Anxiety Disorders are Underdiagnosed and Undertreated in Primary Care

As with depression, the rate of undetected or undertreated anxiety in primary care is substantial. The twelve month prevalence of anxiety disorders in the general community is 19.3%, and is several fold greater in primary care settings (1).

In a three site investigation of university-affiliated primary care practices, researchers found that only 33% of patients diagnosed with anxiety had received any counseling for the condition, and only 25% had received counseling from a mental health professional (the remaining 8% had been counseled by the primary care team only).

Further, only about 10% of these patients received counseling that included multiple elements of cognitive behavioral therapy, the recommended best counseling practice for anxiety disorders. Finally, only 40% of those thus diagnosed received appropriate anti-anxiety medication, and only 25% received those medications at minimally adequate dosage and duration (2).

Of particular note is that these indicia of under-diagnosis and under-treatment of anxiety disorders were found in the primary care practices of university health systems known for their leadership in the area of behavioral health and primary care integration.

Also as with depression, undiagnosed or under-treated anxiety increases patients' utilization of health care services, increases diagnostic testing and hospitalization, consumes large amounts of PCP time, increases misuse of alcohol and prescription and street drugs, and compromises management of co-existing chronic illnesses like diabetes, CHF and COPD (3).

Abundant data point the way to effective management of psychiatric illness in primary care, and to integration of the two disciplines. The remaining challenge - and it is substantial - is translational: Getting what we know from the research setting embedded more firmly and generally in the world of day to day practice. For decision support regarding diagnosis and treatment of the various anxiety disorders, visit the Anxiety Disorders Guideline area of the Federal Agency for Healthcare Research and Quality (AHRQ - Anxiety Guidelines).

(1) Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H-U, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8–19 (2) Stein, MB, Sherbourne, CD, Craske, MG, Means-Christiensen, A, Bystrinsky, A., Katon, W, Sullivan, G, Roy-Byrne, P: Quality of care for primary care patients with anxiety disorders. The American Journal of Psychiatry 2004; 161(12), 2230-2237. (3) Roy-Byrne PP, Stein MB, Russo J, Mercier E, Thomas R, McQuaid JR, Katon WJ, Craske MG, Bystritsky A, Sherbourne CD: Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment. J Clin Psychiatry 1999; 60:492–499