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Psychological Services Barriers to Mental Health Treatment Among Individuals With Social Anxiety Disorder and Generalized Anxiety Disorder Elizabeth M. Goetter, Madelyn R. Frumkin, Sophie A. Palitz, Michaela B. Swee, Amanda W. Baker, Eric Bui, and Naomi M. Simon Online First Publication, August 2, 2018. http://dx.doi.org/10.1037/ser0000254

CITATION Goetter, E. M., Frumkin, M. R., Palitz, S. A., Swee, M. B., Baker, A. W., Bui, E., & Simon, N. M. (2018, August 2). Barriers to Mental Health Treatment Among Individuals With Social Anxiety Disorder and Generalized Anxiety Disorder. Psychological Services. Advance online publication. http://dx.doi.org/10.1037/ser0000254

Barriers to Mental Health Treatment Among Individuals With Social Anxiety Disorder and Generalized Anxiety Disorder

Elizabeth M. Goetter Massachusetts General Hospital, Boston, Massachusetts, and

Harvard Medical School

Madelyn R. Frumkin Massachusetts General Hospital, Boston, Massachusetts

Sophie A. Palitz and Michaela B. Swee Temple University

Amanda W. Baker, Eric Bui, and Naomi M. Simon Massachusetts General Hospital, Boston, Massachusetts, and

Harvard Medical School

Individuals with social anxiety disorder (SAD) or generalized anxiety disorder (GAD) are at risk for not utilizing mental health treatment. The purpose of this research was to examine barriers to treatment in a sample of adults with clinically significant SAD or GAD. Participants were 226 nontreatment-seeking adults with SAD or GAD who underwent semistructured diagnostic interview and received a clinician assessment of symptom severity as part of a clinical research study. Participants completed a self-report measure of barriers to treatment. Individual and combined associations of demographic and symptom severity variables with number of perceived barriers to treatment were examined. Individuals with GAD or SAD endorsed a similar number of overall barriers to treatment. Shame and stigma were the highest cited barriers followed by logistical and financial barriers. Both groups also endorsed not knowing where to seek treatment at high rates. Individuals with greater symptom severity reported more barriers to treatment. Racial and ethnic minorities reported more barriers to treatment even after controlling for symptom severity. Among individuals with GAD or SAD, increased education and culturally sensitive outreach initiatives are needed to reduce barriers to mental health treatment.

Keywords: barriers, anxiety, evidence-based treatment, treatment utilization

The mental health field and broader public health community face a critical challenge to increase the accessibility of evidence- based treatments for anxiety disorders. Anxiety disorders are the most prevalent category of mental health disorders and impact nearly 30% of adults in the United States over the course of their lifetime (Kessler et al., 2005). Social anxiety disorder (SAD), characterized by fear and avoidance of social and performance situations, and generalized anxiety disorder (GAD), marked by uncontrollable worry and physical symptoms of tension, are par-

ticularly common with lifetime prevalence rates of 12% and 6%, respectively (Kessler et al., 2005). Left untreated, GAD is associ- ated with significant distress, worsened quality of life, and more medical problems, as well as first onset of other anxiety, mood, and substance use disorders (Newman, 2000; Ruscio et al., 2007). Similarly, untreated SAD is linked to higher risk of substance use, suicidality, impaired social functioning, and reduced health-related quality of life (Olfson et al., 2000; Sareen, Chartier, Paulus, & Stein, 2006; Schneier et al., 1994; Stein et al., 2005).

Despite the negative consequences of untreated GAD and SAD, the National Comorbidity Survey Replication, based on interview data collected from 9,282 English-speaking adults between 2001 and 2003, found that approximately 75% of those with current SAD or GAD had not utilized mental health treatment for their symptoms in the prior year; utilization rates were lower among individuals with GAD or SAD than among those with panic disorder or any mood disorder, including major depression and dysthymia (Wang et al., 2005). These low health care utilization rates are troubling, especially given that safe, effective, evidence- based psychotherapy and pharmacotherapy treatments for SAD and GAD exist (Borkovec, Newman, Pincus, & Lytle, 2002; Fedoroff & Taylor, 2001; Heimberg, 2002; Mitte, 2005; Roemer, Orsillo, & Salters-Pedneault, 2008).

In order to overcome barriers to treatment and encourage treat- ment utilization, it is important to systematically understand these barriers and then target them in approaches to care. In GAD and

Elizabeth M. Goetter, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, and Department of Psychiatry, Harvard Medical School; Madelyn R. Frumkin, Department of Psychiatry, Massa- chusetts General Hospital; Sophie A. Palitz and Michaela B. Swee, De- partment of Psychology, Temple University; Amanda W. Baker, Eric Bui, and Naomi M. Simon, Department of Psychiatry, Massachusetts General Hospital, and Department of Psychiatry, Harvard Medical School.

Madelyn R. Frumkin is now at the Department of Psychology, Wash- ington University in St. Louis. Naomi M. Simon is now at the Department of Psychiatry, New York University (NYU) Langone.

This research was supported by the Highland Street Foundation. Correspondence concerning this article should be addressed to Elizabeth

M. Goetter, Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, 6th Floor, Boston, MA 02114. E-mail: egoetter@ mgh.harvard.edu

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Psychological Services © 2018 American Psychological Association 2018, Vol. 1, No. 999, 000 1541-1559/18/$12.00 http://dx.doi.org/10.1037/ser0000254

1

SAD, worry about the uncertainty of what treatment might entail and fear of negative evaluation (e.g., from a mental health profes- sional) may be components of the disorders themselves that im- pede treatment utilization. Indeed, one of the largest studies ex- amining barriers to treatment among adults with social anxiety found that fear of what others might say or think was among the top barriers to seeking treatment (Olfson et al., 2000), which is consistent with other studies that have documented the reluctance of individuals with anxiety to seek treatment (Roness, Mykletun, & Dahl, 2005). Notably, there has been a recent proliferation of evidence-based, Internet-mediated treatments for both SAD and GAD, which represent important advances that have enabled greater access to care (Dahlin et al., 2016; Yuen et al., 2013b). Given these factors, alongside broader initiatives aimed at improv- ing dissemination, it is important to further our understanding of reasons why individuals with SAD and GAD may fail to seek treatment (Gallo, Comer, & Barlow, 2013; Taylor & Abramowitz, 2013).

The purpose of the current study was to identify barriers to treatment for individuals with SAD and GAD and to explore whether these barriers differ based on demographic or symptom profiles. While previous research has found that those with social anxiety endorse financial concerns, uncertainty about where to seek help, and fear of what others might say or think as barriers to treatment, few studies have examined specific correlates of barri- ers among individuals with SAD and GAD (Olfson et al., 2000). Furthermore, despite similarly low rates of treatment utilization among individuals with GAD, there is a lack of research examin- ing barriers to treatment in this population specifically. Thus, the primary aims of this study were to examine and compare (a) perceived barriers to care between those with GAD and SAD and (b) specific patient characteristics that identify individuals with GAD and SAD who may be at risk for underutilization of mental health treatment.

Method

Participants

Participants were eligible for this study if they were between the ages of 18 and 65 and had a primary diagnosis of SAD or GAD as determined by a comprehensive semistructured clinical interview. Those with a lifetime history of schizophrenia, psychotic disor- ders, bipolar disorder, intellectual disability, or a mental disorder due to a medical condition or substance; alcohol or substance abuse or dependence within the past 6 months; and serious acute suicidal risk were excluded. In cases where individuals met criteria for both GAD and SAD, primacy of diagnosis was determined after a comprehensive semistructured clinical interview done by a trained clinician and discussion with the participant about the problem they felt was most impairing and distressing to them currently.

Participants were 226 adults, 121 with a primary diagnosis of SAD (57% women, Mage � 28, SD � 10.5) and 105 with a primary diagnosis of GAD (78% women, Mage � 28, SD � 9.7; see Table 1). Consistent with population lifetime prevalence rates (Kessler et al., 1994), there was a gender by primary diagnosis interaction such that there were significantly more males in the

primary SAD group (n � 52, 43%) compared to the GAD group (n � 24, 22%), �2(1, N � 226) � 11.26, p � .001.

Procedure

Participants in the current study were approached for participa- tion after being recruited for and consenting to various nontreat- ment parent studies examining predictors and correlates of anxiety disorders. Participants were recruited for the parent studies via newspaper, radio, and flyer advertisements, clinician referrals, and self-referrals in a large urban area. Advertisements varied subtly depending on the parent study, but were broad and did not require self-identification of GAD or SAD. Typically, the advertisements featured questions like “Are you anxious?” and “Do you worry a lot?” but because participants were being recruited for various simultaneous studies going on at our center, occasionally, adver- tisements featured other questions like “Do you experience panic attacks?” For the parent studies, participants called the center and

Table 1 Demographic Characteristics of Sample

Demographic GAD

(n � 105) SAD

(n � 121) t p

Gender, % –3.43 �.001 Male 22% 43% Female 78% 57%

Age .13 .90 M 28 28 SD 9.7 10.5 Range 18–65 18–62

Race, % 2.66 �.01 White 84% 66% Black or African American 3% 8% Asian 8% 15% Other 2% 3%

More than one 3% 8% Ethnicity, % .10 .92

Not Hispanic or Latino 94% 85% Hispanic of Latino 6% 14%

Income level –1.46 .15 �$15,000 28% 37% �$15,000 53% 45% Not given 19% 18%

Marital status .18 .86 Single 74% 73% Living with partner 11% 11% Married 9% 12% Divorced 4% 1% Widowed 1% 1% Separated 1% 2%

Highest education level 1.04 .30 Graduate school 32% 27% College graduate 39% 41% Partial college 24% 25% High school graduate 5% 7%

Comorbidities GAD N/A 29% SAD 45% N/A MDD 8% 13% 1.25 .22 Specific phobia 27% 17% –2.05 �.05 OCD 4% 2% –1.81 .07

Note. GAD � generalized anxiety disorder; SAD � social anxiety dis- order; MDD � major depressive disorder; OCD � obsessive– compulsive disorder; N/A � not applicable.

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spoke with a bachelor’s level research coordinator who completed a brief phone screen and then scheduled the individual to come in for assessment with a doctoral level clinician. On the day of the scheduled visit, participants arrived in person to our research center. After providing informed consent, participants met with a doctoral-level study clinician in one of the coinvestigator’s offices and were evaluated using a semistructured, diagnostic psychiatric interview. Participants eligible for the current study were then asked if they were interested in participating in an additional study examining predictors and correlates of anxiety and related conditions. Participants were told that this additional study involved administra- tion of additional self-report questionnaires and clinician- administered instruments that would take approximately 1 addi- tional hour. Participants were given the option to complete the self-report measures onsite or take them home and return by prepaid mail. Participants who were interested went through an additional informed consent process and were then evaluated, in the same setting, using clinician-administered assessments of anx- iety, depression, and general functioning. A total of 268 individ- uals who initiated one of the parent studies were potentially eligible for the current study and 63.81% (n � 171) went on to participate. There were no differences in age between those who participated (M � 30.84, SD � 12.21) and those who did not (M � 29.64, SD � 11.21), t � 0.74, p � .46, and no differences in biological sex between those who participated (65.09% women) and those who did not (64.58% women), �2(1, N � 265) � 0.007, p � .93. An additional subset of our sample (n � 55) participated in the current study despite ineligibility for one of the parent studies (e.g., due to comorbid depression diagnosis).

Typically, administration of all clinician-administered mea- sures, including initial diagnostic assessment took approximately 90 –120 min. Doctoral-level study clinicians had a doctorate in clinical psychology and had been certified by the study coordinator to reliably administer the diagnostic interview and other clinician administered measures. To be certified, clinicians had to reliably corate two recordings of another clinician administering the study measures. This was followed by a supervised administration of the assessments, which had to be corated accurately before clinicians were deemed able to conduct independent study assessments. Following this evaluation, participants completed a self-report assessment of barriers to treatment. Certain measures were not completed by some participants due to the nature of the primary study in which they participated. We note where sample sizes were discrepant with the overall sample. Participants received financial remuneration ($25) for their participation in the research study. All procedures were approved by the local Institutional Review Board.

Measures

Clinician-administered measures. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disor- ders (fourth edition, text revision; SCID) was used to assess the presence of psychiatric diagnoses (First, Spitzer, Gibbon, & Wil- liams, 2002). This is a well-established and widely used semistruc- tured, clinician-administered diagnostic interview that assesses criteria of Axis I disorders in the Diagnostic and Statistical Man- ual of Mental Disorders (fourth edition, text revision; American Psychiatric Association, 2000). Symptom criteria are assessed as either present, subthreshold, or absent. The clinician begins by

asking several screening questions and then uses decision-tree logic to assess whether criteria are met for a particular disorder. Earlier versions of this instrument used in clinical samples have demonstrated adequate interrater reliability and test–retest reliabil- ity in a 1- to 3-week period (Zanarini & Frankenburg, 2001).

The Liebowitz Social Anxiety Scale (LSAS; Heimberg et al., 1999) was used to assess social anxiety symptom severity. The LSAS is a 24-item measure divided into two subscales that address social interactional (11 items) and performance (13 items) anxiety. Clinicians rate the individual’s level of anxiety and avoidance on each of the items. Items are rated on a 0 –3 Likert scale, with higher scores indicating greater social anxiety severity. The LSAS has been shown to be a reliable measure for the assessment of individuals experiencing social anxiety, exhibiting excellent inter- nal consistency and good convergent validity (Heimberg et al., 1999). Internal consistency was very good (Cronbach’s alpha � .96).

General anxiety symptom severity was measured using the Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1960). This is a 14-item scale with responses rated on a 0 – 4 Likert scale. Total scores range from 0 to 56, with higher scores indicating greater severity of anxiety symptoms. The HAM-A has been shown to be a reliable scale for assessment of anxiety severity and to demon- strate sufficient concurrent validity (Maier, Buller, Philipp, & Heuser, 1988). Internal consistency was adequate (Cronbach’s � � .78).

Depressive symptoms were measured using the Montgomery– Asberg Depression Scale (MADRS; Montgomery & Asberg, 1979). This is a 10-item scale with responses rated on a 0 – 6 Likert scale. Total scores range from 0 to 60, with higher scores indicat- ing greater severity of depression symptoms. The MADRS has been shown to have good interrater reliability and good construct validity (Davidson, Turnbull, Strickland, Miller, & Graves, 1986). Internal consistency was adequate (Cronbach’s � � .73).

Finally, life satisfaction and functional impairment were mea- sured with the Range of Impaired Functioning Tool (Leon et al., 1999). Items are rated on a 1– 6 Likert scale. Total scores range from 4 to 20, with higher scores indicating higher severity of impairment. Responses of 0 (not applicable) or 6 (no information) are reported as missing and not included in calculation of the total score. The Range of Impaired Functioning Tool has demonstrated good interrater reliability and good concurrent and predictive validity (Leon et al., 1999). Internal consistency was lower than other measures (Cronbach’s � � .68), which likely reflects that fewer (i.e., four) items factor into the total score.

Trained clinician raters also used the Clinical Global Impression Scale–Severity (CGI-S) rating to evaluate overall psychiatric se- verity (Guy, 1976). The CGI-S is a 7-point scale widely used by clinical evaluators to measure symptom severity. Each point rep- resents a distinct characterization of wellness. The CGI-S has been found to strongly correlate with patient and clinician-administered measures of symptom severity (Zaider, Heimberg, Fresco, Sch- neier, & Liebowitz, 2003).

Self-report measures. Participants completed a standard de- mographics questionnaire and the Barriers to Treatment Question- naire (BTQ; Marques et al., 2010). The BTQ is a 23-item self- report measure that assesses an individual’s perceived barriers to seeking treatment. Individuals were asked, “How much each of the following factors influenced your decision to delay or avoid seek-

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3BARRIERS TO TREATMENT

ing mental health treatment in the last 12 months?” The measure assesses a number of potential barriers including logistic and financial, stigma and shame, treatment perception, and satisfac- tion. Each item is endorsed on a 4-point Likert scale ranging from 0 (not at all) to 4 (extremely). Total scores range from 0 to 92. Internal consistency was very good (Cronbach’s � � .86).

Data Analyses

To describe the frequency of specific types of barriers to care, endorsement rates (i.e., percent of participants who rated the item at 1 or greater) for each of the 23 barriers assessed by the BTQ were reported by primary diagnosis. An independent-samples t test was used to determine whether there were differences in total BTQ score by primary diagnosis. To examine relationships between demographic variables and total BTQ score across those with primary SAD and primary GAD, we conducted a series of t tests and one-way analyses of variance. For our analyses, given the sample size of 226 (SAD n � 121; GAD n � 105), we had 80% power to detect a small to medium between-groups effect size (Cohen’s d � 0.37). Pearson’s pairwise correlations were used to examine the association between symptom severity scores and total score on the BTQ. To determine the unique contribution of demographic and symptom factors on perceived barriers to treat- ment, we conducted a hierarchical multiple regression. Total BTQ was entered as the dependent variable and the independent vari- ables were symptom variables (entered in Step 1) and statistically significantly correlated demographic variables (entered in Step 2). Data were analyzed using STATA Version 12 (StataCorp, 2011). The level of statistical significance was set to 0.05 (two-tailed).

Results

Demographic data are detailed in Table 1. Anxiety and depres- sion symptoms by diagnosis are presented in Table 2. Global symptom severity scores on the CGI did not differ significantly by primary diagnosis and reflected moderate levels of symptom se- verity across the sample (M � 4.44, SD � .81).

Barriers to Treatment

Across both diagnostic groups, logistical and stigma/shame- related barriers were endorsed most frequently (see Figure 1).

Specifically, for individuals with primary GAD, the most fre- quently endorsed barriers included wanting to handle problems oneself (81%), feeling embarrassed about needing help (75%), not knowing where to go for treatment (74%), and being worried about the cost of treatment (74%). Similarly, for those with primary SAD, wanting to handle problems oneself (83%), feeling embar- rassed about one’s problems (79%), and not knowing where to go for treatment (69%) were the most frequently endorsed barriers to treatment.

Characteristics Associated With Perceived Barriers to Treatment

Total score on the BTQ did not differ significantly by primary diagnosis (see Table 2). Age was significantly correlated with total score on the BTQ, such that younger individuals perceived more barriers, r � �0.39, p � .01. Ethnic minority individuals also scored significantly higher on the BTQ (M � 26.49, SD � 15.76) compared to those who identified as non-Hispanic White (M � 20.39, SD � 10.98; t � �3.36, p � .001). There was a significant association of relationship status with total perceived barriers, such that individuals who were single (M � 23.71, SD � 13.34) scored significantly higher on the BTQ than partnered individuals (M � 17.18, SD � 10.20), t � 3.17, p � .01. Individuals with an annual income below $15,000 (chosen as an approximation of the poverty level) also reported greater perceived barriers (M � 24.88, SD � 14.92) relative to those with an annual income above $15,000 (M � 19.60, SD � 11.29), t � 2.76, p � .01. Total BTQ scores did not differ by gender, t � �0.67, p � .50, or level of education, F(3, 221) � 1.33, p � .26. Pairwise correlations revealed signif- icant positive correlations between perceived barriers to treatment (i.e., total score on the BTQ) and global severity (CGI-S, r � .29), social anxiety (LSAS, r � .28), and general anxiety (HAM-A, r � .23) scores and barriers to treatment (all p values � .01). There was no significant correlation between MADRS score and total score on the BTQ (r � .16).

A multiple regression was conducted to examine the relation- ships among demographic and symptom variables with total score on the BTQ (see Table 3). In the first step, we included those clinical variables that demonstrated significant univariate correla- tions with total BTQ score. The model was significant, F(3, 199) � 9.82, p � .0001, and accounted for 12% of the variance in BTQ score. In the second step, we added minority status, age, income, and relationship status. The overall model was significant, F(7, 159) � 6.94, p � .0001, and accounted for 20% of the variance in total BTQ score.

Discussion

Individuals similarly endorsed many barriers to treatment re- gardless of whether SAD or GAD was their primary anxiety disorder diagnosis. Shame and stigma were the most frequently cited barriers followed by logistical and financial barriers. These findings are consistent with those by Marques et al. (2010), who assessed barriers to treatment in individuals with obsessive– compulsive symptoms and found that concerns about cost of treatment and shame were most frequently endorsed. In our sam- ple, greater severity of anxiety symptoms was associated with more perceived barriers to treatment. Furthermore, over half of the

Table 2 Total Score on the Barriers to Treatment Questionnaire and Clinician Assessed Levels of Anxiety, Social Anxiety, Depression, and Global Symptom Severity Among Individuals With Social Anxiety Disorder (SAD) and Generalized Anxiety Disorder (GAD)

Measures n SAD, M (SD) GAD, M (SD) t p

BTQ 226 23.23 (14.45) 21.30 (11.02) 1.11 .27 HAM-A 214 13.25 (7.63) 17.58 (6.71) –4.28 �.001 LSAS 206 73.96 (22.89) 45.32 (26.64) 8.29 �.001 MADRS 111 7.72 (5.44) 11.12 (7.16) –2.82 �.01 CGI-S 214 4.52 (.88) 4.34 (.72) 1.61 .12

Note. BTQ � Barriers to Treatment Questionnaire; HAM-A � Hamilton Anxiety Rating Scale; LSAS � Liebowitz Social Anxiety Scale; MADRS � Montgomery–Asberg Depression Scale; CGI-S � Clinical Global Impression Scale–Severity.

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4 GOETTER ET AL.

0% 20% 40% 60% 80% 100%

I was afraid treatment would be too upsetting.

I had difficulty motivating myself to seek treatment.

I feel like my problems were normal for someone in my situation.

I was afraid I would not be able to communicate in treatment because of language barriers.

I could not find a mental health professional of my same race or ethnicity.

I was afraid of being treated badly in treatment because of my race or ethnicity.

I was not satisfied with the treatments that were available.

I don’t trust mental health professionals.

I received treatment before and it did not help with my problems.

I did not think treatment could help with my problems.

I was afraid of being committed to a hospital against my will.

I was worried about being judged or criticized by my family if I sought treatment.

I was worried about being judged or criticized by my friends if I sought treatment.

I felt embarrassed about needing help for my problems.

I felt embarrassed about my problems.

I wanted to handle my problems on my own.

I could not get to treatment because of problems with transportation.

I could not get an appointment.

I could not choose the person I wanted to see for treatment.

My health insurance does not cover treatment.

There is no time in my schedule for treatment.

I was worried about the cost of treatment.

I did not know who to see or where to go for treatment.

Endorsement Rate

SAD GAD

Figure 1. Endorsement rates of barriers to treatment among individuals with generalized anxiety disorder and social anxiety disorder.

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5BARRIERS TO TREATMENT

sample endorsed a belief that treatment would not help with their symptoms. This is unsettling because the findings suggest that those with more severe symptoms, who may benefit most from treatment, are precisely those who perceive the most barriers and fail to recognize their need for treatment. Individuals also endorsed not knowing where to seek treatment. This finding is of concern especially because the study took place in a large urban area with many mental health clinics and many anxiety-specific treatment centers.

These findings speak to the importance of increasing public education and awareness about the symptoms and available treat- ments (including information about how to find them) for GAD and SAD. Increasing public awareness not only enhances public mental health literacy, but it may also reduce stigma (Wang & Lai, 2008). Our findings that individuals perceive barriers associated with making time for treatment also emphasize the need to en- hance the convenience of mental health treatment. Bibliotherapy, online self-help interventions, virtual therapy, telemedicine, and stepped-care models show promise for treating GAD and SAD (Abramowitz, Moore, Braddock, & Harrington, 2009; Draper & O’Donohue, 2011; Gershkovich, Herbert, Forman, & Glassman, 2016; Yuen, et al., 2013a, 2013b). With the evidence base of these approaches well established, efforts must be made to market and target these approaches to individuals who may not be willing to seek conventional therapy due to logistical barriers.

Our findings also suggest that within the population of individ- uals with GAD and SAD, independent of the effect of anxiety symptom severity, racial and ethnic minorities perceive greater barriers to treatment. These findings corroborate those of a previ- ous study of women with depression, which found that stigma about receiving treatment was more prevalent among immigrant and U.S.-born Black women (Nadeem et al., 2007). Unfortunately, these findings mirror data on actual treatment use among minority individuals. For example, in another study of individuals with depression, Latinos, Asians, and African Americans were signifi- cantly less likely to have accessed mental health treatment in the past year relative to non-Latino, European Americans (Alegría et al., 2008). In a large study of individuals with a variety of mood and anxiety disorders, specialty mental health treatment use was

also significantly lower among African American and Latino in- dividuals compared to European Americans (Alegría et al., 2008). Among African Americans, this difference remained significant even after controlling for both psychiatric illness and demographic variables such as income and geographic location (Alegría et al., 2008).

A hypothesis that one might draw from the current findings is that individuals with GAD and SAD perceive barriers to treatment, and social efforts to address and reduce these barriers have been less successful among ethnic minority groups. Another hypothesis is that racial and ethnic minorities face additional barriers to treatment that are not faced by European Americans. Indeed, this is consistent with a study of African American individuals with obsessive– compulsive disorder who reported having to contend with not knowing where to find treatment and concerns about discrimination, barriers that were not endorsed among a compara- ble sample of European American individuals (Williams, Do- manico, Marques, Leblanc, & Turkheimer, 2012). Together, these findings illuminate the need to better understand barriers faced by diverse ethnic minority groups to inform culturally sensitive out- reach initiatives.

In clinical settings, providers are encouraged to discuss barriers to treatment among their patients with SAD and GAD. Particular attention should be paid to the potential barriers faced by racial and ethnic minority clients. Providers may consider administering a measure such as the BTQ to facilitate a discussion with their patients in an aim to maximize treatment engagement. Systemi- cally, campaigns designed to target stigma and increase mental health access should target individuals with anxiety disorders who are at greatest risk for having unmet needs. Initiatives must con- sider the diversity of the potential audience and speak to the unique barriers faced by individuals from different backgrounds and com- munities. As others have suggested, educational presentations in the community (e.g., community centers, churches), information sessions hosted by mental health clinics, and employing bilingual staff and outreach workers in clinics may help individuals over- come barriers to care (Snowden, Masland, Ma, & Ciemens, 2006). These efforts speak to the importance of increasing cultural com- petence among mental health providers and the organizations they represent.

Strengths of the present study include both self-report and clinician-rated assessment of symptoms. We conducted a compre- hensive assessment of perceived barriers to treatment in a rela- tively large sample, which strengthens the study’s validity. Our conclusions are tempered by several limitations including incom- plete data and not entirely overlapping samples on the various self-report measures. Due to the ancillary nature of this study, some individuals did not complete or receive all measures. Addi- tionally, our regression model accounted for a relatively small amount of variance suggesting the need to investigate other factors that are associated with an individual’s perceived barriers to care. Also, while SAD and GAD are two of the most common anxiety disorders, we did not include individuals with other primary anx- iety diagnoses, although somewhat tempering this concern is the high prevalence of comorbidities within the sample. Additionally, the symptom severity scores of the sample reflected moderate symptom levels. Barriers to treatment may be different among those with more severe clinical presentations or other primary anxiety disorders (e.g., panic disorder). Furthermore, we assessed

Table 3 Summary of Hierarchical Multiple Linear Regression Analyses for Variables Associated With Barriers to Treatment

Model 1 Model 2

Variable B SE B � B SE B �

Symptom LSAS .09 .04 .20� .11 .04 .23��

HAM-A .26 .13 .15� .44 .14 .25��

CGI-S 1.97 1.40 .12 .48 1.53 .03 Demographic

Minority status 6.24 2.05 .22��

Age –.04 .10 –.03 Income –1.37 2.11 –.05 Relationship status –3.42 2.24 –.11

Note. LSAS � Liebowitz Social Anxiety Scale; HAM-A � Hamilton Anxiety Rating Scale; CGI-S � Clinical Global Impression Scale– Severity. � p � .05. �� p � .01.

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barriers to treatment broadly and are unable to comment on dif- ferences in barriers as they relate to psychotherapy versus phar- macotherapy. Individuals were not seeking treatment as part of their participation in the current study and we did not systemati- cally measure exposure to prior mental health treatment. Thus, we are unable to address the potential relationship between history of mental health treatment and current perception of barriers to treat- ment. Importantly, participants were still willing to come discuss symptoms with a mental health professional and so this sample may be less severely impacted by barriers than the population at large. Finally, we did not examine barriers to treatment by differ- ent racial or ethnic minority groups nor did we include a measure of ethnic identity. Importantly, we do not wish to contribute to discrimination by assuming, based on these findings, that the barriers faced by one ethnic minority group are necessarily uni- form across or within ethnic minority groups. Future studies, including both large-scale studies and smaller qualitative studies, are needed to gather more nuanced information about barriers to mental health treatment faced by different minority groups. As others have noted, additional questions pertaining to issues like insurance status, income, and the role of culture must be addressed alongside the issue of barriers to treatment (Williams et al., 2012).

In conclusion, individuals with GAD and SAD, particularly those with greater anxiety symptom severity, endorse a high de- gree of stigma and logistical barriers to seeking treatment. Addi- tionally, ethnic minority individuals perceive more barriers to treatment. Future efforts to address unmet clinical need should pay particular attention to those who may be at highest risk of failing to access treatment. Culturally sensitive research and outreach initiatives are needed to reduce unmet mental health needs.

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Received July 10, 2017 Revision received February 18, 2018

Accepted February 25, 2018 �

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