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

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

Cognitive behavioural therapy for mood and anxiety disorders delivered by mental health nurses: Outcomes and predictors of response in a real-world outpatient care setting

“…Thus, the findings of this study using real-world data have significant implications for the dissemination of MHN-led CBT in routine practice. Furthermore, a previous study indicated that CBT for anxiety disorders is more effective when provided by psychiatrists or clinical psychologists than when provided by MHNs (Parker et al, 2021). Despite this, in terms of within-group effect size, our results were comparable to those of other studies in which mental health professionals other than MHNs delivered psychological interventions (including CBT) in a routine care setting.…”

“…However, service users' access to CBT in Japan is generally suboptimal owing to the scarcity of CBT providers under the health insurance scheme, which requires CBT to be only provided by skilled and experienced psychiatrists (Ono, 2011). Research has shown that psychological treatments, predominantly CBT, for anxiety are more effective when they are delivered by a psychiatrist or clinical psychologist than when delivered by MHNs (Parker et al, 2021). However, to improve access to CBT in Japan, the subsequent FY 2016 revision of medical fees expanded the range of eligible CBT providers to include MHNs.…”

Effective Treatment Interventions for Patients with a Diagnosed Anxiety Disorder

“…The most common treatment for anxiety disorders regardless of severity is pharmaceutical management [12]. In addition to being effective, pharmaceutical management also tends to be more accessible than other treatment options [12]. Numerous groups of pharmacological treatments exist for the anxiety disorder.…”

Changes in anxiety in the general population over a six-year period

“…Anxiety disorders are common in patients and in the general population [1]. In primary care settings, anxiety disorders are among the most frequent disorders observed [2][3][4], and these disorders are associated with high use of health care services [5]. Sex and age differences in anxiety have been investigated in several studies.…”