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Resident Presentations
2001 Wyeth-Ayerst American Psychiatric Association
Resident Reporter
GRETCHEN W. CARLSON, MA, MD
WYETH AYERST LABORATORIES
AMERICAN PSYCHIATRIC ASSOCIATION ANNUAL MEETING 2001
RESIDENT REPORTER PROGRAM
Barriers to the Effective Treatment of Anxiety Disorders
Abstract
Anxiety disorders are common, with an estimated one-year prevalence
of 19.2%.1 Anxiety disorders, however, are underdiagnosed
and undertreated in all clinical settings. For those who eventually
receive treatment, there is often a considerable delay. This delay may
be secondary to any number of barriers, including pretreatment patient-related
barriers, professional barriers, and treatment-specific barriers.
Rates of Treatment
The most common anxiety disorder is simple phobia, with a one-year
prevalence of 8.8%, followed by social phobia (7.9%), PTSD (3.9%), agoraphobia
(3.8%), generalized anxiety disorder (3.1%) and panic disorder (2.3%).2
Despite their high prevalence, a small percentage of people suffering
from anxiety disorders receive any treatment. According to the National
Comorbidity Survey,3 27% of people with any anxiety disorder
receive treatment in a given 12 month period, and only 19% of those
receive treatment in the health sector, either general medical or specialty
mental health setting. Those with panic disorder are most likely to
receive treatment (46%), followed by generalized anxiety disorder (39%),
posttraumatic stress disorder (38%), agoraphobia (33%), specific phobia
(26%) and social phobia (23%).
Timing of First Treatment
Approximately 40% of people with new-onset anxiety disorders will seek
treatment within one year of onset of symptoms.4 A smaller
percentage will seek treatment in subsequent years. On average, the
delay for seeking treatment is 8 years for anxiety disorders.5
A number of variables affect the likelihood of seeking treatment. First,
time to initial treatment seeking is dependent on the type of anxiety
disorder one has. Persons with new-onset panic disorder are the most
likely to seek treatment in the first year of onset (65%),5
presumably because of the abrupt onset of symptoms and the concern that
they might have a medical etiology. Approximately 35% of people with
generalized anxiety disorder and 10% of people with phobias, including
social phobia and agoraphobia, seek treatment in the first year. Overall,
only 50% of those with generalized anxiety disorder and 30% of those
with phobias ever make treatment contact.
A second factor influencing the likelihood of treatment is the age
of onset. Delays in seeking treatment in the year of onset are more
pronounced in all early-onset anxiety disorders with the exception of
panic disorder.6 For example, approximately 10% of people
with the onset of phobia before the age of 20 will seek treatment in
the first year, versus 35% of those who have the onset at age 30 years
or older. Presumably these disorders go undetected in adolescents because
their anxiety does not result in worrisome behaviors, so their parents
are unaware of the disorder and do not bring it to medical attention.
In contrast, adolescents with addictive disorders have a higher likelihood
of being treated within the first year of onset.
The probability of seeking treatment at any time is decreased in those
with early onset disorders, even though early-onset disorders tend to
be more chronic and severe. For example, treatment contact for phobia
is twice as likely in those with onset after age 30 than before age
20.6 The reasons for decreased probability of treatment in
early-onset disorders are not known, but they may have to do with the
onset of symptoms occurring at a time when adolescents are individuating,
and these symptoms become integrated into their identities. Consequently,
these individuals adjust their lifestyles and expectations of themselves
to accommodate their anxiety.
The National Comorbidity Survey also found that there was a decrease
in lag time to seeking treatment in those born in the most recent cohort.6
This is most likely due to increased public education and acceptance
of mental disorders, as well as improved treatment.
Barriers to Effective Treatment
The delay to first contact can be conceptualized in terms of a number
of barriers to treatment. First, there are pretreatment, patient-related
barriers. An individual must perceive that he has a mental health problem,
decide to seek treatment, and act on this decision by making an appointment.
Secondly, there are provider barriers, which include errors in diagnosis
of anxiety disorders, and inadequate or inappropriate treatment. Finally,
there are treatment barriers, such as patients' acceptance of treatment
and willingness to maintain treatment.
Pretreatment patient barriers The first step in seeking treatment
for an anxiety disorder is self appraisal. Self recognition of anxiety
disorders varies depending on the disorder: up to 25% of individuals
with social anxiety disorder, 15% with generalized anxiety disorder,
and 10% with panic disorder do not believe they have an anxiety disorder.7
Studies vary greatly as to how much perceived need for treatment there
is among patients with mental disorders, but up to two-thirds of patients
with mental disorders may not believe that they need treatment.8
This is reflected in a high rate of referral refusal among participants
who are found to have social anxiety disorder, generalized anxiety disorder
and panic disorder on National Anxiety Disorders Screening Day.7
The mediators of treatment refusal are not well understood, but there
are demographic correlations. Being male and under the age of twenty-five
is associated with decreased perceived need for treatment. Ethnic minorities
are also less likely to seek treatment for mental disorders, despite
having equivalent insurance and income.9 Individuals are
more likely to think they need treatment if they have a real or perceived
physical health problem, impairment in daily activities, or suicidal
ideation.8 Comorbidity also increases the perceived need
for treatment. An individual has a 21% probability of perceiving a need
for mental health treatment if he has an anxiety disorder without comordity,
37% if comorbid with a substance use disorder, 56% if comorbid with
a mood disorder, and 63% if comorbid with substance and mood disorders.8
Approximately half of those who perceive a need for mental health treatment
and have a comorbid disorder make treatment contact in any setting in
a 12-month period. This suggests that severity of symptoms is one factor
that motivates individuals to seek treatment.
Another hypothetical obstacle to treatment is the lack of insurance
coverage of mental health disorders. However, when time to first treatment
contact in Ontario and the United States is compared, there is no overall
difference in delay.5 Even in the cohort with the lowest
socioeconomic status, there was no significant difference in delay to
treatment between the two countries. From this study it does not appear
that universal coverage would improve access to treatment. But, there
may be other issues interfering with timely treatment in Canada, such
as limited access to psychiatrists in their health system.5
When patients are queried about why they delayed seeking treatment,
they do report expenses and lack of insurance as primary reasons.4,9Other
self-reported reasons for delay include: wanted to handle it on my own,
did not know where to go, and feeling embarrassed or ashamed.4
A fear of what others might think or say was particularly common in
those with social anxiety disorder.10 Thus, the stigma of
mental illness and seeing a mental health provider, and the logistics
of finding care both appear to be mediators in the delay to treatment
of anxiety disorders.
Provider barriers Provider barriers are a significant factor in delaying
treatment of anxiety disorders. Both primary care and mental health
providers frequently miss the diagnosis of an anxiety disorder. In the
primary care setting, the diagnosis of panic disorder is missed in 61%
of cases,11 and the diagnosis of social anxiety disorder
in 75% of cases.12 The likelihood of identifying and correctly
diagnosing an anxiety disorder is not much improved in the mental health
setting from the limited data available. Shear, et al.13
found poor correlation between diagnoses made by the Structured Clinical
Interview for DSM-IV (SCID)14 and those made by clinicians
in an urban academic mental health clinic and a rural mental health
clinic. Clinicians at these two sites diagnosed only one quarter of
the anxiety disorders identified by SCID. Anxiety disorders were most
commonly misdiagnosed as adjustment disorders and mood disorders. The
majority of these diagnostic assessments were conducted by non-physicians.
However, when physician diagnoses were examined in the rural clinic,
there was no improvement in diagnostic agreement. Social anxiety disorder
appears to be the most under-recognized. Even mental health clinicians
particularly trained to screen for social anxiety during an anxiety
disorders screening day frequently missed the diagnosis of social anxiety
disorder.10
Another aspect of professional delay is inappropriate or inadequate
treatment. Salzman, et al.15 looked at the treatment of generalized
anxiety disorder in 1989 and 1996. They found that 33% individuals with
GAD alone or comorbid with another anxiety disorder received no medication
in 1989, versus 27% in 1996. Those who had comorbid major depression
faired somewhat better, with 26% receiving no treatment in 1989 versus
8% in 1996. As one would expect, the majority of individuals with anxiety
disorders were treated with benzodiazepines in 1989, whereas greater
use of antidepressants, either alone or in combination with anxiolytics,
was found in 1996.
Studies of depression suggest there are certain characteristics associated
with the likelihood of being offered treatment once seen by a provider.
These characteristics include ethnicity, type of clinic, and prior treatment
history. Caucasians are nearly three times as likely as minority patients
to be offered antidepressants.16 Patients who were treated
in a university-based clinic were significantly more likely than those
in a community mental health clinic to have antidepressants recommended
(87% versus 57%). Individuals recently treated with antidepressants
had a 98% chance of receiving further antidepressant treatment, versus
60% for patients who had not recently taken antidepressants. And patients
who had prior hospitalizations were significantly more likely to receive
antidepressant treatment (88% versus 67%).16
The likelihood of receiving treatment may also depend on the patient's
participation in the decision-making process. Patients with higher income
and those who had more prior visits with their primary care physician
were more likely to initiate discussion of psychotropics.17
These interactions included asking for refills of medications that the
patient was already taking. Patients were more likely to initiate discussion
about refills, and physicians were more likely to initiate discussion
about new psychotropics. Age, gender and ethnicity of the patient were
not significant factors in determining who initiated pharmacotherapy
discussion.
Finally, providers may prescribe inappropriate or inadequate treatment.
A survey of depressed and anxious patients seen in primary care and
mental health clinics found that one quarter of these patients received
psychotropic medications for their disorder, and one fifth received
appropriate treatment.18 The majority (80%) of these patients
were treated by their primary care physicians. One third received some
counseling, but only 18% received appropriate psychotherapy. Appropriate
care was significantly more likely in Caucasians, women, patients aged
30 to 60 years old, and those with a higher level of education. Inappropriate
or inadequate care occurred in 80% of patients in the primary care setting,
versus 11% seen by mental health practitioners.
Treatment barriers Once treatment has been recommended, a patient must
be willing to accept the treatment. Patient preferences play an important
role in accepting and adhering to treatment regimens. Among depressed
primary care patients, factors associated with a preference for counseling
over medication included being African American or female, and having
greater knowledge about counseling. The only factor associated with
a preference for medication was being on unpaid leave.19
Acceptance of pharmacotherapy might increase if physicians educated
patients about the efficacy and safety of antidepressants.
After an individual accepts appropriate and adequate treatment, maintenance
of treatment becomes the main focus. Discontinuation rates for antidepressants
are high. Approximately 28% of patients with depression will discontinue
antidepressants in the first month, and 44% at 3 months in the primary
care setting.20 Factors that improve adherence include educating
patients about how to take the medication, informing them of how long
the medication will take to work, and discussing behavioral strategies
to treat their illness. Early discontinuation is more likely with severe,
but not mild or moderate, side effects, and greater disability. The
only significant predictor of late adherence was prior antidepressant
use. In a study of panic disorder patients, increased monitoring and
closer follow-up improved adherence to medication and outcome.21
Patients who discontinue antidepressants are at significantly higher
risk of relapse or recurrence of their disorder.22
Conclusion
When all of the possible barriers to the treatment of anxiety disorders
are considered, the low prevalence of treatment is not surprising. This
is unfortunate in light of the disability that anxiety disorders cause,
and the existence of efficacious pharmacotherapy and psychotherapy for
all anxiety disorders. Improvement in the treatment of anxiety will
not be possible without removing barriers in all stages of the treatment
process. For instance, increase in self-appraisal may not translate
into better treatment if diagnosis remains insufficient, just as universal
coverage does not bring about shorter delays in the treatment of mental
disorders in the Canadian health care system.
Earlier identification may be facilitated by further public education
and outreach programs that may help destigmatize these disorders. In
addition, diagnostic screening tools may aid providers in identifying
individuals with anxiety. Healthcare professionals need to become more
competent in treating anxiety disorders, as well as educating their
patients about their disorders and available treatments. Finally, expanding
third party coverage for mental disorders in the United States is one
of the links in the chain that will likely result in more widespread
and appropriate treatment of anxiety disorders.
References
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at the APA 2001 Annual Meeting, May 5-10, 2001, New Orleans, Louisiana.
2. Kessler RC et al: Lifetime and 12-month prevalence o f SDM-III-R
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