This study had two phases: a literature search and questionnaire development, and the Delphi process. Please see Figure 1 for a summary of the steps.
Literature search
The aim of the literature search was to cover the full domain of potentially helpful actions to assist someone who is experiencing a panic attack. It was not a literature review and did not include literature outside of the scope of first aid. The focus for the search was to find statements which instruct the reader on how to respond at the time of the attack, and how and when to recommend professional help to someone who has experienced a panic attack. The literature search was conducted across three domains: (1) the medical and research literature, (2) the content of existing crisis intervention guidelines and relevant courses for the public, and (3) lay literature. The lay literature included books written for the general public, particularly consumers' and carers' guides, websites and pamphlets.
The medical and research literature was accessed through searches of PsycInfo and PubMed. The search term was 'panic attack AND intervention OR (first aid)' and all records for the 20 years leading to the search date were reviewed. Papers were excluded first on the basis of their titles and then on the basis of their abstracts.
Papers which described interventions to decrease the severity or duration of a panic attack, or offered suggestions about when to recommend professional help, were reviewed, giving a total of 37 papers. Most of the advice given in these papers was very clinically oriented, or required extensive training to be applicable. For example, some papers described clinical interventions in which a panic attack was induced in vivo and then de-escalated. A small number of papers did include brief advice and simple intervention instructions. Statements were drawn from 12 of the 37 relevant records. All statements felt to be simple enough for lay people to use were included.
To find appropriate websites, we used the search engines Google [22], Google Australia [23], and Google UK [24] using three sets of search terms; 'panic attack' and 'self help', 'panic attack' and 'first aid', and 'panic attack' and (care or carer or caring). The first 50 websites listed by each were reviewed; beyond the first 50 websites, most new records were abstracts from journal papers. Since most websites were listed by more than one search engine, and were retrieved for more than one of the search terms, 178 websites were reviewed. The websites were read thoroughly, once again looking for statements which suggested a potential first aid action (what the first aid giver should do) or relevant awareness statement (what the first aid giver should know). Any external links to other websites were followed and the same process applied to each of them.
The fifty most popular books on the Amazon [25] website which listed the word 'panic' in the title or keywords were selected. This site was chosen because of its extensive coverage of books in and out of print, including works about mental health aimed at the public. Books which were autobiographical in nature and clinical manuals were excluded. The remaining books were read to find useful statements. The majority of these were carers' guides, which do contain advice relevant for first aid, but focussed on general caring for a mentally ill family member.
Any relevant pamphlets were sought and read, and statements were taken from these as well.
Only one training course for members of the public was found to be relevant, as most training in critical incident response is designed for professional responders such as paramedics and the police. Material from the Mental Health First Aid Program [14] was reviewed and statements drawn from it.
Questionnaire development
The questionnaire was developed by first grouping statements into the following categories: general intervention principles; de-escalating a panic attack; slowing down a person's breathing; things to say during a panic attack; professional help during a panic attack; alternative approaches to stopping a panic attack; seeking professional help, and self-help strategies.
Similar or near-identical statements were frequently derived from multiple sources, and they were not repeated in the questionnaire. A working group comprised of the authors of this paper and colleagues working on similar projects convened at each stage of the process to discuss each item in the questionnaire. The role of the working group was to ensure that the questionnaire did not include ambiguity, repetition, items containing more than one idea or other problems which might impede comprehension. The wording was carefully designed to be as clear, unambiguous and action-oriented as possible. All participants answered the questionnaire via the Internet, using an online survey website, Surveymonkey [26].
The Delphi process
The aim was to recruit participants into one of three panels: professionals (clinicians and researchers), consumers (people who had experienced panic attacks in the past) and carers. The professional panel had 50 experts, the consumer panel 6, but no carers could be recruited. All panel members were from developed English speaking countries (Australia, New Zealand, The United States, Canada, Ireland, England, and the United Kingdom). Participants were recruited in a number of ways. Professionals recruited were those who had publications in the areas of panic disorder or agoraphobia or experience in treating these patients. When letters were sent to professionals asking them to be involved, they were also invited to nominate any colleagues who they felt would be appropriate panel members. Those active in clinical practice were also asked to consider any former patients who might be willing to be involved.
The 50 professional participants belonged to the following (sometimes multiple) groups: 44 academics (researchers, lecturers and professors), 23 clinical psychologists, 21 medical doctors of whom 12 were psychiatrists, 1 nurse (also an academic), 1 clinical social worker and 1 drug and alcohol counsellor working with anxiety patients with tranquilliser addiction.
Consumers were recruited from advocacy organisations and referral by clinicians. They were also identified if they had written websites offering support and information to other consumers. Consumers were difficult to recruit for this study. All six consumers were working in some form of advocacy role. In addition, 1 was an academic researcher, 1 was the convener of a mutual help group, and 1 was a clinical psychologist who chose to participate as a consumer.
Many attempts were made to recruit carers from carers' support organisations and informal sources, but no carers chose to participate in this study. It may be that many carers for people with panic related conditions do not identify themselves as such. They may be a group that is less inclined to be involved with carers' organisations than those who are carers for people with schizophrenia, depression, or eating disorders [19–21]. Similar difficulties were found recruiting carers for people who have been suicidal or engaged in non-suicidal self-injury [17, 18].
Three rounds of questionnaires were distributed as follows, with each statement being rated up to two times. In Round 1 the questionnaire, derived from the process described above, was given to the panel members. The questionnaire included space after each of the sections to add any suggestions for new statements that panel members felt should be included.
In each round of the study, the usefulness of each statement for inclusion in the mental health first aid guidelines was rated as 'essential', 'important', 'don't know or depends', 'unimportant', or 'should not be included'. The options 'don't know and depends' were collapsed into one point on the scale because operationally, they are the same response. Most of the statements were, very reasonably, noted to be useful in some cases and not others, meaning they could not be generalised in guidelines, which is also true of statements participants did not feel confident to rate.
The suggestions made by the panel members in Round 1 were reviewed by the working group and used to construct new items for the Round 2. Suggestions were accepted and added to Round 2 if they represented a truly new idea, could be interpreted unambiguously by the working group, and were actions. Suggestions were rejected if they were near-duplicates of items in the questionnaire, if they were too specific (for example, 'focus on the guided meditation imagery negotiated between myself and my psychologist'), too general ('just be there'), or were more appropriate to therapy than first aid ('remember to avoid using safety behaviours'). Unexpectedly, in Round 1, no items describing techniques to control breathing were endorsed by the professional panel, although many were endorsed by the consumer panel. The working group chose to add any new item about breathing techniques suggested by panel members, in spite of some being close to duplicates of Round 1 items, in case one was felt to be acceptable to the professional panel.
Items rated as 'essential' or 'important' by 80% or more of both the professional panel and the consumer panel were accepted for inclusion in the guidelines. If they were endorsed by 80% or more of one of the panels, or by 70–80% of both panels, they were re-rated in the subsequent round. Items which met neither condition were rejected. Before Round 2 and 3 of the study, each participant was sent a summary of the results of the previous round, listing which items had been accepted, which had been rejected, and which were to be re-rated. When an item was to be re-rated by the panellists, they were provided with their own response and a table outlining how many people in each group had endorsed the item. They were told that they did not have to change their responses when re-rating an item, but that if they wished to, they would have the opportunity to do so.