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BMC Primary Care
Published in: BMC Primary Care 1/2021

01-12-2021 | Anxiety Disorder | Research article

Contemporary treatment of anxiety in primary care: a systematic review and meta-analysis of outcomes in countries with universal healthcare

Authors: Erin L. Parker, Michelle Banfield, Daniel B. Fassnacht, Timothy Hatfield, Michael Kyrios

Published in: BMC Primary Care | Issue 1/2021

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Abstract

Background

Anxiety disorders are highly prevalent mental health conditions and are managed predominantly in primary care. We conducted a systematic review and meta-analysis of psychological and pharmacological treatments in countries with universal healthcare, and investigated the influence of treatment provider on the efficacy of psychological treatment.

Method

PubMed, Cochrane, PsycINFO, CINAHL, and Scopus were searched in April 2017 for controlled studies of evidence-based anxiety treatment in adults in primary care, published in English since 1997. Searches were repeated in April 2020. We synthesised results using a combination of meta-analysis and narrative methods. Meta-analysis was conducted using a random-effects multi-level model to account for intercorrelation between effects contributed different treatment arms of the same study. Moderator variables were explored using meta-regression analyses.

Results

In total, 19 articles (from an initial 2,247) reporting 18 studies were included. Meta-analysis including ten studies (n = 1,308) found a pooled effect size of g = 1.16 (95%CI = 0.63 – 1.69) for psychological treatment compared to waitlist control, and no significant effect compared to care as usual (p = .225). Substantial heterogeneity was present (I2 = 81.25). Specialist treatment produced large effects compared to both waitlist control (g = 1.46, 95%CI = 0.96 – 1.96) and care as usual (g = 0.76, 95%CI = 0.27 – 1.25). Treatment provided by non-specialists was only superior to waitlist control (g = 0.80, 95%CI = 0.31 – 1.28). We identified relatively few studies (n = 4) of medications, which reported small to moderate effects for SSRI/SNRI medications and hydroxyzine. The quality of included studies was variable and most studies had at least “unclear” risk of bias in one or more key domains.

Conclusions

Psychological treatments for anxiety are effective in primary care and are more effective when provided by a specialist (psychologist or clinical psychologist) than a non-specialist (GP, nurse, trainee). However, non-specialists provide effective treatment compared with no care at all. Limited research into the efficacy of pharmacological treatments in primary care needs to be considered carefully by prescribers

Trial registration

PROSPERO registration number CRD42018050659
Appendix
Available only for authorised users
Literature
1.
Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med. 2013;43(5):897–910.PubMedCrossRef
2.
Kessler RC. The global burden of anxiety and mood disorders: putting the European Study of the Epidemiology of Mental Disorders (ESEMeD) findings into perspective. J Clin Psychiatry. 2007;68(Suppl 2):10–9.PubMedPubMedCentral
3.
Baxter AJ, Vos T, Scott KM, Ferrari AJ. The global burden of anxiety disorders in 2010. Psychol Med. 2014;44(11):2363–74.PubMedCrossRef
4.
Burgess PM, Pirkis JE, Slade TN, Johnston AK, Meadows GN, Gunn JM. Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry. 2009;43(7):615–23.PubMedCrossRef
5.
Bijl RV, Ravelli A. Psychiatric morbidity, service use, and need for care in the general population: results of the Netherlands Mental Health Survey and Incidence Study. Am J Public Health. 2000;90(4):602–7.PubMedPubMedCentralCrossRef
6.
Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, Bruffaerts R, de Girolamo G, de Graaf R, Gureje O, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet (London, England). 2007;370(9590):841–50.CrossRef
7.
8.
Chapdelaine A, Carrier J-D, Fournier L, Duhoux A, Roberge P. Treatment adequacy for social anxiety disorder in primary care patients. PLoS ONE. 2018;13(11):e0206357–e0206357.PubMedPubMedCentralCrossRef
9.
Harris MG, Hobbs MJ, Burgess PM, Pirkis JE, Diminic S, Siskind DJ, Andrews G, Whiteford HA. Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults. Med J Aust. 2015;202(4):185–9.PubMedCrossRef
10.
Wittchen HU. Generalized anxiety disorder: prevalence, burden, and cost to society. Depress Anxiety. 2002;16(4):162–71.PubMedCrossRef
11.
Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Pan Y, Charles J, Pollack AJ, Wong C, et al. General practice activity in Australia 2015–16. Sydney: Sydney University Press; 2016.
12.
National Institute for Health and Care Excellence. Anxiety disorders: quality standard. London: Author; 2014.
13.
Andrews G, Bell C, Boyce P, Gale C, Lampe L, Marwat O, Rapee R, Wilkins G. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry. 2018;52(12):1109–72.CrossRef
14.
National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. London: Author; 2011.
15.
National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. London: Author; 2013.
16.
van Schaik DJF, Klijn AFJ, van Hout HPJ, van Marwijk HWJ, Beekman ATF, de Haan M, van Dyck R. Patients’ preferences in the treatment of depressive disorder in primary care. Gen Hosp Psychiatry. 2004;26(3):184–9.
17.
Mohlman J. A community based survey of older adults’ preferences for treatment of anxiety. Psychol Aging. 2012;27:1182–90.PubMedCrossRef
18.
Richards JC, Ryan P, Mccabe MP, Groom G, Hickie IB. Barriers to the effective management of depression in general practice. Aust N Z J Psychiatry. 2004;38(10):795–803.PubMedCrossRef
19.
van Boeijen CA, van Oppen P, van Balkom AJLM, Visser S, Kempe PT, Blankenstein N, van Dyck R. Treatment of anxiety disorders in primary care practice: a randomised controlled trial. Br J Gen Pract. 2005;55(519):763–9.PubMedPubMedCentral
20.
Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, Newby JM. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: an updated meta-analysis. J Anxiety Disord. 2018;55:70–8.PubMedCrossRef
21.
Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS ONE. 2010;5(10):e13196.PubMedPubMedCentralCrossRef
22.
23.
Seekles W, Cuijpers P, Kok R, Beekman A, van Marwijk H, van Straten A. Psychological treatment of anxiety in primary care: a meta-analysis. Psychol Med. 2013;43(2):351–61.PubMedCrossRef
24.
Sonnenberg CM, Bierman EJ, Deeg DJ, Comijs HC, van Tilburg W, Beekman ATF. Ten-year trends in benzodiazepine use in the Dutch population. Soc Psychiatry Psychiatr Epidemiol. 2012;47(2):293–301.PubMedCrossRef
25.
Stephenson CP, Karanges E, McGregor IS. Trends in the utilisation of psychotropic medications in Australia from 2000 to 2011. Aust N Z J Psychiatry. 2013;47(1):74–87.PubMedCrossRef
26.
Hedges LV. Distribution theory for glass’s estimator of effect size and related estimators. J Educ Behav Stat. 1981;6(2):107–28.CrossRef
27.
Hedges LV, Olkin I. Statistical methods for meta-analysis. Orlando: Academic Press; 1985.
28.
Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw. 2010;36(3):1–48.CrossRef
29.
Gleser LJ, Olkin I. Stochastically dependent effect sizes. In: Cooper H, Hedges LV, Valentine JC, editors. The handbook of research synthesis and meta-analysis. 2nd ed. New York: Russell Sage Foundation; 2009. p. 357–76.
30.
Berkey CS, Hoaglin DC, Antczak-Bouckoms A, Mosteller F, Colditz GA. Meta-analysis of multiple outcomes by regression with random effects. Stat Med. 1998;17(22):2537–50.PubMedCrossRef
31.
Deeks JJ, Higgins JPT, Altman DG. Chapter 10: analysing data and undertaking meta-analyses. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, editors. Cochrane handbook for systematic reviews of interventions version 61 (updated September 2020). Welch: The Cochrane Collaboration; 2020.
32.
33.
Sterne JA, Egger M. Regression methods to detect publication and other bias in meta-analysis. In: Rothstein HR, editor. Publication bias in meta-analysis: Prevention, assessment and adjustments. Sutton AJ: M B; 2005. p. 99–110.
34.
Viechtbauer W, Cheung MW-L. Outlier and influence diagnostics for meta-analysis. Res Synth Methods. 2010;1(2):112–25.PubMedCrossRef
35.
Cook RD. Influential observations in linear regression. J Am Stat Assoc. 1979;74(365):169–74.CrossRef
36.
Cook RD. Detection of influential observation in linear regression. Technometrics. 1977;19(1):15–8.
37.
38.
Christensen H, Pallister E, Smale S, Hickie IB, Calear AL. Community-based prevention programs for anxiety and depression in youth: a systematic review. J Primary Prevent. 2010;31(3):139–70.CrossRef
39.
Roy-Byrne P, Craske MG, Sullivan G, Rose RD, Edlund MJ, Lang AJ, Bystritsky A, Shaw Welch S, Chavira DA, Golinelli D, et al. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: A randomized controlled trial. J Am Med Assoc. 2010;303(19):1921–8.CrossRef
40.
Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res. 2011;187(1–2):113–20.PubMedCrossRef
41.
Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Stepped care treatment for depression and anxiety in primary care. a randomized controlled trial. Trials. 2011;12:171.
42.
Blomhoff S, Haug TT, Hellström K, Holme I, Humble M, Madsbu HP, Wold JE. Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Br J Psychiatry. 2001;179(1):23–30.PubMedCrossRef
43.
Kendrick T, Simons L, Mynors-Wallis L, Gray A, Lathlean J, Pickering R, Harris S, Rivero-Arias O, Gerard K, Thompson C. A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients The CPN-GP study. Health Technol Assess. 2005;9(37):1–104.PubMedCrossRef
44.
Klein B, Richards JC, Austin DW. Efficacy of internet therapy for panic disorder. J Behav Ther Exp Psychiatry. 2006;37(3):213–38.PubMedCrossRef
45.
Laakmann G, Schüle C, Lorkowski G, Baghai T, Kuhn K, Ehrentraut S. Buspirone and lorazepam in the treatment of generalized anxiety disorder in outpatients. Psychopharmacology. 1998;136(4):357–66.PubMedCrossRef
46.
Lader M, Scotto JC. A multicentre double-blind comparison of hydroxyzine, buspirone and placebo in patients with generalized anxiety disorder. Psychopharmacology. 1998;139(4):402–6.PubMedCrossRef
47.
Llorca PM, Spadone C, Sol O, Danniau A, Bougerol T, Corruble E, Faruch M, Macher JP, Sermet E, Servant D. Efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder: A 3-month double-blind study. J Clin Psychiatry. 2002;63(11):1020–7.PubMedCrossRef
48.
Power KG, Sharp DM, Swanson V, Simpson R. Therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care. Clin Psychol Psychother. 2000;7(1):37–46.CrossRef
49.
Sharp DM, Power KG, Swanson V. A comparison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care. Clin Psychol Psychother. 2004;11(2):73–82.CrossRef
50.
Gensichen J, Hiller TS, Breitbart J, Brettschneider C, Teismann T, Schumacher U, Lukaschek K, Schelle M, Schneider N, Sommer M, et al. Panic disorder in primary care. Dtsch Arztebl Int. 2019;116(10):159–66.PubMed
51.
Lenox-Smith AJ, Reynolds A. A double-blind, randomised, placebo controlled study of venlafaxine XL in patients with generalised anxiety disorder in primary care. Br J Gen Pract. 2003;53(495):772–7.PubMedPubMedCentral
52.
Sundquist J, Lilja A, Palmer K, Memon AA, Wang X, Johansson LM, Sundquist K. Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial. Br J Psychiatry. 2015;206(2):128–35.PubMedCrossRef
53.
Newby JM, Mackenzie A, Williams AD, McIntyre K, Watts S, Wong N, Andrews G. Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care. Psychol Med. 2013;43(12):2635–48.PubMedCrossRef
54.
Muntingh ADT, Van Der Feltz-Cornelis C, Van Marwijk H, Spinhoven P, Assendelft W, De Waal M, Adèr H, Van Balkom A. Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial. Psychother Psychosom. 2014;83(1):37–44.PubMedCrossRef
55.
Oosterbaan DB, Verbraak MJPM, Terluin B, Hoogendoorn AW, Peyrot WJ, Muntingh A, Van Balkom AJLM. Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomised controlled trial. Br J Psychiatry. 2013;203(2):132–139.
56.
Nordgren LB, Hedman E, Etienne J, Bodin J, Kadowaki A, Eriksson S, Lindkvist E, Andersson G, Carlbring P. Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: a randomized controlled trial. Behav Res Ther. 2014;59:1–11.PubMedCrossRef
57.
Berger T, Urech A, Krieger T, Stolz T, Schulz A, Vincent A, Moser CT, Moritz S, Meyer B. Effects of a transdiagnostic unguided Internet intervention ('velibra’) for anxiety disorders in primary care: Results of a randomized controlled trial. Psychol Med. 2017;47(1):67–80.
58.
Review Manager (RevMan) [Computer Program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration; 2014.
59.
Mörtberg E, Clark DM, Bejerot S. Intensive group cognitive therapy and individual cognitive therapy for social phobia: sustained improvement at 5-year follow-up. J Anxiety Disord. 2011;25(8):994–1000.PubMedCrossRef
60.
van Dis EAM, van Veen SC, Hagenaars MA, Batelaan NM, Bockting CLH, van den Heuvel RM, Cuijpers P, Engelhard IM. Long-term outcomes of cognitive behavioral therapy for anxiety-related disorders: a systematic review and meta-analysis. JAMA Psychiat. 2020;77(3):265–73.CrossRef
61.
Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: A review of progress. J Clin Psychiatry. 2010;71(7):839–54.PubMedCrossRef
62.
Bandelow B, Sher L, Bunevicius R, Hollander E, Kasper S, Zohar J, Möller H-J. Guidelines for the pharmacological treatment of anxiety disorders, obsessive–compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract. 2012;16(2):77–84.PubMedCrossRef
63.
Muntingh ADT, van der Feltz-Cornelis CM, van Marwijk HWJ, Spinhoven P, van Balkom AJLM. Collaborative care for anxiety disorders in primary care: a systematic review and meta-analysis. BMC Fam Pract. 2016;17(1):62.PubMedPubMedCentralCrossRef
64.
Wang S-M, Han C, Bahk W-M, Lee S-J, Patkar AA, Masand PS, Pae C-U. Addressing the side effects of contemporary antidepressant drugs: a comprehensive review. Chonnam Med J. 2018;54(2):101–12.PubMedPubMedCentralCrossRef
65.
Hart G, Panayi MC, Harris JA, Westbrook RF. Benzodiazepine treatment can impair or spare extinction, depending on when it is given. Behav Res Ther. 2014;56:22–9.PubMedCrossRef
66.
Westra HA, Stewart SH, Conrad BE. Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia. J Anxiety Disord. 2002;16(3):233–46.PubMedCrossRef
Metadata
Title
Contemporary treatment of anxiety in primary care: a systematic review and meta-analysis of outcomes in countries with universal healthcare
Authors
Erin L. Parker
Michelle Banfield
Daniel B. Fassnacht
Timothy Hatfield
Michael Kyrios
Publication date
01-12-2021
Publisher
BioMed Central
Published in
BMC Primary Care / Issue 1/2021
Electronic ISSN: 2731-4553
DOI
https://doi.org/10.1186/s12875-021-01445-5

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