a comparative framework,including all diseases together so as to put mental disorders (includingphobias) in ‘‘parity’’ with physical disorders.When one applies similarcriteria to measure the burden, costs, effectiveness and other systemoutcomes, the glaringly unequal treatment for mental disorders becomesevident.Such comparative assessments should be made public to informpolicy and shape health care provision.Both policy makers and practitioners are in need of good evidence to guide their decision making.Evidence alone cannot change the world.It takes quite a long time untilevidence is assimilated in daily practice.The gap between evidence andpractice arises because of the complex systems challenges, which we are not especially well equipped to deal with.Bridging this gap may be facilitated by employing the learning tools that have emerged from systems thinkingas it applies to quality improvement in health care [5].This ‘‘pragmaticscience’’ is a kind of operational research that identifies the Plan–Do–Study–Act (PDSA) method and the principles of its application to systemschallenges.Using science and information technology we can speed up thedissemination and uptake of good practices [6].REFERENCES1.U¨ stu¨n T.B.(2000) Unmet need for management of mental disorders in primary care.In Unmet Need in Psychiatry: Problems, Resources, Responses (Eds G.Andrews, S.Henderson), pp.157–171.Cambridge University Press, London.2.U¨ stu¨n T.B., Sartorius N.(1995) Mental Illness in General Health Care: An International Study.John Wiley & Sons, Chichester.3.Kessler R.(2003) The impairments caused by social phobia in the generalpopulation: implications for intervention.Acta Psychiatr.Scand., 417 (Suppl.): 19–27.4.U¨ stu¨n T.B., Chatterji S., Rehm J.(1998) Limitations of diagnostic paradigm: it doesn’t explain ‘‘need’’.Arch.Gen.Psychiatry, 55: 1145–1146.5.Berwick D.M., Nolan T.W.(1998) Physicians as leaders in improving health care.Ann.Intern.Med., 128: 289–292.6.Berwick D.M.(2003) Disseminating innovations in health care.JAMA, 289:1969–1975.____________________________________________________________________________________________________________________________________________Indexabuse and dependence liability 164methods of delivery 182–3adolescentsincomplete evidence 199Brazilian studies 299–301onset and discourse 17effectiveness of treatment 298panics in 17–18fear, anxieties and treatment efficacypharmacotherapy of 128–9, 159,283–5167–70implications for public policy 297–9politicization of 36internalizing/externalizing behaviourpsychological treatment 228–9300psychotherapeutic interventionsphobias in179–80commentaries 280–302rates of treatment-seeking 333review 245–79social and economic burden 348psychosocial interventions 257–69targeted maintenance treatment 169treatment strategy for 271–2without history of panic disorderadrenergic agents 127–816–19affective disorders 50, 73–4without panic disorder 45, 144, 175,age effects 65297–8age of onset 11–12, 297agoraphobic syndrome 340identification of 90airport travellers 161agoraphobia 6–12, 16–19, 23, 25, 37, 46,alcohol, hazards of 16162, 109, 132, 147, 149alcohol abuse 100, 161, 318–20, 334age of onset 297alprazolam 118, 125, 129, 149and panic attacks 33–6, 55, 147, 171–2American Psychiatric Association 1and panic disorder 243, 297–8amitriptyline 13see also panic disorderanimal models 96–7areas still open to research 200animal phobia 7, 12, 24, 47choice of treatment 168–9animal studies 151combined in vivo exposure andanorexia nervosa 26pharmacotherapy 181–2anticonvulsants 126–7, 153consistent evidence 198antidepressants 39, 42, 120–1, 123, 128,definitions 42130, 147, 161–2, 168diagnosis 40delayed action 169differential diagnosis 18–19discontinuation of 169drug trials for treatment 171non-responders to 164economic burden 340panic disorder 128evidence-based treatment guidelinesantipanic drugs 36168antipanic medications 39future studies 347antipsychotics 100, 127help seeking and use of medicationanxiety 11, 62305and therapeutic relationship 240in childhood 247as manifestation of depressive illnessin vivo exposure 34, 181–2, 186, 220–1238basic components 180–1epidemiological dissection 81efficacy of 181meaning and etiology 239–40Phobias.Edited by Mario Maj, Hagop S.Akiskal, Juan JoseĹo´pez-Ibor and Ahmed Okasha.&2004 John Wiley & Sons Ltd: ISBN 0-470-85833-8356 ______________________________________________________________________________________________ INDEXanxiety (cont
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