Most individuals with anxiety disorders receive their mental health care from primary care providers.7;17
Many patients seen in primary care receive little or no treatment for their anxiety disorders.18
When care is received, it has often been noted to be suboptimal in terms of quality 12;29
Whereas an outpatient trend toward increased use of antidepressants and decreased use of psychotherapy for anxiety disorders was noted in the late 1990s 30
it is uncertain to what extent there has been an overall trend toward quality improvement.
The present study suggests that there remains a lot of room for improvement in the quality of care delivered to primary care outpatients with anxiety disorders. This study is neither a nationally representative sample, nor is it a longitudinal study, so direct comparison to other studies or to earlier times is not possible. However, the data show that less than half of outpatients in this relatively large sample (N = 1004) received guideline concordant care. This observation is particularly interesting (and worrisome) in that all patients had been recognized by their PCP as having a problem with anxiety by virtue of their referral to this study. In particular, although nearly 1/3 of patients received quality pharmacotherapy, only approximately 1/5 received quality psychotherapy. These data are consistent with prior studies that have pointed to particularly low rates of psychotherapy utilization and/or quality among primary care outpatients with anxiety disorders.12;18;30
But they also extend the findings by suggesting that awareness by the PCP of a current anxiety problem (though not necessarily its precise diagnostic type or severity) seems to have had little impact on quality of care (although more disabled patients were more likely to get better pharmacotherapy). The inference is that identification alone (i.e., making PCPs aware of their patient’s diagnosis and/or need for anxiety treatment) is unlikely to have a positive impact on quality of care for anxiety disorders.
Meta-analysis of knowledge transfer methods for improvement of primary care anxiety treatment shows that conventional educational strategies (e.g., conferences or passive dissemination of guidelines) have minimal impact on clinical practice and patient outcomes, whereas collaborative care approaches are much more promising.31
Our data point to several potential targets for improving such care in the future.
First, we noted the possible existence of particular sociodemographic disparities in the provision of quality care. Hispanic patients were less likely than other ethnic groups to receive quality pharmacotherapy. It is difficult to be certain about the origins of this disparity, which may, at least in part, reflect reduced preference for pharmacotherapy (e.g., with antidepressants) among certain minority groups.22
Although rates of anti-anxiety medication use were not lower among Hispanic patients, the lower rate of quality anti-anxiety pharmacotherapy may nonetheless reflect more subtle attitudinal factors consistent with lower preference for pharmacotherapy that could influence patient adherence (e.g., reluctance to increase dosage or to stay on the medication for adequate duration). This is an area that clearly requires more study, especially in light of other recent reports of ethnic disparities in mental healthcare for anxious and depressed outpatients.20;21
Second, we noted that persons with less education were significantly less likely to receive psychotherapy. Although this did not carry over to a significantly lower likelihood of receiving quality psychotherapy (perhaps because these rates were so low overall that a difference could not be detected), the fact that less educated persons were less likely to receive psychotherapy is a disparity that must be addressed in future research.
Third, we found higher rates of quality pharmacotherapy and psychotherapy when patients received some or all of their mental health care in specialty settings (e.g., seen by psychiatrists or psychologists, respectively). These observations underscore the notion that it is reasonable to expect that specialists can often (though not always) 18
provide more intensive or higher quality care than can reasonably be provided by PCPs, who must juggle many medical priorities in each time-limited visit. The fact that mental health specialists can bring added value does strongly suggest, however, that their integration into the primary healthcare equation cannot be overlooked. The challenge is how to most efficiently and cost-effectively incorporate their expertise.
The most striking finding to emerge from this study pertained to satisfaction with care, and its relationship to the provision of quality care. Patients who received quality psychotherapy (defined on the basis of the inclusion of elements consistent with evidence-based CBT for anxiety disorders) were the most satisfied with their mental health care. In fact, this was the only positive predictor of satisfaction. Moreover, a dose-response relationship was evident: the more CBT elements provided, and the greater the consistency of their delivery, the greater was the satisfaction with care. This relationship was not explained by the number of visits. On the contrary, it was the specific content of the visits, and not the number of visits, that tracked with satisfaction. Interestingly, the delivery of quality pharmacotherapy was not associated with satisfaction with care.
How are these findings pertaining to satisfaction to be interpreted? It seems readily apparent that patients both detect and value psychotherapies that target their principal complaint(s) in a direct fashion. Although it is improbable that many patients in this study were aware of the evidence in favor of CBT as a treatment for anxiety disorders, they nonetheless reported satisfaction with therapies that included CBT components, and especially when these components were provided consistently throughout the course of therapy. These data are consistent with the expressed treatment preferences of primary care patients with anxiety disorders for psychotherapies 32
which may be an additional reason to increase their availability. In contrast, patients did not seem to value quality pharmacotherapy in the same way, possibly – at least in part – because it would have been difficult for them to know whether or not the medication provided was at optimal dose or duration.
This study has a number of limitations that influence its interpretation. As noted earlier in this discussion, although it included a large, diverse, sample of anxious outpatients in 17 clinical settings spread across 4 regions in the US, it was purposively selected and cannot be expected to be representative of US outpatients with anxiety disorders. The fact that patients were referred by their PCPs suggests that this group may have been biased towards being more difficult to treat, and the generalizability of our findings should be considered in that context. Although this can be viewed as a limitation, that kind of sample is probably more relevant from a public health point of view since the spontaneous remitters or rapid responders are unlikely to occupy clinician time and service delivery resources.
Our methods for assessing quality of pharmacotherapy and psychotherapy, though built upon our prior work in this area 12
are still subject to possible response biases and to errors in reporting. In future work, it would be useful to have available objective measures of quality (e.g., from direct review of medical records) that do not rely on patient self-reporting. It could also be argued that our definition of quality psychotherapy was either too narrow or too broad. It is clear from our data that the mere act of seeing a therapist did not increase satisfaction with care. Although we based our quality indicators on the reported inclusion of particular CBT elements in therapy, critics might argue that other more subtle (e.g., sense by the patient that the therapist was empathic) or less CBT-specific indicators of quality – taking into consideration the possibility that other forms of psychotherapy may be useful for anxiety disorders 33
– should also have been included. Accordingly, additional research is needed to map out the various means by which quality and satisfaction can be increased.
Regardless of the explanation for the finding that CBT provision was strongly associated with satisfaction, the finding is robust and leads to the obvious recommendation that CBT should be included more often if the aim is to improve satisfaction with outpatient care for anxiety disorders. This recommendation would be even stronger if it is shown that the inclusion of CBT leads not only to greater satisfaction, but to improved symptomatic and functional outcomes. We are hopeful that future results from the CALM study, which included the option of a brief, computer-assisted form of CBT for primary care outpatients with anxiety disorders 19;27;34
will further inform this recommendation.