The path from initial inquiry to initiation of treatment for social anxiety disorder in an anxiety disorders specialty clinic

https://doi.org/10.1016/S0887-6185(02)00259-1Get rights and content

Abstract

Efficacious treatments for social anxiety disorder have become increasingly available, with approximately three-quarters of treatment completers showing significant improvement [Arch. Gen. Psychiatry 55 (1998) 1133.]. However, very few individuals with social anxiety disorder access these services. The present study reports on the path to initiation of treatment for social anxiety disorder among individuals contacting an anxiety disorder specialty clinic. Of 395 initial telephone inquiries, only 60 individuals (15%) started treatment. Three “critical points” associated with high pretreatment attrition were identified: scheduling an initial interview, attending a scheduled initial interview, and initiating a treatment program after receiving a principal diagnosis of social anxiety disorder. Several demographic variables (e.g., level of education, race) were related to attendance at the initial interview. However, no differences were found between those who did and did not initiate treatment on demographic variables, symptom severity, or quality of life. Given that most individuals who complete treatment for social phobia experience significant benefit, results of the current study suggest that future efforts should be devoted to increasing number of patients who access these services.

Introduction

Social anxiety disorder has been shown to respond well to both cognitive-behavioral and pharmacological interventions. For example, a large randomized clinical trial (Heimberg et al., 1998) found that both 12 weeks of cognitive-behavioral group therapy (CBGT) and 12 weeks of pharmacotherapy (phenelzine) produced significant improvements in the majority of clients who completed treatment (75 and 77%, respectively). Recent studies have also demonstrated efficacy of paroxetine (Stein et al., 1998), sertraline (Van Ameringen et al., 2001), and other medications for social anxiety disorder (see Fresco, Erwin, Heimberg, & Turk, 2000). Despite the mounting evidence that individuals who complete treatment are likely to have favorable outcomes, many appropriate candidates fail to access treatment. Indeed, most adults with social anxiety disorder in the United States do not receive mental health services (Magee, Eaton, Wittchen, McGonalgle, & Kessler, 1996). For example, in the Epidemiological Catchment Area (ECA) study, only 5.4% of community respondents with uncomplicated social anxiety disorder reported they had received outpatient mental health treatment (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992).

That individuals with social anxiety disorder may not receive needed treatment is a serious problem as social anxiety disorder is the third most common psychiatric disorder, with 1-year prevalence estimates ranging from 3.7% (Narrow, Rae, Robins, & Reiger, 2002) to 7.9% (Kessler et al., 1994). Failure to access needed treatment poses both personal and economic burdens. Regarding the former, social anxiety disorder is associated with increased rates of depression (Kessler, Stang, Wittchen, Stein, & Walters, 1999), suicidal ideation (Schneier et al., 1992), and alcohol abuse (Kushner, Sher, & Beitman, 1990), as well as life satisfaction substantially below the norm (Eng, Coles, Heimberg, & Safren, 2001; Safren, Heimberg, Brown, & Holle, 1997). Economic burdens include substantial reductions in work productivity, increased utilization of medical services, and a greater likelihood of being dependent on welfare or disability payments (Davidson, Hughes, George, & Blazer, 1993; Schneier et al., 1992; Wittchen, Fuetsch, Sonntag, Muller, & Liebowitz, 1999). Failure to access appropriate treatment prolongs these personal and economic burdens.

Variables associated with failure to access treatment for social anxiety disorder have been identified in community samples. In the ECA study, people with social anxiety disorder who did not seek treatment were significantly younger, of lower socioeconomic status, less educated, and less likely to be white than those who had sought treatment for an emotional problem (Schneier et al., 1992). Individuals with uncomplicated social anxiety disorder were less likely to seek treatment than individuals with social anxiety disorder and comorbid conditions.

Another study (Olfson et al., 2000) utilized a large-scale national anxiety screening program to directly examine barriers to treatment among individuals with social anxiety. Three primary barriers were identified: (1) uncertainty as to where to go for help, (2) financial barriers, and (3) fear of what others might think or say. Interestingly, the majority of individuals with social anxiety recognized that they were likely to have an anxiety disorder. Only 8.2% reported failing to access treatment because they did not believe they had an anxiety disorder.

In conclusion, evidence suggests that very few individuals with social anxiety disorder receive the treatment that they need. Existing studies of possible treatment barriers suggest some factors worthy of further investigation, such as race, education, and socioeconomic status. The current study examined the path from initial telephone inquiry to initiation of treatment in a large sample of individuals contacting a university-based anxiety disorders specialty clinic for help with social anxiety. Although treatment outcome studies (e.g., Heimberg et al., 1998; Juster, Heimberg, & Engelberg, 1995; Turner, Beidel, Wolff, Spaulding, & Jacob, 1996) have addressed attrition during treatment, this is the first study to examine the path to initiating treatment. A better understanding of this path should be useful in clarifying factors related to pretreatment attrition and suggesting points of intervention to improve clinical outcomes.

Section snippets

Participants and procedure

Participants were individuals who contacted the Adult Anxiety Clinic of Temple University (AACT) seeking treatment for social anxiety. Most callers responded to advertisements in local newspapers and flyers posted on campus and in local stores. These advertisements described common situations in which social anxiety may occur (e.g., giving a speech, talking with others) and stated that confidential treatment was available from a clinic specializing in the treatment of anxiety. Readers were

Results

Fig. 1 presents summary information on the path from initial telephone inquiry to initiation of treatment for all individuals who contacted the AACT regarding treatment for social anxiety between June 1997 and December 1999.1 Notably, of 395 telephone inquiries, only 60 individuals (15%)

Discussion

Only a small percentage of individuals inquiring about treatment for social anxiety ultimately started treatment at our center (15%). Many of the individuals who declined services may have qualified for and benefited from treatment. An important direction for future research should be the development of methods to improve our ability to engage socially anxious individuals in the treatment process, beginning with the first telephone contact.

An important first step will be encouraging appropriate

Acknowledgements

This research was supported in part by grant 44119 to Richard G. Heimberg from the National Institute of Mental Health.

References (32)

  • E.J. Brown et al.

    Validation of the Social Interaction Anxiety Scale and the Social Phobia Scale across the anxiety disorders

    Psychological Assessment

    (1997)
  • M.E. Coles et al.

    A psychometric evaluation of the Beck Depression Inventory in adults with social anxiety disorder

    Depression and Anxiety

    (2001)
  • J.R.T. Davidson et al.

    The epidemiology of social phobia: findings from the duke Epidemiological Catchment Area study

    Psychological Medicine

    (1993)
  • DiNardo, P. A., Brown, T. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-IV: Lifetime Version...
  • W. Eng et al.

    Quality of life following cognitive behavioral treatment for social anxiety disorder: preliminary findings

    Depression and Anxiety

    (2001)
  • Fresco, D. M., Erwin, B. A., Heimberg, R. G., & Turk, C. L. (2000). Social and specific phobias. In: M. Gelder, N....
  • Cited by (0)

    Portions of this paper were presented at the annual meeting of the Association for Advancement of Behavior Therapy, New Orleans, November 2000.

    View full text