Primary care patients with anxiety disorders receive potentially adequate medication

Racial disparity evident

A new study by Brown University psychiatry researchers found that seven in 10 primary care patients with anxiety disorders eventually received potentially adequate medication or psychotherapy, but for many it took years to happen and it was considerably less likely for minorities.

In the five-year study of 534 people published online Nov. 4 in the journal Depression and Anxiety, researchers found that 28 percent of them were receiving "potentially adequate" medication (19 percent) or psychotherapy (14 percent) or both when first recruited into the study from one of 15 primary care sites in four New England states. By year five of follow-up, 69 percent had received either or both appropriate medication (60 percent) or psychosocial treatment, such as cognitive behavioral therapy (36 percent).

"The good news here was that eventually, most patients got some good treatment," said study lead author Risa Weisberg, associate professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University. "The bad news is that pharmacotherapy wasn't sustained for long periods of time, that cognitive-behavioral therapy was rarely received even over the longer time period, and that ethno-racial minorities were less likely to get good care."

Most studies of anxiety treatment adequacy have only looked at one time point and have therefore found very low levels of care. But anxiety disorders are often chronic and primary care providers typically have an ongoing relationship with patients, Weisberg said. This study looked at a longer term.

Another key feature of the study was that it measured the provision of "potentially adequate" therapy. In the case of medication, that meant a drug had to have known efficacy and be taken at an adequate dose for enough time. For psychotherapy, the authors defined cognitive therapy or behavioral therapy as potentially adequate based on the method having empirical support and on meeting basic benchmarks such as identifying problematic patterns in thinking and recommending a course to change them or asking patients to conduct exposure exercises in which they attempt to engage in feared behaviors.

Although over the course of five years many patients eventually received care, some patients were less likely to receive it. Minorities, for example, were less than half as likely to receive "potentially adequate" treatment for anxiety either at the beginning of the five-year study period or by the end. People of any race or ethnicity with a college education, on the other hand, were almost twice as likely to receive care.

The patients were recruited through via the Primary Care Anxiety Project and were tracked through a follow-up period that ran from 2002 to 2007.

Weisberg said it is possible that rates of referral to potentially adequate care have categorically increased since then, but there was no evidence in the study data that the rates were systematically increasing during the study's five-year period.

Instead, she said, patients may take a while to eventually get potentially adequate care because primary care physicians often employ a strategy of "watchful waiting" to see if symptoms will improve. Weisberg and her co-authors noted in the study that patients with more severe anxiety symptoms were more likely to get potentially adequate care.

In a future work, Weisberg said, she hopes to study explicitly what triggers the start of anxiety therapy for primary care patients.