Panic Attacks, Anxiety, and Your Primary Care Physician: Are You Getting the Best Care?

I found an editorial in the March 6, 2007 edition of the Annals of Internal Medicine that I believe is spot-on. It was written by Wayne Katon, M.D. and Peter Roy-Byrne, M.D., from the University of Washington School of Medicine. The subject matter was poor treatment practices, as well as outcomes, for anxiety disorder sufferers who receive primary care-based mental health care.

The editorial begins with Drs. Katon and Roy-Byrne referring to the anxiety disorders as “the neglected stepchild of primary care-based mental health care.” Curiously, there are mountains of research floating about with regard to primary care-based mental health care for depression. But, such is certainly not the case for the anxiety disorders. And that’s really very remarkable when you consider that the anxiety disorders are the most frequently occurring mind variances (my stigma-busting replacement term for “mental illnesses”) in the United States, if not the world. And let’s not forget about the devastating social, educational, and vocational havoc they can wreak.

It can’t be of any great surprise that anxiety disorder sufferers are frequent flyers at primary care practices. And that’s “primarily” because of all of the anxiety-generated physical symptoms we experience and endure. I mean, there’s chest pain, rapid heart rate, heart palpitations, breathing difficulty, gastrointestinal issues, and on and on. And on top of the physical hub-bub is a very tough layer of psychiatric comorbidities, such as mood disorders, other anxiety disorders, and substance abuse and dependence.

In their editorial, Drs. Katon and Roy-Byrne cite the research of Kurt Kroenke, M.D., of Indiana University and the Regenstrief Institute. Dr. Kroenke’s work reveals generalized anxiety disorder (GAD), panic disorder, social anxiety disorder (social phobia), and posttraumatic stress disorder (PTSD) as the most frequently presenting anxiety disorders at a primary care practice. Also noted in Kroenke’s research was the prevalence of comorbidities such as depression, somatization issues, and overall functional impairment. Kroenke’s study goes on to indicate there are several brief and reliable screening questionnaires that address all four of the disorders just mentioned, most notably the GAD-2 and GAD-7. And, finally, Kroenke’s work reveals that more than 40% of studied patients who presented with an anxiety disorder stated they weren’t receiving any mental health treatment whatsoever.

Now, certainly, screening for the anxiety disorders at a primary care practice is a crucial first step; however, according to Katon and Roy-Byrne, arriving at a diagnosis doesn’t at all equate to improvement in quality of care or outcomes. Indeed, studies show anxiety patients who are receiving primary care-based mental health care, and are accurately diagnosed, show significant gaps in care. Among these are poor physician follow-up, which often leads to meds non-compliance, and very limited exposure to efficacious psychotherapies. So, when you pull together the data, primary care-based mental health care just doesn’t appear to be an option for anxiety sufferers.

Drs. Katon and Roy-Byrne believe it’s time for major change and suggest looking at primary care-based depression screening protocols as a starting point. They go on to recommend greater emphasis upon anxiety screening and linking screened anxiety sufferers with proven treatment resources. And they propose the use of allied health professionals in supporting the work of the primary care physician. Imagine a qualified professional who provides anxiety education to patients and staff. And this same team member could monitor treatment compliance and outcomes, facilitating physician follow-up appointments should the patient’s circumstances not improve. This allied professional could even work with a psychiatrist on medication adjustments and recommendations, passing the information on to the physician.

Well, this is all very interesting and revealing information, don’t you think? And as distressing as much of it is, there’s every reason in the world to be hopeful. And that’s because studies show the recommendations of change suggested by Drs. Katon and Roy-Byrne work. Period. So, it’s time to identify barriers to correction and push them aside.

There’s absolutely no reason why an anxiety sufferer shouldn’t be able to see his/her primary care physician and benefit from a great initial, and ongoing, collaborative offensive against their nemesis. Anything less is simply an injustice and an overwhelmingly sad missed opportunity.