Psychiatry and Primary CareRecognition of anxiety disorders by the general practitioner: results from the DASMAP Study
Introduction
Anxiety disorders, as a group, are the most common mental disorders, both in the general and in the primary health care (PHC) setting [1], [2]. Among PHC attendees, 12-month prevalence of anxiety disorders ranges between 8% and 20% [3], [4], [5], [6], [7]. Those most often seen in the PHC are panic disorder (PD), with point prevalence ranging from 1.5% to 3.1%, and generalized anxiety disorder (GAD), with point prevalence from 3.7% to 8.5% [5], [6], [8], [9].
In the last 20 years, considerable efforts have been made to increase recognition of both depression and anxiety by general practitioners (GPs). In spite of the substantial advance made with depression, anxiety disorders are still largely underdiagnosed by GPs [8]. Recent clinical guidelines for common disorders published by the National Institute for Health and Clinical Excellence (NICE) state that just 1 in 10 people with an anxiety disorder is identified in the primary care (PC) setting (compared with 1 in 3 for depressive disorder) [10]. Several factors are related to this low rate of recognition: patients' fear to express their anxious feelings due to the stigma, and lack of GP education in mental health issues. Recognition of anxiety disorders in the PHC could be complicated because patients also present comorbid chronic conditions and somatic complaints. GPs and patients are used to focusing on the physical symptoms, avoiding the possibility of a mental disorder [9]. Moreover, GPs work under extreme time pressure with increasing expectations of what should be done during a medical consultation. Many complain about the burden of their workloads, and they view psychiatric patients as adding to these demands and as ‘blockers’ who complicate and lengthen visits [11].
Recognition of anxiety disorders is important due to the serious impact that these conditions have from both a social and individual perspective. Anxiety disorders affect patients' quality of life, are highly debilitating and place extreme limitations on people's lives [12]. For instance, a study assessing the impact of anxiety disorders in the quality of life using the Short Form Health Survey showed that PD impacted the subscales of physical health and bodily pain, whereas the effects of GAD were observed in the subscales of emotional role [13]. The societal cost, both from a human and economic point of view, is also high. In a recent study, anxiety disorders ranked third in the burden of disease in PHC, being responsible for almost 805 quality-of-life years lost (per 100,000 PHC attendees) [14].
Moreover, anxiety disorders are associated to higher economical costs due to the use of health services and loss of productivity [15].
There is scarce scientific evidence on course of undetected and untreated anxiety disorders. A recent observational Dutch study concludes that there was no difference in the course of anxiety disorders between treated and untreated patients, with both groups showing a modest decrease in anxiety symptoms after 1 year. As the authors said, this result could be related to the kind of treatment that recognized cases receive (not necessary the treatment with the best evidence) [16]. On the other hand, other studies showed the opposite. A longer duration of untreated GAD was associated to a worse clinical course [17]. Similarly, if PD is left untreated, patients could develop other psychiatric conditions (such as agoraphobia or depression), which may complicate PD outcome [18], [19].
As the majority of people suffering anxiety disorders are seen in the PHC, GPs are in a privileged position to detect these disorders in patients and either treat or refer them to the mental health specialist. Moreover, as some subtypes of anxiety disorders such as GAD and PD vary in severity, complexity, course and recommendations of treatment, it could be interesting to assess specific recognition of these anxiety subtypes. The aim of this study is to determine levels of anxiety disorder recognition by the GP and examine associated factors.
Section snippets
Methods
The study was a face-to-face, cross-sectional survey of a representative sample of adult patients (18 years or older) at PHC centers in Catalonia (Spain). Catalonia is one of the 17 autonomous regions that comprise Spain, with a population of 7,134,697 according to the 2006 census. In 1981, Spain began a process of decentralization of health service management, and this is now carried out by each autonomous region. Data were collected between October 2005 and March 2006 using a paper-and-pencil
Recognition of anxiety disorders by the GP
Twelve-month prevalence of any anxiety disorder according to the SCID-I was 18.49% [95% confidence interval (CI) 15.77%–21.55%; n=666]. GPs identified 185 of the 666 individuals diagnosed with the SCID-I (sensitivity 0.28, or 0.32 when excluding diagnoses missing from the clinical chart). As expected, due to the relatively low prevalence of anxiety disorders, the specificity was high (0.90), whereas the positive predictive value was 0.38. The Kappa value was 0.20 (Table 1).
The sensitivity rate
Discussion
This study has several strengths. To our knowledge, this is the first study focusing on recognition of anxiety disorders by the GPs conducted in a Mediterranean country. Previous studies were from USA, UK or China, countries with different cultural values and health systems. Moreover, it has been conducted in a large representative sample of PC attendees. This allows us to improve its external validity. In addition, the gold standard for anxiety diagnosis was applied through the administration
Acknowledgments
This study was funded by the “Direcció General de Planificació i Avaluació Sanitària-Departament de Salut-Generalitat de Catalunya” (Barcelona, Spain). A.F. and J.V.L. are grateful to the “Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III” (Red RD06/0018/0017) for a predoctoral and a postdoctoral contract, respectively.
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2015, Journal of Affective DisordersCitation Excerpt :Specificity was significantly lower for anxiety than for depressive disorders. Other studies that used representative samples such as DASMAP or Depression 2000 obtained opposite results: sensitivity for depressive disorders was higher in patients with comorbid disorders (Fernández et al., 2012; Wittchen et al., 2002a). According to our results, PC physicians seem to use a different diagnostic hierarchy, which works in the opposite direction than that of psychiatrists, and leading them to detect psychopathology, but misclassifying depressive disorders as anxiety disorders.