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Diagnoses of anxiety disorders may depend on the doctor’s perceptions as much as on the symptoms. There has to be a better way.
Studies have shown that general practitioners tend to supplement DSM criteria for the various mental health disorders with their own preconceptions and judgment. This, naturally influences their perception, recall and diagnosis of the patient’s condition.
For instance, a preconception that severe depression leads to feelings of worthlessness may result in the doctor unconsciously looking for signs to confirm that this is, indeed, the case. Suspicion that a patent has suicidal thoughts may lead to recall of this being the case despite it never actually having been discussed.
This places the onus on the patient to be thoroughly explicit when describing his/her symptoms since missed or mistaken diagnoses can only lead to greater problems. Correct diagnosis calls for clear communication on both sides. General practitioners do not, as a rule, have the experience in diagnosing mental illnesses that psychiatrists and other specialists do. But they are the first port of call in getting treatment and you, the patient, must ensure that you are both on the same wavelength. Don’t presume. Ensure that he/she has the all the details. If you suspect a bias, you’ll need another opinion. This is not always possible so try to get it right the first time. It shouldn’t be this way, but be aware that it often is the case.
Anxiety disorders are prevalent in general practice but the rate of recognition is low due to combinations of poor communication between doctor and patient, the general practitioner’s limited knowledge, and possible bias, in regard to psychiatric disorders. Add to this, other factors such as the patient’s inability to discuss the problem, due to fear of stigma, the competing demands on the doctor’s time and limited referral possibilities. It becomes obvious, then, that there is a need for a chronic care system for anxiety disorders in general practice, such as those used in diabetes care and other chronic diseases.
Unfortunately in many, or even, in most cases at present, treatment in primary care consists of benzodiazepines and/or antidepressants. While effective, such drug therapy often results in discontinuation due to side effects, relapse when treatment ends, or addiction if it doesn’t. The more effective cognitive–behavioural therapy (CBT) is difficult for primary care physicians to deliver due to both therapist training time and the time involved in its provision. Under collaborative management, it could become accessible.
In a collaborative approach, a care manager coordinates treatment, monitoring treatment response and actively following the patient’s progress. This care manager works in close collaboration with the general practitioner and they are both assisted by a specialist. In terms of mental health disorders, either a mental health nurse or a psychologist with training as a CBT facilitator, would act as care manager and a psychiatrist as the consultant specialist.
In this way, stepped care can be put in place. Stepped care is provided in three steps – guided self-help based on cognitive behavioural principles; CBT; antidepressant medication. Bibliotherapy becomes the first line treatment and medication is used as a last resort. The doctor no longer has to resort to drug therapy in the first instance, the specialist’s expertise reaches more patients and, even the time spent on CBT is reduced by the education involved in the guided self-help or bibliotherapy before it commences.
The care manager coordinates treatment, provides the guided self-help and the CBT, and evaluates each step. The doctor prescribes medication and evaluates all progress with the care manager. Both the care manager and the doctor consult the psychiatrist about treatment decisions. Patient involvement is enhanced through monitoring by the care manager and relapse is prevented by monthly follow-up calls.
A three year study of a collaborative stepped care treatment program for patients with either panic disorder or general anxiety disorder is currently being undertaken in the Netherlands. Studies done in recent years in the United States demonstrate that collaborative care is more effective than traditional care but show no consensus on the costs involved. The addition of guided self-help in the program being undertaken in the Netherlands study is expected to reduce overall cost by eliminating the need for both steps two and three in some cases and reducing the cost of step two and eliminating step three in others.
Copyright Jean Jardine Miller.
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