Most Anxious Clients See Physicians Instead of Therapists

 

With the growing list of empirically supported treatments for anxiety, it seems a disservice to potential clients that so many of them first seek medical treatment from physicians and medical clinics. Anxiety and depression often manifest in the kinds of somatic symptoms that garner the attention of people who suffer from these conditions. Haug (2002), in a large study of over 62,000 people who had reported gastro-intestinal symptoms of nausea, found that just over 41% were suffering from anxiety that had not been previously diagnosed. Of these people, anxious women far outnumbered men (17.9 to 12.5 %). Depression was also a common and previously undiagnosed condition, with no gender differential: 10.4 % of both males and females reporting gastro-intestinal nausea were found to have symptoms of depression. “Nausea is a common complaint in primary care settings and a differential diagnosis for nausea should include both anxiety and depression,” notes Tone. “This may lead to avoidance of long-term use of potentially harmful medications for nausea, unnecessary medical investigation and probably a better quality of life for the patients.”

There are two important issues for psychotherapists here. The first is obviously the well-being of people who suffer from both diagnosed and undiagnosed anxiety. If anxiety is driving the somatic symptoms, they are not being served best by seeking medical treatment with the side effects of medication or other physical interventions. Even if we keep in mind that the relationship between somatic and emotional symptoms is often bidirectional—physical distress can exacerbate or cause anxiety or depression, and anxiety or depression can exacerbate or cause physical symptoms—it seems obvious and imperative that the emotional dimension get treated, and many patients don’t seek treatment for the psychological component. Faghri et al. (2010) find that 30% of the patients of primary care physicians are being treated by their PCPs for mental health issues. Other estimates run as high as 70% (Kolbasovsky, 2005).

The second issue may be surprising to psychotherapists. Cummings (1991) has long argued that the future of psychology lies in integrating services with physicians. He points out that 70 percent of a general physician’s caseload consists of patients whose physical complaints include psychological dimensions such as psychogenic illness or poor treatment compliance (Cummings 1991). Physicians actually spend 50 percent of their time, Cummings says, addressing concerns that therapists are better trained to handle. These unaddressed concerns double physical healthcare costs. Many physicians do not particularly like working with patients whose somatic symptoms are emotionally based. Like psychotherapists, physicians like to be effective in helping people, and people who are helped, whether by physicians or psychotherapists, are more satisfied and less troublesome patients. Thus, psychotherapists not only have an obligation to forge alliances and ongoing referrals with physicians for the benefit of this large number of anxious or depressed clients, but there is a significant opportunity to increase one’s psychotherapy practice.

It is important to note that the high prevalence of anxiety co-existing with somatic symptoms varies considerably among studies, with Cummings at the high end. A recent large scale study of nearly 260,000 patients who visited a primary care physician with a somatic complaint deemed more likely to co-exist with anxiety or depression (Gates, 2016) finds a considerably lower linkage: fewer than 4% were subsequently diagnosed with anxiety or depression. But as Gates notes, the incidence varies depending upon the criteria for the sample. When researchers looked at people who visited physicians with a medically unexplained condition—which occurs among about one-third of all general physician visits, the incidence of anxiety rose to nearly 15% for anxiety and 23% for depression (Kroenke, 1997).

Haug’s study describes how people who experience nausea—a physical complaint that’s often psychogenic—move futilely, with much discomfort and expense, through the medical system, from general practitioners to gastrointestinal specialists. The association between nausea and anxiety and depression is higher among patients seeing gastrointestinal specialists than among those seeing general practitioners. This suggests that as long as these psychological components are present, the nausea isn’t amenable to treatment, Haug says. She recommends that whenever patients complain about nausea, doctors should check for anxiety and depression—and that’s an assessment that therapists are better qualified to make.

References:

Clarke, David D., (2016). Diagnosis and treatment of medically unexplained symptoms and chronic functional syndromes. Families, Systems, & Health, Vol 34(4), Dec 2016, 309-316. Special Section: Medically Unexplained Symptoms.doi: https://dx.doi.org/10.1037/fsh0000228.

Cummings, N.A., Austad, C. (Ed); Berman, W (eds) (1991). Psychotherapy in managed health care: The optimal use of time & resources. Washington, DC: American Psychological Association.

Faghri, N.M., Boisvert, C. & Faghri, S (2010). Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions, Mental Health in Family Medicine Mar 7(1): 17–25.

Gates, Kristin; Petterson, Stephen; Wingrove, Peter; Miller, Benjamin; Klink, Kathleen (2016). You can’t treat what you don’t diagnose: An analysis of the recognition of somatic presentations of depression and anxiety in primary care. Families, Systems, & Health, Vol 34(4), Dec 2016, 317-329. Special Section: Medically Unexplained Symptoms. doi: https://dx.doi.org/10.1037/fsh0000229.

Kolbasovsky A, Reich L, Romano I, et al.(2005). Integrating behavioral health into primary care settings: a pilot project. Professional Psychology: Research and Practice 36:130–5.

Kroenke, Kurt (2016). Somatic symptoms deserve our attention. Families, Systems, & Health, Vol 34(4), Dec 2016, 330-333. Special Section: Medically Unexplained Symptoms. doi: https://dx.doi.org/10.1037/fsh0000236.

Tone, T.H, Arnstein, M (2002). The prevalence of nausea in the community: psychological, social and somatic factors. General Hospital Psychiatry, 24 (2).