Recommendations for Psychological Treatment of Anxiety in Primary Care

The estimated prevalence of anxiety disorders among primary care patients is 15% to 20%, and subclinical anxiety affects a substantial number of additional patients.^1-3 However, findings suggest that only a minority of these individuals receive adequate pharmacologic or psychological treatment for anxiety in primary care clinics, although this is the preferred treatment setting cited by many patients.^4,5 Those who do receive adequate care for anxiety are treated with medication more often than with psychological interventions, despite the latter being the preference of most primary care patients.⁵

Studies on brief cognitive behavioral therapy (CBT) adapted for anxiety treatment in primary care have demonstrated large and moderate effect sizes (d=1.06 and 0.57, respectively).^6.7 CBT is well suited to this setting, as it has shown effectiveness for a range of anxiety disorders and is appropriate for brief sessions and treatment duration. According to a recent review funded by the Department of Veterans Affairs, increased implementation of integrated primary care (IPC) could help to improve the availability of psychological treatment for this patient population.⁵

One of the most common models of IPC service delivery is primary care behavioral health (PCBH), a population-based model^8,9 in which behavioral healthcare providers are “embedded within primary care to serve as consultants to [primary care physicians (PCPs)], providing assessment and brief intervention [while sharing] the same physical space, medical record, and treatment plan,” the review authors explained.⁵ “The PCBH model provides an excellent foundation for the translation of evidence-based psychological interventions into primary care to help meet the unmet treatment needs of primary care patients” with clinical or subclinical anxiety symptoms.

Noting the scarcity of evidence regarding PCBH, they examined research pertaining generally to psychological interventions for anxiety for adult primary care patients.⁵ The review included 44 studies, of which there were 31 randomized controlled trials (RCTs), 12 pre-post designs, and 1 matched cohort study. The majority of research was conducted in the United States and the United Kingdom and involved predominantly white participants when race was noted. Sample sizes varied widely, as did the number and duration of sessions provided in each study.

CBT was the primary intervention in the majority of studies, whereas others implemented related approaches such as mindfulness-based cognitive therapy or acceptance and commitment therapy. Most interventions were delivered by psychologists, followed by a self-help design or delivery by counselors, PCPs, or both PCPs and psychologists. Interventions were provided face-to-face individually (52.3%) or in a group format (20.5%), by computer (9.1%), or in a self-help format (20.5%), with some using a combination of these approaches.

Findings regarding assessments used and treatment effectiveness are summarized below.

• Of the 44 studies, 29 (65.9%) demonstrated a reduction in patients’ anxiety symptoms.
• In 15 of the 18 studies (83.3%) with at least one posttreatment follow-up assessment, treatment response was maintained at follow-up.
• Of the 29 studies showing decreased patient anxiety, 17 were RCTs. In the RCTs with a follow-up assessment, 9 reported sustained treatment gains.
• Of the 12 pre-post studies, 11 showed reductions in patient anxiety, with sustained treatment gains observed in 6 of 8 studies with a posttreatment follow-up. 
• Self-report questionnaires such as the Hospital Anxiety and Depression Scale and the Beck Anxiety Inventory were used in 35 studies, and 9 studies involved clinician-rated scales, such as the Hamilton Rating Scale for Anxiety or diagnostic clinical interviews.  
• In 32 of the 44 studies reviewed, comorbid depression was also included as an outcome and was most commonly assessed by self-report questionnaires including the Beck Depression Inventory-II and the Hospital Anxiety and Depression Scale. Of these, a reduction in patients’ depressive symptoms was found in 20 studies, including 13 RCTs. Sustained treatment gains were observed in 9 of the 16 studies that included a follow-up assessment, including 5 RCTs. 

Although these results are promising overall, the longer formats and narrow symptom targets of the interventions used by most studies reviewed limit their potential translation into clinical practice, according to the authors. For example, more than half of studies required a diagnosed anxiety disorder for patient inclusion, although IPC typically does not involve a formal diagnostic assessment and many patients have subclinical symptoms.

“The lack of inclusion of subthreshold conditions is problematic as they are up to [2 to 4] times more common³ than diagnostic-level disorders and are commonly treated in primary care,” the researchers noted. “Early detection and intervention for subthreshold anxiety fits well with the stepped care approach of PCBH¹⁰ by helping prevent escalation of symptoms to more impairing levels.”⁵

For broad applicability in the primary care setting, interventions that target anxiety at various severity levels are warranted. The authors further cited methodologic limitations, such as homogenous samples and restrictive eligibility criteria, that must be overcome to facilitate the successful integration of anxiety interventions into primary care. 

Considering the “widespread, increasing implementation of the PCBH model, and its great potential to help address undertreatment of mental health conditions in primary care, anxiety interventions that are compatible with the PCBH model are needed,” they concluded. “Future research using dismantling designs is needed to identify the essential components of interventions to shorten the number and duration of sessions, in an effort to ease translation into real-world clinical practice.”⁵

References

1. Ansseau M, Dierick M, Buntinkx F, et al. High prevalence of mental disorders in primary care.J Affect Disord. 2004;78(1):49-55.
2. Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.
3. Helmchen H, Linden M. Subthreshold disorders in psychiatry: clinical reality, methodological artifact, and the double-threshold problem. Compr Psychiatry. 2000;41(2; Suppl 1):1-7.
4. Weisberg RB, Beard C, Moitra E, Dyck I, Keller MB. Adequacy of treatment received by primary care patients with anxiety disorders.Depress Anxiety. 2014;31(5):443-450.
5. Shepardson RL, Buchholz LJ, Weisberg RB, Funderburk JS. Psychological interventions for anxiety in adult primary care patients: a review and recommendations for future research.J Anxiety Disord. 2018;54:71-86.
6. Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression.BMC Med. 2010;8:38.
7. Seekles W, Cuijpers P, Kok R, Beekman A, van Marwijk H, van Straten A. Psychological treatment of anxiety in primary care: a meta-analysis. Psychol Med. 2013;43(2):351-361.
8. Hunter CL, Funderburk JS, Polaha J, Bauman D, Goodie JL, Hunter CM. Primary care behavioral health (PCBH) model research: current state of the science and a call to action. J Clin Psychol Med Settings. 2018;25(2):127-156.
9. Vogel ME, Kanzler KE, Aikens JE, Goodie JL. Integration of behavioral health and primary care: current knowledge and future directions. J Behav Med. 2017;40(1):69-84.
10. Magruder KM, Calderone GE. Public health consequences of different thresholds for the diagnosis of mental disorders.Compr Psychiatry. 2000; 1(2; Suppl 1):14-18.

This article originally appeared on Psychiatry Advisor