Perceived social support mediates anxiety and depressive symptom changes following primary care intervention.

BACKGROUND: The current study tested whether perceived social support serves as a mediator of anxiety and depressive symptom change following evidence-based anxiety treatment in the primary care setting. Gender, age, and race were tested as moderators. METHODS: Data were obtained from 1004 adult patients (age M = 43, SD = 13; 71% female; 56% White, 20% Hispanic, 12% Black) who participated in a randomized effectiveness trial (coordinated anxiety learning and management [CALM] study) comparing evidence-based intervention (cognitive-behavioral therapy and/or psychopharmacology) to usual care in the primary care setting. Patients were assessed with a battery of questionnaires at baseline, as well as at 6, 12, and 18 months following baseline. Measures utilized in the mediation analyses included the Abbreviated Medical Outcomes (MOS) Social Support Survey, the Brief Symptom Index (BSI)-Somatic and Anxiety subscales, and the Patient Health Questionnaire (PHQ-9). RESULTS: There was a mediating effect over time of perceived social support on symptom change following treatment, with stronger effects for 18-month depression than anxiety. None of the mediating pathways were moderated by gender, age, or race. CONCLUSIONS: Perceived social support may be central to anxiety and depressive symptom changes over time with evidence-based intervention in the primary care setting. These findings possibly have important implications for development of anxiety interventions.

Does a quality improvement intervention for anxiety result in differential outcomes for lower-income patients?

OBJECTIVE: The authors examined the effects of a collaborative care intervention for anxiety disorders in primary care on lower-income participants relative to those with higher incomes. They hypothesized that lower-income individuals would show less improvement or improve at a lower rate, given that they would experience greater economic stress over the treatment course. An alternative hypothesis was that lower-income participants would improve at a higher rate because the intervention facilitates access to evidence-based treatment, which typically is less available to persons with lower incomes. METHOD: Baseline demographic and clinical characteristics of patients with lower (N=287) and higher (N=717) income were compared using t tests and chi-square tests for continuous and categorical variables, respectively. For the longitudinal analysis of intervention effects by income group, the outcome measures were jointly modeled at baseline and at 6, 12, and 18 months by study site, income, time, intervention, time and intervention, income and time, income and intervention, and time, intervention, and income. RESULTS: Although lower-income participants were more ill and had greater disability at baseline than those with higher incomes, the two income groups were similar in clinical response. The lower-income participants experienced a comparable degree of clinical improvement, despite receiving fewer treatment sessions, less relapse prevention, and less continuous care. CONCLUSIONS: These findings contribute to the ongoing discussion as to whether or not, and to what extent, quality improvement interventions work equally well across income groups or require tailoring for specific vulnerable populations.

Anxiety treatment improves physical functioning with oblique scoring of the SF-12 short form health survey.

OBJECTIVE: No studies have found a positive effect of anxiety treatment on physical functioning, but recent investigations of the 12-item Short Form Health Questionnaire (SF-12), which is frequently used to assess physical functioning, have suggested that orthogonal scoring of the summary measure may distort representations of physical health. The current study reanalyzes whether anxiety treatment improves physical functioning using oblique scoring in the Coordinated Anxiety Learning and Management (CALM) randomized clinical trial for the treatment of anxiety disorders. Replication was tested in reanalysis of data from the earlier Collaborative Care for Anxiety and Panic (CCAP) randomized clinical trial for the treatment of panic disorder. METHOD: The CALM study included 1004 primary care patients with panic, social anxiety, generalized anxiety or posttraumatic stress disorders. Patients received usual care (UC) or an evidence-based intervention (cognitive behavioral therapy, psychotropic medication or both; ITV). Physical functioning (SF-12v2) was assessed at baseline and at 6, 12 and 18 months. Oblique and orthogonal scoring methods for the physical functioning aggregate measure from SF-12 scale items were compared. RESULTS: In CALM, physical functioning improved to a greater degree in ITV than UC for oblique but not orthogonal scoring. Findings were replicated in the CCAP data. CONCLUSIONS: Evidence-based treatment for anxiety disorders in primary care improves physical functioning when measured using oblique scoring of the SF-12. Due to this scoring issue, effects of mental health treatment on physical functioning may have been understated.

Functional impact and health utility of anxiety disorders in primary care outpatients.

OBJECTIVE: The objective of this study was to examine the relative impact of anxiety disorders and major depression on functional status and health-related quality of life of primary care outpatients. METHOD: Four hundred eighty adult outpatients at an index visit to their primary care provider were classified by structured diagnostic interview as having anxiety disorders (panic disorder with or without agoraphobia, social phobia, and posttraumatic stress disorder; generalized anxiety disorder was also assessed in a subset) with or without major depression. Functional status, sick days from work, and health-related quality of life (including a preference-based measure) were assessed using standardized measures adjusting for the impact of comorbid medical illnesses. Relative impact of the various anxiety disorders and major depression on these indices was evaluated. RESULTS: In multivariate regression analyses simultaneously adjusting for age, sex, number of chronic medical conditions, education, and/or poverty status, each of major depression, panic disorder, posttraumatic stress disorder, and social phobia contributed independently and relatively equally to the prediction of disability and functional outcomes. Generalized anxiety disorder had relatively little impact on these indices when the effects of comorbid major depression were considered. Overall, anxiety disorders were associated with substantial decrements in preference-based health states. CONCLUSIONS: These observations demonstrate that the presence of each of 3 common anxiety disorders (ie, panic disorder, posttraumatic stress disorder, and social phobia)-over and above the impact of chronic physical illness, major depression, and other socioeconomic factors-contributes in an approximately additive fashion to the prediction of poor functioning, reduced health-related quality of life, and more sick days from work. Greater awareness of the deleterious impact of anxiety disorders in primary care is warranted.

Assessment of beliefs about psychotropic medication and psychotherapy: development of a measure for patients with anxiety disorders.

OBJECTIVE: This study presents the psychometric properties of a brief measure to assess beliefs about psychotropic medications and psychotherapy among patients with anxiety disorders. METHOD: Data were collected on a large sample of primary care patients with a range of anxiety disorders, as part of the Collaborative Care for Anxiety and Panic study. Factor analyses using principal axis factoring with Varimax rotations were used to determine the factor structure of the beliefs scale. Internal consistency, concurrent validity and predictive validity of the resulting subscales were examined. RESULTS: Two subscales emerged, one reflecting beliefs about psychotropic medications and the other assessing beliefs about psychotherapy. Both showed strong internal consistency and concurrent validity. The beliefs about psychotropic medication demonstrated strong predictive validity. CONCLUSIONS: This measure may be a useful tool for assessing treatment beliefs among patients with anxiety disorders toward the provision of more quality treatment for this population. Its brevity may make it particularly useful in primary health care settings.

Perceived unmet need for mental health treatment and barriers to care among patients with panic disorder.

OBJECTIVE: This study estimated the extent of perceived unmet need for mental health treatment among individuals with panic disorder in primary care settings, investigated the determinants of unmet need, and assessed barriers to care. METHODS: Data were from baseline interviews in a clinical trial that investigated primary care treatment of panic disorder. Participants were asked whether there was any time in the past three months when they did not get as much care for emotional or personal problems as they needed or whether they had delays in getting care. Patients who endorsed unmet need were asked about specific perceived barriers. Logistic regression was used to investigate the determinants of unmet need. RESULTS: Of the 231 patients eligible for the study, 88 (38 percent) endorsed unmet need for emotional or mental health problems. Individuals with worse mental health, those who were more worried about panic, and those without sick pay were significantly more likely to report unmet need. Commonly reported barriers included being unable to find out where to go for help (43 percent), worry about cost (40 percent), lack of coverage by health plan (35 percent), and being unable to get an appointment soon enough (35 percent). CONCLUSIONS: The relatively low level of patient-reported unmet need for mental health treatment among primary care patients with panic disorder suggests that efforts to improve treatment of panic disorder should include patient education about mental illness and the effective treatments available. Although discussion of barriers to care has traditionally centered on stigma and economic factors, the results of this study suggest that simple logistic factors, such as not knowing whom to call for help, are also important barriers.

Beliefs about psychotropic medication and psychotherapy among primary care patients with anxiety disorders.

Primary health care clinics are increasingly providing psychiatric/psychological treatment of anxiety disorders, particularly for patients who do not have adequate access to specialty mental health services. Adequate treatment requires knowledge of and attention to patients' beliefs about available treatment options. The current investigation examined beliefs about psychotropic medications and psychotherapy among a sample of primary care patients with anxiety disorders. The influence of key demographic variables on strength of these beliefs was also explored. The presence of specific anxiety disorders was not found to impact strength of beliefs about either type of treatment. In contrast, there was a trend for the presence of depression to relate to more favorable attitudes toward psychotropic medication. Consistent with previous studies, ethnic minority patients reported less favorable attitudes toward both psychotropic medications and psychotherapy. These findings underscore the importance of assessing patient beliefs prior to the initiation of either psychotropic medications or psychotherapy across diagnostic and demographic groups. Practitioners should be particularly alert to the possibility that patients with anxiety disorders and members of ethnic minority groups may have less favorable attitudes toward treatment options. Treatment adherence may therefore be increased by addressing these beliefs directly.

Use of herbal medicine in primary care patients with mood and anxiety disorders.

Studies have documented the increasing use of complementary and alternative medicine over the last decade, especially in distressed individuals with symptoms of anxiety, depression, and pain. Herbal medicine is a specific form of complementary and alternative medicine often used by individuals seeing traditional medical practitioners and, hence, has the potential to interact with other medically prescribed treatments. The study examined the use of herbal medicine in a group of primary care patients with symptoms of anxiety and depression. The rate of use of herbal medicines was 11%, and use was selectively associated with a diagnosis of major depression, higher education, and a lower burden of medical illness. Use was not associated with receipt of pharmacotherapy or psychotherapy for anxiety or depression.

Improving clinical trials: American Society of Clinical Psychopharmacology recommendations.

The major purpose of this American Society of Clinical Psychopharmacology-sponsored meeting was to identify strategies for more efficiently detecting clinical drug effects, thus reducing the economic and scientific risks of investigating new chemical entities in psychiatric disorders. The meeting consisted of presentations and discussions by experts who repeatedly had difficulty pursuing scientific, public health--relevant goals. Many approaches to improving the detection of potentially beneficial agents were reviewed. In this article, we discuss technically feasible study improvements. The scope of inquiry included identifying means of shifting institutional and regulatory assumptions and processes, even to the point of seeking appropriate national incentives.