The path from initial inquiry to initiation of treatment for social anxiety disorder in an anxiety disorders specialty clinic☆
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)
- et al.
Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation
Clinical Psychology Review
(1988) - et al.
The issue of subtypes in the diagnosis of social phobia
Journal of Anxiety Disorders
(1993) - et al.
Assessment of anxiety in social interaction and being observed by others: the Social Interaction Anxiety Scale and the Social Phobia Scale
Behavior Therapy
(1992) - et al.
Self selection and sample selection in a treatment study of social phobia
Behaviour Research and Therapy
(1995) - et al.
Development and validation of measures of social phobia scrutiny fear and social interaction anxiety
Behaviour Research and Therapy
(1998) - et al.
Clinical features affecting treatment outcome in social phobia
Behaviour Research and Therapy
(1996) - et al.
Disability and quality of life in pure and comorbid social phobia: findings from a controlled study
European Journal of Psychiatry
(1999) - American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington,...
- Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York:...
- et al.
Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders
Journal of Abnormal Psychology
(2001)
Validation of the Social Interaction Anxiety Scale and the Social Phobia Scale across the anxiety disorders
Psychological Assessment
A psychometric evaluation of the Beck Depression Inventory in adults with social anxiety disorder
Depression and Anxiety
The epidemiology of social phobia: findings from the duke Epidemiological Catchment Area study
Psychological Medicine
Quality of life following cognitive behavioral treatment for social anxiety disorder: preliminary findings
Depression and Anxiety
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Portions of this paper were presented at the annual meeting of the Association for Advancement of Behavior Therapy, New Orleans, November 2000.