The treatment of anxiety disorders in a primary care HMO setting

Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment

Tobacco use, and thus tobacco-related morbidity, is elevated amongst patients with behavioral health treatment needs. Consequently, it is important that centers providing health care to this group mandate providers' use of tobacco screenings to inform the need for tobacco use disorder intervention. This study examined the prevalence of mandated tobacco screenings in 80 centers providing health care to Texans with behavioral health needs, examined key factors that could enhance screening conduct, and delineated providers' perceived barriers to tobacco use intervention provision. The results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in health records and were marginally more likely to make training on tobacco screening available to providers. The most widespread barriers to tobacco use disorder care provision were relative perceived importance of competing diagnoses, lack of community resources to refer patients, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, the results suggest that there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to better address tobacco-related health disparities in this group. Health care centers can support their providers to intervene in tobacco use by mandating screenings, streamlining clinical workflows with hard stops in patient records, and educating providers about the importance of treating tobacco with brief evidence-based intervention strategies while providing accurate information about patients' interest in quitting and providers' potential impacts on a successful quit attempt.

Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research

Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.

Preparing the workforce for integrated healthcare: A systematic review

Integrated healthcare is recommended to deliver care to individuals with co-occurring medical and mental health conditions. This literature review was conducted to identify the knowledge and skills required for behavioral health consultants in integrated settings. A review from 1999 to 2015 identified 68 articles. Eligible studies examined care to the U.S. adult population at the highest level of integration. The results provide evidence of specific knowledge of medical and mental health diagnoses, screening instruments, and intervention skills in integrated primary care, specialty medical, and specialty mental health. Further research is required to identify methods to develop knowledge/skills in the workforce.

Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care

BACKGROUND

Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services.

METHODS

Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data.

RESULTS

Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals.

CONCLUSION

Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care.

Treatment of active duty military with PTSD in primary care: A follow-up report

First-line trauma-focused therapies offered in specialty mental health clinics do not reach many veterans and active duty service members with posttraumatic stress disorder (PTSD). Primary care is an ideal environment to expand access to mental health care. Several promising clinical case series reports of brief PTSD therapies adapted for primary care have shown positive results, but the long-term effectiveness with military members is unknown. The purpose of this study was to determine the long-term outcome of an open trial of a brief cognitive-behavioral primary care-delivered protocol developed specifically for deployment-related PTSD in a sample of 24 active duty military (15 men, 9 women). Measures of PTSD symptom severity showed statistically and clinically significant reductions from baseline to posttreatment that were maintained at the 6-month and 1-year follow-up assessments. Similar reductions were maintained in depressive symptoms and ratings of global mental health functioning.

Differences in prescribing patterns for anxiety and depression between General Internal Medicine and Family Medicine

INTRODUCTION

Depression and anxiety are routinely managed by physicians in Family Medicine (FM) or General Internal Medicine (GIM). Because FM requires more behavioral health training than GIM, we sought to determine if prescribing patterns for patients with anxiety, depression, or both differed between FM vs. GIM providers.

METHODS

In a cross-sectional design, patient data and provider type were obtained from 2008 to 2013 electronic medical record patient data registry (n=27,225 (FM=10,994, GIM=16,231)) Prescription orders were modeled for specific benzodiazepines and antidepressants and by drug class. Covariates included gender, age, race, marital status and comorbidity index. Separate logistic regression models were computed, before and after adjusting for covariates, to estimate the odds of FM vs. GIM providers prescribing benzodiazepine or antidepressant medication to patients with anxiety, depression, and both disorders.

RESULTS

After adjusting for covariates, patients with anxiety alone, depression alone, and both had significantly greater odds of receiving an antidepressant (OR=2.08;95%CI:1.46-2.96, OR=2.13;95%CI:1.48-3.06, and OR=2.26;95%CI:1.09-4.66, respectively) if treated by FM vs. GIM. Benzodiazepine prescription did not differ by physician type.

LIMITATIONS

It is not known if results will generalize to other regions of the United States.

CONCLUSIONS

Patients with anxiety, depression, and both seen by FM providers, as compared to GIM providers, are more likely to receive antidepressant medications. Further investigation into the determinants of these differences is warranted. Under-treatment in GIM may result in less advantageous outcomes.

Suicidal ideation and risk factors in primary care patients with anxiety disorders

The presence of an anxiety disorder is associated with greater frequency of suicidal thoughts and behaviors. Given the high personal and societal costs of suicidal behaviors, suicide prevention is a priority. Understanding factors present within individuals with anxiety disorders that increase suicide risk may inform prevention efforts. The aims of the present study were to examine the prevalence of suicidal ideation and behaviors, as well as factors associated with suicide risk in patients with anxiety disorders in primary care. Data from a large scale randomized controlled study were analyzed to assess prevalence of suicidal thoughts and behaviors, as well as factors associated with suicide risk. Results revealed that suicidal ideation and behaviors were relatively common in this group. When examining mental and physical health factors jointly, presence of depression, mental health-related impairment, and social support each uniquely accounted for variance in suicide risk score. Methodological limitations include cross-sectional data collection and lack of information on comorbid personality disorders. Moreover, patients included were from a clinical trial with exclusion criteria that may limit generalizability. Results highlight the complex determinants of suicidal behavior and the need for more nuanced suicide assessment in this population, including evaluation of comorbidity and general functioning.

Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study

OBJECTIVE

To determine the incidence of major depressive disorder, bipolar disorder, panic disorder, social anxiety disorder, and generalized anxiety disorder and to assess their detection rates in the Canadian primary care setting.

METHOD

The descriptive, cross-sectional study was conducted in 7 primary care clinics in 3 Canadian provinces, Ontario, British Columbia, and Nova Scotia, from December 6, 2005, to May 5, 2006. Patients in clinic waiting rooms who consented to participate in the study were administered the Mini International Neuropsychiatric Interview (MINI) (N = 840). These patients' medical charts were then reviewed for evidence of previous diagnosis of a mood or anxiety disorder. Misdiagnosis was defined as cases for which a diagnosis was reached on the MINI but not in the patient's chart.

RESULTS

Of the 840 primary care patients assessed, 27.2%, 11.4%, 12.6%, 31.2%, and 16.5% of patients met criteria for major depressive disorder, bipolar disorder, panic disorder, generalized anxiety disorder, and social anxiety disorder, respectively. Misdiagnosis rates reached 65.9% for major depressive disorder, 92.7% for bipolar disorder, 85.8% for panic disorder, 71.0% for generalized anxiety disorder, and 97.8% for social anxiety disorder.

CONCLUSIONS

With high prevalence rates and poor detection, there is an obvious need to enhance diagnostic screening in the primary care setting.

Effectiveness of cognitive behavioural therapy in primary health care: a review

BACKGROUND

Depression and anxiety are highly prevalent disorders causing substantial impairment in daily life. Cognitive behavioural therapy (CBT) delivered face-to-face or as self-help has shown to be an effective treatment for these disorders. Such treatments may be suitable for delivery in primary health care.

AIM

The aim of the article was to review research on the effectiveness of CBT for depression and anxiety disorders delivered in primary care by primary care therapists.

METHODS

A literature search of quantitative studies of the effectiveness of CBT delivered in primary care was conducted on multiple electronic databases. A total of 17 studies were included in the review.

RESULTS

Eight studies of supported Internet- or computer-based CBT, six of which were randomized controlled trials (RCTs), indicate that this treatment is effective for mild to moderate depression and anxiety. Five studies suggest that this treatment may be more effective than usual care for mild to moderate but not for more severe symptoms. Results of four RCTs of brief therapies using written self-help material suggest that while such interventions are effective, no particular approach outperformed any other, including usual care. Five RCTs of CBT delivered face-to-face show that this treatment can be effective when delivered by therapists highly educated in the mental health field. However, many primary care therapists may find such interventions too time consuming.

CONCLUSIONS

CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists.

The relationship between sleep disturbance and the course of anxiety disorders in primary care patients

This study examined the relationship between sleep disturbance and the course of anxiety disorders in primary care patients. Participants were part of the Primary Care Anxiety Project (PCAP), a naturalistic, longitudinal study of anxiety disorders in primary care. Participants completed an intake evaluation and follow-up assessments at 6 months, 12 months, and annually thereafter. Only participants with sleep data at intake were included in the current study (n=533). The majority (74%) reported experiencing sleep disturbance at intake. Those with a diagnosis of generalized anxiety disorder (GAD) or post-traumatic stress disorder (PTSD) were over 2 times more likely to have sleep problems. Sleep disturbance at intake did not relate to the longitudinal course of GAD, social phobia, panic disorder, or obsessive-compulsive disorder. However, it did predict the course of PTSD, controlling for comorbid major depressive disorder (MDD) and having more than one anxiety disorder diagnosis intake, those with sleep disturbance at intake being less likely to remit from PTSD in the 5 years of follow-up. By year 5, only 34% of those with sleep problems at intake remitted from PTSD whereas 56% of those without sleep disturbance remitted from the disorder. The findings suggest that sleep disturbance in PTSD may have prognostic significance and may be important to address in clinical interventions.

Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus

OBJECTIVE

To examine the lifetime prevalence of mood and anxiety disorders in patients with systemic lupus erythematosus (SLE). Demographic and disease-related variables were examined for association with lifetime major depressive disorder (MDD) and the presence of any mood or anxiety disorder.

METHODS

Three hundred twenty-six white women with SLE completed the Composite International Diagnostic Interview and the Systemic Lupus Activity Questionnaire, a self-report measure of SLE disease activity. The binomial test was used to compare the prevalence of psychiatric diagnoses in patients with SLE with a population sample of white women.

RESULTS

Sixty-five percent of the participants received a lifetime mood or anxiety diagnosis. MDD (47%), specific phobia (24%), panic disorder (16%), obsessive-compulsive disorder (9%), and bipolar I disorder (6%) were more common among patients with SLE than among other white women (P = 0.00009 for specific phobia; for all other values P = 0.00001). Although most patients with histories of mood disorders reported their psychiatric symptoms to a medical provider, a substantial number of patients with anxiety disorders did not. Self-reported disease activity was associated with a lifetime history of MDD (P = 0.001) and presence of a mood or anxiety disorder (P = 0.001), after controlling for demographic and clinical characteristics.

CONCLUSION

Several mood and anxiety disorders were more common in women with SLE compared with the general population, and disease activity may contribute to this higher risk. Brief self-report questionnaires may help providers identify patients with these conditions, particularly when patients are reluctant to disclose their symptoms.

Co-occurrence of Insomnia and Anxiety Disorders: A Review of the Literature

Insomnia and anxiety disorders are highly prevalent and are associated with significant impairment and disability. There is evidence that insomnia and anxiety disorders commonly co-occur, in addition to both being highly comorbid with major depressive disorder. Thus, it is important for health care providers to be familiar with the literature in this area. Therefore, the purpose of this review was to examine the empirical literature on the co-occurrence of insomnia and anxiety disorders, as well as discuss the clinical and research implications of the findings. Studies were identified through PubMed and PsycINFO searches (1975-2007) and a bibliographic review of published articles. The results from this literature review suggest that certain anxiety disorders, such as panic disorder and generalized anxiety disorder, are clearly associated with symptoms of insomnia (eg, delayed sleep onset, restless sleep). Although there are some discrepancies in the literature, the findings suggest that individuals with posttraumatic stress disorder also experience significant sleep problems (eg, middle-of-the-night insomnia, poor sleep quality, nightmares), and the presence of such problems during the early posttrauma period predicts later development of the disorder. Few empirical studies examine sleep in other anxiety disorders, and the majority of studies on insomnia and anxiety disorders in general have not examined the effects of comorbid major depressive disorder, indicating a need for additional research. Overall, the findings highlight the importance of screening for and treating anxiety symptoms when a patient presents with symptoms of insomnia and vice versa. Clearly, treatment development work on interventions that address co-occurring insomnia and anxiety disorders is greatly needed.

Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety

OBJECTIVE

To summarize current evidence on the effectiveness of different knowledge transfer and change interventions for improving primary and ambulatory anxiety care to provide guidance to professionals and policy-makers in mental health care.

METHOD

We searched electronic medical and psychological databases, conducted correspondence with authors, and checked reference lists. Studies examining the effectiveness of knowledge transfer and interventions targeted at improvement of the recognition or management of anxiety in primary and ambulatory health care settings were included. Methodological details and outcomes were independently extracted and checked by 2 reviewers. Where appropriate, data concerning the impact of interventions on symptoms of anxiety were pooled using metaanalytical procedures.

RESULTS

We identified 24 studies that met our inclusion criteria. Seven professional-directed interventions and 17 organizational interventions (including patient-oriented interventions) were identified. The methodological quality of studies was variable. Professional-directed interventions only impact the process and outcome of care when embedded in some sort of organizational intervention. Metaanalysis (n = 8 studies) showed no effect of diverse organizational interventions on patients' anxiety symptoms (effect size, -0.08; 95% confidence interval, -0.31 to 0.15; P = 0.50). Collaborative care interventions proved to be the most effective organizational intervention strategies. Six studies reported economic results: 4 studies showed that intervention had a high probability of being cost-effective.

CONCLUSIONS

Collaborative care seems to be very promising for improving primary and ambulatory care for anxiety. At the level of management and policy, the results of this review mandate the need to offer fair and reasonable reimbursement for collaborative care programs.

Psychiatric treatment in primary care patients with anxiety disorders: a comparison of care received from primary care providers and psychiatrists

OBJECTIVE

This study examined psychiatric treatment received by primary care patients with anxiety disorders and compared treatment received from primary care physicians and from psychiatrists.

METHOD

Primary care patients at 15 sites were screened for anxiety symptoms. Those screening positive were interviewed to assess for anxiety disorders. Information on psychiatric treatment received and provider of pharmacological treatment were collected.

RESULTS

Of 539 primary care participants with at least one anxiety disorder, almost half (47.3%) were untreated. Nearly 21% were receiving medication only for psychiatric problems, 7.2% were receiving psychotherapy alone, and 24.5% were receiving both medication and psychotherapy. Patients receiving psychopharmacological treatment received similar medications, often at similar dosages, regardless of whether their prescriber was a primary care physician or a psychiatrist. One exception was that patients were less likely to be taking benzodiazepines if their provider was a primary care physician. Those receiving medications from a primary care provider were also less likely to be receiving psychotherapy. Overall, patients with more functional impairment, more severe symptoms, and comorbid major depression were more likely to receive mental health treatment. Members of racial/ethnic minority groups were less likely to be treated. Frequently endorsed reasons for not receiving pharmacological treatment were that the primary care physician did not recommend it and the patient did not believe in taking medication for emotional problems.

CONCLUSIONS

Nearly half the primary care patients with anxiety disorders were not treated. However, when they were treated, the care received from primary care physicians and psychiatrists was relatively similar.

Anxiety in primary care

Anxiety disorders are common within primary care (PC) settings and are associated with patient functional impairment, distress, and high utilization of medical care services. Data from PC settings indicate that detection of anxiety disorders is low. Furthermore, adequate psychosocial and pharmacologic treatment of anxiety disorders in accordance with empirically validated guidelines remains low in PC. When patients do receive treatment or referrals from their PC providers, a bias exists for pharmacologic over psychological interventions despite theoretical strengths, empirical evidence, and long-term cost efficiency supporting the use of psychotherapeutic interventions such as cognitive-behavioral therapy (CBT). Objectives of this article include increasing awareness of the prevalence of anxiety disorders in PC, impairment associated with anxiety disorders, issues of detection of anxiety in PC, treatment model and components of CBT, and data supporting the application of CBT to PC to improve patient functioning.

Frequency and patterns of psychiatric comorbidity in a sample of primary care patients with anxiety disorders

The current report examines the rates of psychiatric comorbidity in a sample of 539 primary care patients diagnosed with anxiety disorders using the Structured Clinical Interview for DSM-IV (SCID-IV). Though not a typical psychiatric sample, rates of comorbidity were found to be as high or higher than those reported in studies conducted in traditional mental health settings. Multiple anxiety disorders were diagnosed in over 60% of participants and over 70% of participants had more than one current axis I diagnosis. Rates of current and lifetime comorbid major depression were also very high. Patterns of diagnostic comorbidity were also examined, with significantly elevated risks for the co-occurrence of several specific pairings of disorders being found. The study results are discussed in context of a recently published, large-scale study of anxiety disorder comorbidity in psychiatric patients (Brown et al., 2001). Implications of these results for both the mental health and primary care fields are also discussed.

Mental health treatment received by primary care patients with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is receiving growing attention as a pervasive and impairing disorder but is still undertreated. Our purpose was to describe the characteristics of mental health treatment received by primary care patients diagnosed with PTSD.

METHOD

4383 patients from 15 primary care, family practice, or internal medicine clinics were screened for anxiety symptoms using a self-report questionnaire developed for the study. Those found positive for anxiety symptoms (N = 539) were interviewed with the Structured Clinical Interview for DSM-IV. Of these patients, 197 met diagnostic criteria for PTSD and were examined in the present study regarding the rates and types of mental health treatment they were currently receiving. Data were gathered from July 1997 to May 2001.

RESULTS

Nearly half (48%) of the patients in general medical practice with PTSD were receiving no mental health treatment at the time of intake to the study. Of those receiving treatment, psychopharmacologic interventions were most common. Few patients were receiving empirically supported psychosocial interventions. Current comorbid major depressive disorder and current comorbid panic disorder with agoraphobia were significantly associated with receiving mental health treatment (major depressive disorder, p <.10; panic disorder with agoraphobia, p <.05). The most common reason patients gave for not receiving medication was the failure of physicians to recommend such treatment, which was also among the most common reasons for not receiving psychosocial treatment.

CONCLUSIONS

Despite the morbidity, psychosocial impairment, and distress associated with PTSD, substantial proportions of primary care patients with the disorder are going untreated or are receiving inadequate treatment. Results suggest a need for better identification and treatment of PTSD in the primary care setting.