In a study of 15 New England medical practices, only half the primary care
patients with anxiety disorders were receiving treatment, possibly because
patients rejected treatment or doctors failed to recommend it. However, both
primary care physicians and psychiatrists chose similar medications and
dosages when prescribing pharmacotherapy.
"These data suggest that there remains substantial room for further
improvement in reducing the burden of anxiety disorders on society,"
wrote Risa Weisberg, Ph.D., and colleagues in the February American
Journal of Psychiatry.
Such improvement is dependent on a number of factors, including better
identification and treatment of patients in primary care settings and
addressing barriers that prevent patients from obtaining or seeking the care
Little is known about care in primary practices of patients with anxiety,
said Weisberg, an assistant professor (research) in the departments of
psychiatry and behavioral sciences and family medicine at Brown University
School of Medicine.
To remedy that lack of information, the researchers recruited patients from
waiting rooms in primary care practices in New Hampshire, Vermont,
Massachusetts, and Rhode Island. The study did not track whether the patients
had been diagnosed previously with anxiety.
Those who were interested in participating in the study completed a
self-report form designed to evaluate the key features of DSM-IV
anxiety disorders. The patients who screened positive for anxiety symptoms
were offered a full diagnostic interview using the SCID modules for mood,
substance use, and eating disorders; Global Assessment of Functioning Scale;
and the Global Social Adjustment Scale.
The research was part of the Primary Care Anxiety Project, which is
following patients with anxiety over a period of years. The current report
covers only baseline data, gathered from patients who entered the study from
1997 to 2001.
The study was funded by Pfizer Pharmaceuticals and a career-development
award from the National Institute of Mental Health.
Of the 539 patients with an anxiety disorder ultimately enrolled in the
study, 50 percent had more than one anxiety disorder. Many (41 percent) had
comorbid major depression, eating disorders (11 percent), or an alcohol or
substance use disorder (10 percent).
Only 284 of the patients (52.7 percent), however, were in treatment for
their psychiatric diagnoses at the time they were enrolled. Out of that group,
113 were prescribed medication alone, 132 were getting both medication and
psychotherapy, and 39 received psychotherapy alone.
"Anxiety is probably underrecognized because symptoms are not
presented or visible in the little time in the doctor's office, so the
higher-functioning patient slips by," she said. Many respondents said
they were unaware of having any problem, and others said their primary care
provider had not recommended treatment.
"Primary care physicians have a hard job," agreed Wayne Katon,
M.D., a professor and vice chair of psychiatry and behavioral sciences at the
University of Washington School of Medicine, in an interview.
"Eighty percent of patients with anxiety disorders present with
physical complaints, so their primary physician has to rule out any
life-threatening conditions before considering psychiatric diagnoses,"
he said. "Vague somatic complaints take precious time to figure out and
more time to educate patients and prescribe or refer them to
Of the 539 study participants, 245 were being treated with medications, in
about equal proportions from primary care physicians (41 percent) and
psychiatrists (40 percent). About 7 percent got their medications from other
The most commonly prescribed drugs from all clinicians were SSRIs (60
percent prescribed them) and benzodiazepines (35 percent). The equal use of
SSRIs by psychiatrists and primary care physicians suggests the latter know
about new developments in treating anxiety. Psychiatrists were more likely to
prescribe benzodiazepines, possibly because their patients had more severe
anxiety symptoms. The only factor predicting medication treatment from a
psychiatrist was the patient's lower score on the Global Social Adjustment
Scale. Medicare or Medicaid recipients were more likely to be treated by any
type of clinician than were patients with private insurance or no
"This was a surprise," said Weisberg, who is still studying
this point. "It's not just their ability to pay, but may be a proxy for
The researchers interviewed a subgroup of patients with anxiety disorder to
ask why they believed they were not receiving medication or psychotherapy.
Among those not treated with drugs, 39 percent said their primary care
provider had not prescribed medications for them. About 17 percent of patients
not getting psychotherapy gave the same reason. Almost 20 percent of those not
taking medications and 24 percent of those not receiving psychotherapy said
they didn't know they had a treatable problem. Furthermore, 37 percent of the
unmedicated group and 28 percent of those not getting psychotherapy said they
didn't believe in those types of treatment for emotional problems.
Such resistance may have cultural roots, said Weisberg. "We didn't
assess this, but I think that people feel that therapy or medication is just
not how they cope with problems. They'd rather 'tough it out' or 'get over
Weisberg made clear that her study should not be seen as an epidemiological
study of anxiety prevalence in private practice.
"Taking subjects out of a waiting room might give greater prominence
to 'high attenders,' that is, patients more likely to visit the doctor six or
10 times a year and who have greater psychological distress," said
Weisberg's group will continue its research by looking at how outcomes vary
by type of clinician to see whether patients in primary care do as well as
those under the care of specialists.
"Psychiatric Treatment in Primary Care Patients With Anxiety
Disorders: A Comparison of Care Received From Primary Care Providers and
Psychiatrists" is posted at<ajp.psychiatryonline.org>
under the February issue. ▪