ajp.2007.164.2.276

Article

276 Am J Psychiatry 164:2, February 2007ajp.psychiatryonline.org

Psychiatric Treatment in Primary Care Patients With Anxiety Disorders: A Comparison of Care Received From

Primary Care Providers and Psychiatrists

Risa B. Weisberg, Ph.D.

Ingrid Dyck, M.P.H.

Larry Culpepper, M.D.

Martin B. Keller, M.D.

Objective: This study examined psychi-atric treatment received by primary carepatients with anxiety disorders and com-pared treatment received from primarycare physicians and from psychiatrists.

Method: Primary care patients at 15sites were screened for anxiety symp-toms. Those screening positive were inter-viewed to assess for anxiety disorders. In-formation on psychiatric treatmentreceived and provider of pharmacologicaltreatment were collected.

Results: Of 539 primary care participantswith at least one anxiety disorder, almosthalf (47.3%) were untreated. Nearly 21%were receiving medication only for psy-chiatric problems, 7.2% were receivingpsychotherapy alone, and 24.5% were re-ceiving both medication and psychother-apy. Patients receiving psychopharmaco-log ical trea tment received s imi larmedications, often at similar dosages, re-gardless of whether their prescriber was aprimary care physician or a psychiatrist.

One exception was that patients were lesslikely to be taking benzodiazepines iftheir provider was a primary care physi-cian. Those receiving medications from aprimary care provider were also less likelyto be receiving psychotherapy. Overall,patients with more functional impair-ment, more severe symptoms, and co-morbid major depression were morelikely to receive mental health treatment.Members of racial/ethnic minority groupswere less likely to be treated. Frequentlyendorsed reasons for not receiving phar-macological treatment were that the pri-mary care physician did not recommendit and the patient did not believe in takingmedication for emotional problems.

Conclusions: Nearly half the primarycare patients with anxiety disorders werenot treated. However, when they weretreated, the care received from primarycare physicians and psychiatrists was rela-tively similar.

(Am J Psychiatry 2007; 164:276282)

More than half of patients with a psychiatric problemreceive treatment for their symptoms from a primary carephysician rather than a mental health specialist (1, 2). Gen-eral medical physicians also facilitate or impede access tomental health specialty services through referral decisions(3, 4). A survey of U.S. adults with depressive and anxietydisorders found that only 1.9% visited a mental health spe-cialist without seeing a primary care physician (5).

Anxiety disorders are among the most common mentalhealth problems seen in a primary care setting. As muchas one-third of primary care patients have been found tohave significant anxiety symptoms (6). Approximately15% have a current anxiety disorder, and 24% have a life-time anxiety disorder, as assessed by diagnostic interview(7). Primary care patients with anxiety disorders typicallyhave considerable disability and impairment in function-ing (8, 9). They also have high utilization of general medi-cal services, resulting in higher health care costs (10).

Only a few studies have investigated the nature of men-tal health treatments for primary care patients with anxi-ety disorders. An analysis of the National Ambulatory

Medical Care Survey database from 1985 to 1998 foundthat when anxiety was diagnosed, treatment was offeredin over 95% of visits to psychiatrists but in only 60% of vis-its to a primary care physician (11). An international studycoordinated by the World Health Organization docu-mented the prescribing patterns of primary care physi-cians in regard to the treatment of psychiatric disorders(12). Of primary care patients with anxiety disorders, 7.7%were found to be treated with antidepressant medications,34.1% with anxiolytics and hypnotics, and 21.1% with mis-cellaneous other medications. The use of antidepressants(in 23% of the patients with anxiety disorders) was notice-ably higher in the United States than in other countries. Inthe study most similar to our own, primary care patientswith anxiety disorders self-reported the treatment they re-ceived. Just over half (58.7%) received any psychotropicmedication, 35.8% received counseling by their primarycare provider, and only 31.3% of patients reported treat-ment that met the authors criterion for quality care (13).However, this study did not investigate differences in carereceived from primary care providers and psychiatrists. In

Am J Psychiatry 164:2, February 2007 277

WEISBERG, DYCK, CULPEPPER, ET AL.

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the treatment of depression, when primary care physi-cians prescribe antidepressants, they use dosages lowerthan recommended by guidelines and lower than used bypsychiatrists (14, 15).

The current study was designed to address the relativelack of information on the type of treatments prescribed topatients with anxiety disorders seen at primary care set-tings. The specific goals were to provide descriptive infor-mation on the proportion of primary care patients withanxiety disorders who receive mental health treatmentand to examine potential differences in treatment re-ceived from primary care physicians and psychiatrists.Predictors of receiving treatment for an anxiety disorderwere explored to ascertain whether mental health treat-ments are more likely to be initiated for certain subgroupsof patients.

Method

Study Design

The subjects were participants in the Primary Care AnxietyProject, which is a longitudinal study of individuals with anxietydisorders in primary care settings (16). Patients with anxiety dis-orders are assessed at study baseline, 6 and 12 months postbase-line, and then yearly thereafter in follow-up interviews. This re-port examines baseline data only.

The Primary Care Anxiety Project was conducted across 15 pri-mary care practices in New Hampshire, Massachusetts, Rhode Is-land, and Vermont. Both internal medicine and family practiceoffices were involved, including four independent practice of-fices, four university-affiliated clinics, and seven clinics at univer-sity teaching hospitals.

Participant Recruitment and Assessment

Participants in the Primary Care Anxiety Project were recruitedfrom primary care waiting rooms. Inclusion criteria were the fol-lowing: a general medical appointment on the day of screening, atleast 18 years of age, English proficiency, and meeting DSM-IVcriteria for one or more of seven intake anxiety disorder diag-noses. Exclusion criteria included active psychosis, the absenceof a current address and telephone number, and pregnancy.

A research assistant asked all eligible participants in the pri-mary care waiting room if they were interested in participating ina study of different types of stress or nervousness. Interested pa-tients were asked to complete a screening form designed to eval-uate the key features of DSM-IV anxiety disorders. The patientswho screened positive for anxiety symptoms were offered a fulldiagnostic interview. After complete description of the study hadbeen given, written consent was obtained from all participants.Institutional review boards at each of the sites approved the re-search protocol. A detailed description of recruitment has beenpublished (17).

Measures

Anxiety Screener. A 32-item self-report measure was used to as-sess the key features of each anxiety disorder. Items were derivedfrom the central features of DSM-IV criteria. To avoid exclusion ofpotentially eligible participants, the screener was designed to behighly sensitive. A separate validation study conducted on this in-strument (16) found that the screening form had a sensitivity of 1.0and a specificity of 0.67. No individual in the validation samplescreened negative but was found to have a Structured Clinical In-terview for DSM-IV (SCID) anxiety disorder diagnosis.

Clinical Interview. All subjects were diagnosed with the SCID(18). After the psychotic screen, the SCID anxiety disorders mod-ule was administered first. The participants who received an anx-iety disorder diagnosis proceeded to complete the mood, sub-stance use, and eating disorders modules.

Psychosocial Functioning. At the completion of the SCID, theinterviewer rated the Global Assessment of Functioning (GAF)Scale score that is part of the DSM-IV system (19). This is a mea-sure of functioning and symptom severity. The interviewers alsorated the patient on the Global Social Adjustment Scale as part ofthe interview based on the Longitudinal Interval Follow-Up Eval-uation for DSM-IV (20). This is a 15 scale (1=no impairment andvery good functioning, 5=marked or severe impairment) indicat-ing overall level of current psychosocial functioning.

Nonpsychiatric medical problems were assessed with a medi-cal history form designed for the study (16). The medical historyform is an interviewer-administered questionnaire in which par-ticipants are asked whether or not they have ever had any of 18different illnesses or medical problems. For the present study, adichotomous (yes/no) variable was constructed indicating thepresence of a major medical illness. This was coded yes for anyparticipant reporting current asthma, cancer, diabetes, epilepsy,heart disease, kidney disease, liver disease, lung or respiratory ill-ness, stroke, and/or thyroid disease.

Treatment Received. Information regarding the participantsuse of psychotropic medications was captured on the psychotro-pic treatment section of the Longitudinal Interval Follow-UpEvaluation for DSM-IV (20). Psychosocial treatment received wasmeasured on the types-of-treatment form, an interviewer-ad-ministered form designed for the present study, and on the Psy-chosocial Treatments Interview for Anxiety Disorders (21).

A subgroup of participants not receiving treatment was inter-viewed with the treatment-not-received form, designed for thepresent study. This is an interviewer-administered measure ex-amining reasons for not receiving and/or complying with recom-mended mental health treatment.

Statistical Methods

Descriptive statistics (means and percents) were used to char-acterize the type of treatment received for the group as a whole.Comparisons between the type and dosage of medications pre-scribed by primary care physicians and psychiatrists were madewith chi-square statistics and t tests, respectively.

Potential predictors of receiving any mental health treatmentand of receiving pharmacotherapy from a psychiatrist versus aprimary care physician were examined. The initial pool of poten-tial predictors included age, gender, race/ethnicity, education, in-surance type, income, marital status, symptom severity, andfunctioning, as measured by the GAF and Global Social Adjust-ment scales, the presence of major depressive disorder, the pres-ence of alcohol/substance use disorder, the presence of a majornonpsychiatric medical illness, the number of anxiety disorders,and the age of onset of anxiety disorders. We reduced this poten-tial pool by examining the univariate relationship between eachpredictor and each outcome variable. All individual variables re-lated to the outcome variable at p0.05 were entered into a step-wise logistic regression. The final logistic regression models wereexamined, including all remaining variables, which were enteredat a 0.05 level of significance.

Results

Group Characteristics

A detailed description of recruitment and group selec-tion, including rates of refusal, has been published (17).

278 Am J Psychiatry 164:2, February 2007

PRIMARY CARE VERSUS PSYCHIATRY


Five hundred thirty-nine primary care patients met crite-ria for one or more of the following index anxiety disordersand were enrolled in the Primary Care Anxiety Project:posttraumatic stress disorder (N=199, 37%), social phobia(N=182, 34%), panic disorder with agoraphobia (N=150,28%), generalized anxiety disorder (N=135, 25%), panicdisorder without agoraphobia (N=85, 16%), agoraphobiawithout history of panic disorder (N=23, 4%), mixed anxi-ety-depressive disorder (N=10, 2%), or generalized anxietydisorder features occurring exclusively within the courseof a mood disorder (N=29, 5%). A total of 50.5% of the pa-tients had more than one of these anxiety disorders. Co-morbid nonanxiety disorders included major depressivedisorder (41%), alcohol/substance use disorders (10%),and eating disorders (11%).

The average age of the participants was 39 years. Themajority were women (76%) and Caucasian (83%). Of the91 participants who were members of a minority group, 41were African American, 20 were Hispanic, nine were NativeAmerican, seven were Asian, and 14 were other. Half of allparticipants were married; the majority had at least a highschool education (67%), and 40% were employed full-time.

Overall Treatment of Anxiety Disorders in Primary Care

Of the total 539 primary care patients with an anxietydisorder, 52.7% (N=284) were receiving treatment for psy-chiatric problems. One hundred thirty-two patients

(24.5%) were receiving both psychopharmacological treat-ment and psychotherapy, 113 (21.0%) were receiving med-ication only, and just 39 (7.2%) were receiving psychother-apy only.

The reasons given by the participants for not receivingpharmacotherapy are shown in Figure 1 and for not re-ceiving psychotherapy in Figure 2. Among the top twomost frequently endorsed reasons for not receiving bothtypes of treatment was that the patient did not believe intreatment for emotional problems. The most commonlyendorsed reason for not receiving pharmacotherapy wasthat the primary care provider did not recommend thistreatment (38.7%). This was also endorsed by 17% of thosenot receiving psychotherapy. Additionally, not realizingthat he or she had a treatable emotional problem was thethird most common reason for not receiving pharmaco-therapy (endorsed by 19.3%) and the second most com-mon reason for not receiving psychotherapy (23.5%).Barriers related to treatment access, such as cost, conve-nience, and knowing how to obtain care, were commonlyendorsed as reasons for not receiving psychotherapy butrarely given as barriers to pharmacotherapy.

To understand the clinical and demographic character-istics associated with a greater likelihood of receivingtreatment for psychiatric problems, stepwise logistic re-gression was conducted. After prescreening variables (asdescribed), the following variables were eligible for exam-ination of receiving/not receiving any treatment: income,ethnicity/race, receiving Medicare or public assistance,GAF Scale score, number of current anxiety disorders, and

FIGURE 1. Reasons Given for Not Receiving Pharmacother-apy in 119 Patients With Anxiety Disorders

Didn't believe intaking medication foremotional problems

Didn't think he orshe had a problem

Concerned aboutside effects

Medicationineffective in past

Inconvenient/too busy

Worried about stigma/embarrassment

Financial reasons

Didn't know howto obtain

Primary care providerdidn't recommend

0 10 20 30 40

Percent of Patients Endorsing Reasonsfor Not Receiving Pharmacotherapy

FIGURE 2. Reasons Given for Not Receiving Psychotherapyin 153 Patients With Anxiety Disorders

Didn't believe inpsychotherapy for

emotional problems

Didn't think he orshe had a problem

Therapyineffective in past

Worried about stigma/embarrassment

Inconvenient/too busy

Financial reasons

Didn't know howto obtain

Primary care providerdidn't recommend

0 10 20 30 40

Percent of Patients Endorsing Reasonsfor Not Receiving Psychotherapy




currently experiencing episode of major depressive disor-der. The results of a forward selection stepwise logistic re-gression analysis revealed that four variables entered thepredictive model at p0.05 (Table 1). Primary care patientswith anxiety disorders who received mental health treat-ment were significantly more likely to have poorer func-tioning and more severe symptoms, as measured by theGAF Scale, to have a concurrent diagnosis of major de-pressive disorder, to be receiving Medicare or public assis-tance, and not to be a member of a minority group.

We ran post hoc analyses to better understand the find-ing that patients with Medicare were more likely to re-ceive treatment. We found that participants with Medi-care were more likely to be receiving treatment (67%)than either participants with no insurance (42% in treat-ment) (2=9.73, df=1, p




1. Only about half of the primary care patients withanxiety disorders were currently receiving any men-tal health treatment.

2. The patients taking psychotropic medications wereequally likely to be receiving the prescription fromtheir primary care provider as from a psychiatrist.

3. SSRIs/selective norephinephrine reuptake inhibitorswere the most commonly prescribed psychotropicmedication, by both primary care providers and psy-chiatrists.

4. Patients were less likely to be taking benzodiazepinesprescribed by primary care physicians than by psy-chiatrists.

5. Individuals receiving psychotropic medications froma primary care physician were less likely than thosegetting pharmacotherapy from a psychiatrist to alsobe receiving psychotherapy.

6. Members of racial/ethnic minority groups were lesslikely to be receiving mental health treatment.

7. Individuals with more impairment and more severesymptoms, as evidenced by lower GAF Scale scores,or with a concurrent major depressive disorder weremore likely to receive mental health treatment.

8. Primary care patients who were not receiving phar-macotherapy for their anxiety disorders stated thattwo of the main reasons for not being treated werethat their doctor never recommended treatment(38.7%) and that they did not believe in medicationfor emotional problems (37%). The most frequentlyendorsed reasons for not receiving psychotherapywere that they did not believe in psychotherapy(27.5%) and that the patients did not know they had aproblem (23.8%).

The fact that only about half of primary care patientswith an anxiety disorder were receiving mental healthtreatment is consistent with the National AmbulatoryMedical Care Survey that reported treatment was offeredat 60% of the primary care office visits for patients withanxiety (11). These data suggest that there remains sub-stantial room for further improvement in reducing theburden of anxiety disorders on society.

Although only about half of the patients with anxietydisorders received any treatment, when pharmacologicaltreatment was implemented, the rates of receiving antide-pressants (SSRIs/selective norephephrine reuptake inhib-itors) from primary care physicians were as high as thosefrom psychiatrists, suggesting that many primary carephysicians are aware of new developments in pharmaco-therapy for anxiety disorders. Similar to our data, a multi-national study of prescribing patterns in primary carefound that in the United States, 23% of the patients with ananxiety problem received a prescription for an antidepres-sant (12). Patients were less likely to receive benzodiaz-epines from primary care physicians compared to psychi-atrists perhaps because of concern by primary care

physicians for a variety of adverse events and abuse liabil-ity that may be associated with these agents (22, 23). Wealso found that the only significant predictor of receivingmedication from a psychiatrist versus a primary care phy-sician was severity of functional impairment. Therefore, itmay be that psychiatrists prescribe more benzodiazepinesthan do primary care physicians because psychiatrists aretreating a more severely impaired population. In terms ofdosing, there was no significant difference between thedosages reported by patients prescribed their medicationby primary care physicians and psychiatrists. However,the difference in dosages for sertraline and fluoxetine felljust short of statistical significance. The group sizes weretoo small to detect anything but large differences, so thisissue needs further investigation.

Our study did not directly evaluate the physicians view-point on why treatment was not implemented for manypatients with anxiety disorders. Analyses of demographicand clinical predictors suggest the possibility that primarycare physicians have a high threshold for recognition and/or treatment of anxiety disorders. This may also be the rea-son why patients receiving public assistance were morelikely to be receiving treatment than their counterpartswith private insurance. Patients with public insurancemay have had worse functioning and appeared more se-verely ill. When patients had more severe symptoms,worse functioning, or comorbid depression, primary carephysicians were perhaps more likely to recognize that apsychiatric disorder was present and to consequently im-plement treatment or refer patients to a psychiatrist fortreatment. Whether the primary care physicians are notaware of the anxiety disorder when functioning is higheror whether they are hesitant to treat higher-functioningpatients with anxiety disorders is not clear. Our data indi-cate that many patients reported that they were unawareof having a problem or that their primary care doctor didnot recommend treatment, suggesting at least a lack ofcommunication between the primary care physician andthe patient. Further research is needed to understand howoften primary care physicians recognize anxiety disordersbut decide not to communicate their diagnoses with pa-tients and not to treat such disorders and whether primarycare physicians are continuing to not recognize such dis-orders when impairment is less severe, as has been docu-mented in the past (6, 24).

Of particular concern is the finding that members of mi-nority groups were less likely to receive mental healthtreatment. This is consistent with the results of a recentprimary care study that found that ethnic minorities wereless likely to receive appropriate antianxiety medications(13). Another previous study failed to find any differencesin the prescribing of antidepressants to non-Latino whitepatients and Latino patients in primary care (25). Furtherstudies are needed to determine if the ethnic disparityfound in our study is unique to anxiety disorders orunique to the sites or geographic areas of the current




study. Additionally, it is important to note that our studymeasured treatment received, as reported by the patient,rather than treatment prescribed, as reported by the phy-sician. Therefore, an important agenda for future researchis to sort out whether barriers to minorities receivingtreatment for anxiety disorders are related more to physi-cian behavior or cultural attitudes toward medication ortherapy among patients.

For some primary care physicians, failure to adequatelytreat anxiety disorders may be related to a belief that theanxiety is secondary to a nonpsychiatric medical disorder.However, in the present study, we found that the presenceof a major nonpsychiatric medical illness was not relatedto the likelihood of receiving treatment.

Our data also suggest that some of the barriers to effec-tive treatment lie within the patient, rather than the pri-mary care doctor. One of the most common reasons fornot receiving pharmacotherapy was not believing in theuse of medication for emotional problems, and the mostcommon reason for not receiving psychotherapy was notbelieving in the use of psychotherapy. These findings indi-cate that efforts to improve the treatment of anxiety disor-ders in primary care must involve patient education, notsolely interventions directed at providers. In the treatmentof major depressive disorder, an intervention that focusedon counseling primary care patients about medicationtreatment was found to improve adherence and enhanceoutcomes among those receiving higher dosages, relativeto treatment as usual (26). The value of patient educationabout anxiety disorders and their treatment also needs tobe investigated.

Limitations of the current study include the fact that allof the primary care sites were in one geographic area of theUnited States. Research involving a broader range of sitesacross the country, including sites with larger populationsof minorities served, would be important to examine thegeneralizability of our findings. Furthermore, our investi-gation is not an epidemiological study in that we did notsystematically interview all members of the available pop-ulation and in that by asking patients if they were inter-ested in participating in a study about stress or nervous-ness we may have biased the study group toward thosewith anxiety disorders. Thus, these data are not meant as areport of anxiety disorder prevalence rates in primarycare. Additionally, this study did not examine the fre-quency of visits to psychiatrists and primary care physi-cians to monitor anxiety and treatment. A potential unre-ported difference in care between these provider typesmay be the follow-up received, especially after the receiptof a prescription for a new medication. The current dataare also limited in that they provide only a single snap-shot about the treatment of anxiety disorders after suchpatients have been seen in a primary care setting. Someprimary care physicians might take a watchful waitingapproach with anxiety disorders to see if the symptoms re-solve over time without treatment. If anxiety symptoms

persist over time, primary care physicians might be com-pelled to implement treatment or refer the patient for spe-cialty care. Longitudinal follow-up data would providesuch information on whether the rate of treatment in-creases if symptoms are persistent. The Primary Care Anx-iety Project is currently tracking the patient cohort de-scribed herein, with assessments at 6 and 12 monthspostintake and then yearly thereafter. Thus, we will even-tually be able to address the issue of how treatments, orlack of treatment, change over time for patients with anxi-ety disorders.

Presented in part at the 29th annual meeting of the North AmericanPrimary Care Research Group, Halifax, N.S., Canada, Oct. 1316, 2001;the 156th annual meeting of the American Psychiatric Association,San Francisco, May 1722, 2003; the Primary Care Anxiety Conferenceof the Anxiety Disorders Association of America, Chantilly, Va., Oct. 2627, 2004; and the 26th annual meeting of the Anxiety Disorders Asso-ciation of America, Miami, March 2326, 2006. Received July 27, 2005;revision received June 21, 2006; accepted July 6, 2006. From the De-partments of Psychiatry and Human Behavior and Family Medicine,Brown University; and the Department of Family Medicine, BostonUniversity Medical Center, Boston. Address correspondence and re-print requests to Dr. Weisberg, Box G-H, Duncan Building, Brown Uni-versity, Providence, RI 02096; [email protected] (e-mail).

Funded by an unrestricted grant from Pfizer Pharmaceuticals. Dr.Weisberg was supported in part through a Mentored Patient-OrientedResearch Career Development Award from NIMH (K23-MH-69595). Dr.Culpepper has been a consultant to Eli Lilly, Forest Laboratories,Pfizer, and Wyeth Pharmaceuticals. Dr. Weisberg has received hono-raria from Cephalon and Eli Lilly. Dr. Keller has been a consultant orhas received honoraria from Collegium, Cypress Bioscience, Cyberon-ics, Eli Lilly, Forest Laboratories, Janssen, Organon, Otsuka, Pfizer,Pharmastar, Sepracor, Vela Pharmaceuticals, and Wyeth Pharmaceu-ticals. He has received grants or research funds from Eli Lilly, ForestLaboratories, Pfizer, and Wyeth Pharmaceuticals. He has been on theadvisory boards of Abbott Laboratories, Bristol-Myers Squibb, Cy-beronics, Cypress Bioscience, Eli Lilly, Forest Laboratories, GlaxoSmith-Kline, Janssen, Novartis, Organon, Pfizer, Sepracor, and Wyeth Phar-maceuticals. Ms. Dyck reports no competing interests.

References

1. Price D, Beck A, Nimmer C, Bensen S: The treatment of anxietydisorders in a primary care setting. Psychiatr Q 2000; 7:3145

2. Shear MK, Schulberg HC: Anxiety disorders in primary care.Bull Menninger Clin 1995; 59(suppl A):A73A85

3. Beardsley RS, Gardocki GJ, Larson DB, Hidalgo J: Prescribing ofpsychotropic medication by primary care physicians and psy-chiatrists. Arch Gen Psychiatry 1988; 45:11171119

4. Weiller E, Bisserbe JC, Maier W, Lecrubier Y: Prevalence and rec-ognition of anxiety syndromes in five European primary caresettings. Br J Psychiatry 1998; 173(suppl 34):1823

5. Young AS, Klap R, Sherbourne CD, Wells KB: The quality of carefor depressive and anxiety disorders in the United States. ArchGen Psychiatry 2001; 58:5561

6. Fifer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP,Buesching DP: Untreated anxiety among adult primary carepatients in a health maintenance organization. Arch Gen Psy-chiatry 1994; 51:740750

7. Nisenson LG, Pepper CM, Schwenk TL, Coyne JC: The natureand prevalence of anxiety disorders in primary care. Gen HospPsychiatry 1998; 20:2128

8. Roy-Byrne PP, Stein MB, Russo J, Mercier E, Thomas R, McQuaidJ, Katon WJ, Craske MG, Bystritsky A, Sherbourne CD: Panic dis-order in the primary care setting: comorbidity, disability, ser-




vice utilization, and treatment. J Clin Psychiatry 1999; 60:492499

9. Sherbourne CD, Wells KB, Meredith LS, Jackson CA, Camp P: Co-morbid anxiety disorder and the functioning and well-being ofchronically ill patients of general medical providers. Arch GenPsychiatry 1996; 53:889895

10. Simon G, Ormel J, VonKorff M, Barlow W: Health care costs as-sociated with depressive and anxiety disorders in primary care.Am J Psychiatry 1995; 152:353357

11. Harman JS, Rollman BL, Hanusa BH, Lenze EJ, Shear MK: Physi-cian office visits of adults for anxiety disorders in the UnitedStates, 19851998. J Gen Intern Med 2002; 17:165172

12. Linden M, Lecrubier Y, Bellantuono C, Benkert O, Kisely S, Si-mon G: The prescribing of psychotropic drugs by primary carephysicians: an international collaborative study. J Clin Psycho-pharmacol 1999; 19:132140

13. Stein MB, Sherbourne CD, Craske MG, Means-Christensen A,Bystritsky A, Katon W, Sullivan G, Roy-Byrne PP: Quality of carefor primary care patients with anxiety disorders. Am J Psychia-try 2004; 161:22302237

14. McManus P, Mant A, Mitchell P, Britt H, Dudley J: Use of antide-pressants by general practitioners and psychiatrists in Austra-lia. Aust N Z J Psychiatry 2003; 37:184189

15. Donoghue JM, Tylee A: The treatment of depression: prescrib-ing patterns of antidepressants in primary care in the UK. Br JPsychiatry 1996; 168:164168

16. Weisberg RB, Bruce SE, Machan JT, Kessler RC, Culpepper L,Keller MB: Nonpsychiatric illness among primary care patientswith trauma histories and post-traumatic stress disorder. Psy-chiatr Serv 2002; 53:848854

17. Weisberg RB, Maki KM, Culpepper L, Keller MB: Is anyone reallyM.A.D.? the occurrence and course of mixed anxiety-depressivedisorder in a sample of primary care patients. J Nerv Ment Dis2005; 193:223230

18. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clini-cal Interview for the DSM-IV Axis I Disorders. New York, NewYork State Psychiatric Institute, Biometrics Research Depart-ment, 1996

19. American Psychiatric Association: Diagnostic and StatisticalManual of Mental Disorders, 4th ed. Washington, DC, Ameri-can Psychiatric Press, 1994

20. Keller MB, Warshaw MG, Dyck I, Dolan RT, Shea MY, Riley K,Shapiro R: LIFE-IV: The Longitudinal Interval Follow-up Evalua-tion for DSM-IV. Providence, RI, Brown University, Departmentof Psychiatry and Human Behavior, 1997

21. Steketee G, Perry JC, Goisman RM, Warshaw MG, Massion AO,Peterson LG, Langford L, Weinshenker N, Farreras IG, KellerMB: The Psychosocial Treatments Interview for Anxiety Disor-ders: a method for assessing psychotherapeutic procedures inanxiety disorders. J Psychother Pract Res 1997; 6:194210

22. Rickels K, Schweizer E, Lucki I: Benzodiazepine side effects, inAmerican Psychiatric Association Annual Review, Vol 6. Editedby Hales RE, Frances AJ. Washington, DC, American PsychiatricPress, 1987, pp 781801

23. Woods JH, Katz JL, Winger G: Benzodiazepines: use, abuse, andconsequences. Pharmacol Rev 1992; 44:151347

24. Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW:Primary health care providers recognition and diagnosis ofmental disorders in their patients. Gen Hosp Psychiatry 1988;10:317321

25. Sleath BL, Rubin RH, Huston SA: Antidepressant prescribing toHispanic and non-Hispanic white patients in primary care. AnnPharmacother 2001; 35:419423

26. Peveler R, George C, Kinmonth AL, Campbell M: Thompson C:Effect of antidepressant drug counselling and information leaf-lets on adherence to drug treatment in primary care: ran-domised controlled trial. BMJ 1999; 319:612615

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