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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

1. Kessler RC, The Cost Burden of Anxiety. Lecture presented 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 psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 51:8-19, 1994.
3. Kessler RC et al: Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. Am J Psychiatry 156:115-123, 1999.
4. Christiana JM et al: Duration between onset and tie of obtaining initial treatment among people with anxiety and mood disorders: an international survey of members of mental health patient advocate groups. Psychological Medicine 30: 693-703, 2000.
5. Olfson M, et al: Psychiatric disorder onset and first treatment contact in the United States and Ontario. Am J Psychiatry 155:1415-1422, 1998.
6. Kessler RC, et al.: Patterns and predictors of treatment contact after first onset of psychiatric disorders. Am J Psychiatry 155:62-69, 1998.
7. Olfson M: Barriers to the Effective Treatment of Anxiety Disorders. Lecture presented at the APA 2001 Annual Meeting, May 5-10, 2001, New Orleans, Louisiana.
8. Mojtabai R, et al., unpublished data reported by Olfson M in Barriers to the Effective Treatment of Anxiety Disorders. Lecture presented at the APA 2001 Annual Meeting, May 5-10, 2001, New Orleans, Louisiana.
9. Padgett DK, et al: Ethnicity and the use of outpatient mental health services in the national insured population. Am J Public Health 84:222-226, 1994.
10. Olfson M, et al: Barriers to treatment of social anxiety. Am J Psychiatry 157:521-527, 2000.
11. Spitzer RL, et al: Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 Study. JAMA 272(22):1749-56, 1994.
12. Weiller E, et al: Social phobia in general health care: an unrecognized undertreated disabling disorder. Br J Psychiatry 168:169-174, 1996.
13. Shear MK, et al: Diagnosis of nonpsychotic patients in community clinics. Am J Psychiatry 157:581-587, 2000.
14. First MD, et al: Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). New York, New York State Psychiatric Institute, Biometrics Research, 1995.
15. Salzman C, et al: Pharmacologic treatment of anxiety disorders in 1989 versus 1996: results from the Harvard/Brown anxiety disorders research program. J Clin Psychiatry 62(3):149-52, 2001.
16. Sirey JA, et al: Predictors of antidepressant prescription and early use among depressed outpatients. Am J Psychiatry 156:690-696, 1999.
17. Sleath B, et al: Physician vs patient initiation of psychotropic prescribing in primary care settings: a content analysis of audiotapes. Soc Sci Med 44(4):541-548, 1997.
18. Young AS, et al: The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry 58:55-61, 2001.
19. Dwight-Johnson M, et al: Treatment preferences among depressed primary care patients. J Gen Intern Med 15:527-534, 2000.
20. Lin EHB, et al: The role of the primary care physician in patient's adherence to antidepressant therapy. Med Care 33:67-74, 1995.
21. Roy-Byrne P, et al: A randomized effectiveness trial of an intervention for panic disorder in primary care. In press, Arch Gen Psychiatry.
22. Melfi CA, et al: The effects of adherence to antidepressant treatment guidelines on relapse and recurrence of depression. Arch Gen Psychiatry 55:1128-32, 1998.

 

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