Anxiety Disorders: Future Directions for Research and Treatment

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Chapter 1

Introduction

Anxiety disorders are one of the most common mental health problems. According to the Mental Health Supplement of the 1990 Ontario Health Survey, 9% of men and 16% of women in Ontario (Canada) experienced anxiety in the twelve months preceding the survey (Ontario Ministry of Health, 1994). A study of psychiatric disorders in Edmonton (Canada) reported a lifetime prevalence of 11.2% for developing an anxiety/somatoform disorder (Bland et al., 1988).

These disorders are often associated with other mental health problems such as depression. There is little doubt that anxiety disorders impose an enormous burden on both individuals with the disorders (and their family members), as well as on society in general. Anxiety disorders are associated with, for example, reduced quality of life, functional impairment, frequent use of both the mental health and health care systems, and lost productivity in the workplace (Leon, Portera, and Weissman, 1995; Salvador-Carulla, Segui, Fernandez-Cano, and Canet, 1995; Siegel, Jones, and Wilson, 1990; Simon, Ormel, VonKorff, and Barlow, 1995; Swinson, Cox, and Woszczyna, 1992).

Effective, empirically validated pharmacological, psychotherapeutic, and behavioural interventions exist to treat the anxiety disorders. Recent evidence, however, suggests a lack of knowledge among health and mental health professionals of appropriate treatments for these disorders, and use of treatments often not based on sound empirical research.

To contribute to the empirical knowledge base of effective treatment strategies for the anxiety disorders, and to further discussions among key stakeholders in the mental health field on these issues, the Health Promotion and Programs Branch of Health Canada commissioned a critical review of the treatment literature and a discussion paper. Both reports were prepared by Martin Antony, Ph.D, and Richard Swinson, M.D., of the Clarke Institute of Psychiatry in Toronto (Ontario).

1. Target Audience

This discussion paper should be of interest to policy makers, administrators, professionals in the mental health and health care fields, researchers, non-governmental organizations, consumer and family groups, and anyone involved in the treatment of anxiety disorders.

2. Methodology

This document is based on the Health Canada report, “Anxiety Disorders and their Treatment: A Critical Review of the Evidence-Based Literature”, available under separate cover. For that review, computer literature searches of the Medline and PsychLit data bases were conducted for articles on the treatment of anxiety disorders published within the past 15 years (1981 to 1996). Key words used were combinations of each disorder name and the word “treatment” (e.g., treatment and panic disorder). In addition, a manual literature search was conducted by scanning the reference sections of recent review papers and treatment studies.

Studies were selected for review according to the following criteria: controlled research studies (involving control or comparison groups); minimum of ten participants per group; and use of diagnostic criteria from no earlier than DSM-III (Diagnostic and Statistical Manual of Mental Disorders, 3rd edition) (American Psychiatric Association, 1980). With the publication of DSM-III, the various anxiety disorders had clear diagnostic criteria that could be replicated across research and clinical sites. In addition, studies of mixed groups of patients (e.g., panic disorder and generalized anxiety disorder) were not included unless it was possible to separate out the effects of treatment on each disorder.

On the basis of these criteria, pharmacotherapeutic studies and studies employing cognitive and behavioural approaches were included for review. Meta-analytic studies were reviewed when available. Studies of self-help (self-instruction) treatments (e.g., self-help books) and treatments involving minimal therapist contact (e.g., treatment by telephone) were also included where available. However, studies of the effectiveness of (participation in) self-help groups did not meet the criteria and were not included. Studies of other forms of psychotherapeutic interventions (e.g., psychodynamic and humanistic approaches) were not included as they did not meet the above criteria. In total, over 200 treatment studies were excluded from the review.

3. Organization of the Report

Chapter 2 presents an overview of the anxiety disorders, including prevalence, comorbidity, risk factors, and health care utilization and economic costs associated with the anxiety disorders. Chapter 3 presents a discussion of pharmacological, psychological (cognitive- behavioural), and behavioural interventions, discusses important treatment considerations, including side effects of medications, and describes effective treatments for each of the anxiety disorders. Chapter 4 identifies gaps in the research literature, provides directions for potential future research, and identifies implications for professional care, and for professional and public education. Three appendices are included: Appendix 1 provides a table of lifetime prevalence rates for the anxiety disorders; Appendix 2 provides a glossary of medications used in the report, and a listing of relevant abbreviations and definitions of technical terms; Appendix 3 contains a listing of useful references on anxiety assessment instruments.

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