Social Anxiety
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Gapsinaccessingtreatmentforanxietyanddepression.pdf
Clinical Psychology Review 24 (2004) 583–616
Gaps in accessing treatment for anxiety and depression:
Challenges for the delivery of care
Kerry A. Collins a,*, Henny A. Westra
a , David J.A. Dozois
b , David D. Burns
c
a Child and Adolescent Centre, London Health Sciences Centre, 346 South Street, London, Ontario, Canada, N6A 4G5
b University of Western Ontario, London, Ontario, Canada, N6A 5B8
c Stanford University, Stanford, CA 94305, USA
Received 12 January 2004; received in revised form 14 April 2004; accepted 7 June 2004
Abstract
Epidemiological studies have identified high prevalence rates of anxiety and depression in North America [e.g.,
J. of Nerv. Ment. Dis. 182 (1994) 290]. However, only a small percentage of these individuals access effective
treatment. The undertreatment of anxiety and depression is a major public health issue and is associated with
significant personal, social, and economic burden. This article describes the existing discrepancy between
prevalence of anxiety and depression and access to effective treatment for adults and children, the contributors to
this discrepancy, and suggests various means through which access to effective treatment may be enhanced. We
begin with a brief overview of the prevalence and associated personal, societal, and systemic burdens of anxiety and
depression. This is followed by a review of current rates of access to treatment and possible individual, provider, and
systemic barriers to accessing treatment. Recommendations for bridging the gap between the high rates of these
disorders and limited accessibility of effective care are then presented.
D 2004 Elsevier Ltd. All rights reserved.
1. Introduction
Epidemiological studies have identified that anxiety and depression are highly prevalent in North
American society (e.g., Blazer, Kessler, McGonagle, & Swartz., 1994; Kessler et al., 1994; Regier et
al., 1993) and associated with a significant burden personally, socially, and economically (Greenberg et
al., 1999; Katzelnick & Greist, 2001). In fact, it is expected that depression will become the second
leading cause of disability worldwide over the next decade (Murray & Lopez, 1996) and rank second
0272-7358/$ - see front matter D 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2004.06.001
* Corresponding author. Tel.: +1-519-685-8500x74778; fax: +1-519-667-6814.
E-mail address: [email protected] (K.A. Collins).
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616584
as the most costly of all illnesses by 2010 (World Health Organization, 1990). Anxiety disorders are
the most prevalent of all mental health problems and are estimated to affect 25% of the population over
a lifetime (Blazer et al., 1994; Kessler et al., 1994). Despite the scope and severity of these problems,
the vast majority of adults and children with anxiety and/or depression do not access effective
treatment. Dissemination of and access to effective treatments for adults and children with these
disorders is imperative, within the present health care system, for improving the quality of life for
individual sufferers, as well as reducing the societal costs and economic burden incurred by these
disorders.
The purpose of the article is to review rates of access to effective treatment among those individuals
with anxiety and depression and to highlight the many barriers regarding accessibility of treatment. Our
evaluation is limited to studies of depression and anxiety disorders in light of the high prevalence of
these disorders in our society. However, it is important to note that many of the issues identified likely
apply to the treatment of other mental health disorders. From this review, we suggest multiple directions
that can be pursued to bridge the gap between disorder and effective treatment. To contextualize these
issues, prevalence of anxiety and depression in adults and children is detailed briefly to draw attention to
the severity and breadth of this public health issue.
2. Prevalence, course, and burden of anxiety and depression
2.1. Prevalence
Numerous epidemiological studies have demonstrated the high occurrence of anxiety and depression
among children and adults (for a review, see Dozois & Westra, 2004). The National Comorbidity Survey
(NCS) (Blazer et al., 1994; Kessler et al., 1994) estimated the cumulative 1-year prevalence rate of 17%
for anxiety disorders and 11% for mood disorders, with lifetime prevalence at 25% and 17%,
respectively. In the Epidemiologic Catchment Area study (Eaton & Kessler, 1985; Eaton et al., 1989;
Regier et al., 1988, 1993), the 6-month prevalence rates for adults ranged from 6.6% to 14.8% across
the combined anxiety and somatoform categories. Lifetime prevalence of major depression was
estimated at 6.3%. These figures are likely an underestimate of the prevalence of these disorders given
that rates of subclinical symptom presentations are high and represent an important risk factor for the
development of later clinical levels of these disorders. For example, up to 30% of adolescents will
exceed the clinical cutoffs on self-report indices of depression (Hammen & Rudolph, 1996), and the first
major depressive episode is usually preceded by a series of subthreshold episodes (Coyne, Pepper, &
Flynn, 1999).
Anxiety and secondly depression are also the most prevalent psychiatric problems in children and the
most common reasons for referral to mental health services (Beidel, 1991). The overall prevalence rate
of anxiety disorders in children and adolescents has been estimated at approximately 10% (Breton,
Bergeron, Valla, Berthiaume, & Gaudet, 1999; McGee et al., 1990), and the rate of major depressive
disorder in children and adolescents, collapsed across ages, ranges between 6% and 8% (Hammen &
Rudolph, 1996). The prevalence of depression may also be increasing, especially among children and
adolescents (Garber & Flynn, 2001; Hammen & Rudolph, 2003), and it has been suggested that by 18
years of age, as many as 25% of adolescents have had at least one depressive episode (Lewinsohn,
Rohde, Seeley, & Fischer, 1993).
2.2. Course
Anxiety and depression tend to be chronic and recurrent. Research has shown that many anxiety
disorders begin early, with the expected course of illness marked by high rates of relapse and recurrence
(Durham, Allan, & Hackett, 1997; Moreno & Delgado, 2000) and low probability of spontaneous
remission (Keller et al., 1994). Only 17% and 39% of individuals with panic disorder with agoraphobia
and panic disorder, respectively, show remission at 1-year follow-up (Keller et al., 1994). Moreover, the
cumulative probability of remission is only 0.21 for GAD and 0.16 for social phobia after 2 years
(Hirschfeld, 1996). While longitudinal studies of children have indicated high rates of remission for
anxiety disorders (e.g., Angold & Costello, 1995; Last, Perrin, Hersen, & Kazdin, 1996), other
investigations suggest that children who suffer anxiety disorders have a higher probability of developing
subsequent depression, social phobia, and panic disorder (Biederman et al., 1993; Black & Robbins,
1990; Moreau & Follett, 1993). Thus, it is apparent that the majority of adults and children with anxiety
disorders tend to endure a persistent and recurrent course.
Research has also clearly demonstrated a chronic and recurrent course for depression. The first onset
of major depressive disorder has been identified to occur in mid to late adolescence (Burke, Burke,
Regier, & Rae, 1990; Hammen, 2001), and depressive disorders can persist for years (Duggan, 1997;
Hoencamp, Haffmans, Griens, Huijbrechts, & Heycop ten Ham, 2001; Kessler, DuPont, Berglund, &
Wittchen, 1999; Kupfer, Frank, & Wamhoff, 1996; Sherbourne et al., 2001). Between 50% and 85% of
depressed patients experience multiple episodes (Coyne et al., 1999), with an average of five episodes
during the course of their life (Gotlib & Hammen, 1992). In fact, at the present time, the best predictor of
future depression is past depression (e.g., Lewinsohn, Hoberman, & Rosenbaum, 1988). In addition,
subclinical depression results in considerable impairment, is associated with increased use of nonpsy-
chiatric health care, and is related to elevated risk for more severe psychiatric conditions (Boulenger,
Fournier, Rosales, & Lavallée, 1997; Gotlib & Beach, 1995; Wittchen & Essau, 1993).
2.3. Burden
The debilitating nature of anxiety and depression becomes more apparent when the personal, social,
and economic burdens of these problems are considered. For instance, children with anxiety disorders
have been found to display poorer academic performance (Dweck, 1999), a higher probability of being
expelled, school absenteeism, and running away from home (Katzelnick & Greist, 2001), as well as family
stress (Costello, 1989; Ezpeleta, Keeler, Erkanli, Costello, & Angold, 2001). Among adults, anxiety
disorders have been associated with unemployment (Leon, Portera, & Weissman, 1995), work absentee-
ism, and financial disability (Katzelnick & Greist, 2001), restrictions in partner relationships, educational/
career development, and family interactions (Schneier et al., 1994). Family members of individuals with
obsessive–compulsive disorder or generalized anxiety disorder, for instance, also report substantial
disruptions in family routine, leisure activities, and interpersonal interaction, as well as increased financial
difficulties (Chakrabarti, Kulhara, & Verma, 1993; Cooper, 1996). Anxiety disorders have been estimated
to cost 42.3 billion dollars annually in the United States, with the majority of costs incurred for
nonpsychiatric medical service utilization (Greenberg et al., 1999). As just one example, up to 40% of
high utilizers of medical care have a lifetime history of generalized anxiety disorder (Katon, 1996).
The symptomatology of depressive disorders impacts most aspects of everyday functioning (Judd et
al., 2000; Lecrubier, 2001), including disruption in occupational functioning (Broadhead, Blazer,
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 585
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616586
George, & Tse, 1990; McQuaid, Stein, Laffaye, & McCahill, 1999), troubled parent–child relationships
(Ingram, 2001), marital distress (Coyne, Gallo, Klinkman, & Calarco, 1998; Dudek et al., 2001), and
other interpersonal difficulties (Joiner & Coyne, 1999; Lewinsohn, Gotlib, & Seeley, 1997). Moreover,
those with a depressive episode in adolescence show a pattern of significant long-term difficulties
including persistent emotional disorder, educational, and employment problems (Fergusson & Wood-
ward, 2002). The direct and indirect monetary costs of depression have been estimated to be a
substantive 44 billion dollars each year in the United States (Cicchetti & Toth, 1998; Finkelstein et
al., 1996; Greenberg, Stiglin, Finkelstein, & Berndt, 1993).
The scope, recurrence, and personal, societal, and economic burden of anxiety and depression in the
general population suggest that availability and efficacy of treatments for these problems is an issue of
critical importance to public health. We now turn our attention to summarizing epidemiological studies
on rates of access to care for anxiety and depression.
3. Rates of access to mental health care in anxiety and depression
The vast majority of individuals who suffer from anxiety and depression do not access treatment for
these problems (e.g., Greenberg et al., 1993; Ohayon, Shapiro, & Kennedy, 2000). This fact is particularly
unfortunate given that highly effective interventions for these problems have been developed over the past
two decades. In general, epidemiological studies reveal significant underutilization of mental health care
among those with mental health problems. The NCS for example identified that only 20% of those with a
12-month psychiatric disorder obtained any professional treatment in the past year (Kessler et al., 1994),
and only 40% of those with a lifetime disorder ever obtained any professional assistance (Wang, Demler,
& Kessler, 2002). In a survey of over 3000 residents in the United States, Wang, Berglund, and Kessler
(2000) reported that only 14.3% of those with a psychiatric disorder within the past 12 months obtained
treatment consistent with evidence-based care recommendations. Comparable rates have been observed in
Canada, as a national mental health survey (Statistics Canada, 2002) reported that only 32% of individuals
with mental health problems talked to a health care professional about this problem in the past year.
Teenagers and young adults were found to be the least likely age group to seek mental health resources
despite having a higher likelihood of suffering mental health problems.
In regard to rates of help seeking for depression and anxiety, a community survey of a major Canadian
city (Ohayon et al., 2000) revealed that only 30% of adults with a current mood disorder, and merely
11% of those with a current anxiety disorder, received some form of treatment. Moreover, only 5% and
1.4% of individuals with a mood and anxiety disorder, respectively, had ever consulted with a
psychiatrist; and only 13% (mood disorder) and 9% (anxiety disorder) of those diagnosed were on
psychotropic medication. As these figures suggest, anxiety disorders, relative to depression, may be at
particular risk for undertreatment. Research has shown that the perceived need for help is lower among
individuals with anxiety disorders compared with those with mood disorders (Mojtabai, Olfson, &
Mechanic, 2002), and symptoms of depression are the leading reason for pursuit of mental health
services (Zimmerman & Mattia, 2000). Yet, most studies also indicate that the majority of individuals
with depression do not receive treatment (Mojtabai et al., 2002; Ohayon et al., 2000; Young, Klap,
Sherbourne, & Wells, 2001).
Although it might be tempting to conclude that specialty mental health care is effectively being
reserved for the most severe cases, epidemiological data do not support this conclusion, as only 25%
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 587
(Wang et al., 2000) to 40% (Kessler et al., 1994) of those with severe mental health problems access
specialty mental health services. And only 15.3% of respondents with a serious mental illness are
estimated to receive minimally adequate treatment (Wang et al., 2002).
The situation of gross undertreatment of anxiety and depression in adults is paralleled among children
with estimates of fewer than 20% of those requiring mental health services receiving the necessary
intervention (McGee et al., 1990; Tuma, 1989). Even though 32% of a large community sample of over
1200 children (aged 9–17) had a psychiatric diagnosis, only 36.5% of those used mental health services
and only 25% of those with severe impairment received such services (Leaf et al., 1996). Similarly, Wu
et al. (2001) found that 36% of children and adolescents (aged 9–17) with depression never sought
professional assistance in a New York community. These results are consistent with findings from a
pediatric setting, where 55% of parents with a child found to carry a diagnosed psychiatric disorder
failed to discuss behavioral/emotional concerns with their pediatrician (Briggs-Gowan, McCue Horwitz,
Schwab-Stone, Leventhal, & Leaf, 2000) and fewer than half of parents of children with a psychiatric
disorder consult their primary care provider about these problems (Dulcan et al., 1990; Leaf et al., 1996).
Parents of affected children are also undertreated. For example, Ferro, Verdeli, Pierre, and Weissman
(2000) found that whereas 14% of mothers who brought their depressed children in for treatment were
themselves currently depressed (and 59% were subthreshold for depression), only 5% were currently
receiving any form of treatment.
Delays in help seeking are also common and exacerbate the personal and societal burden associated
with these mental health difficulties. In a large retrospective study, Christiana et al. (2000) reported
average delays of 8 years for seeking professional treatment among individuals with anxiety and mood
disorders. Moreover, time to help seeking was related to age across all cohorts, suggesting that the longer
such mental health difficulties are undetected, the less likely an individual will obtain treatment. Among
anxiety and mood problems, treatment-seeking delays tend to be longest for generalized anxiety disorder
(up to 14 years from the time of onset; Kessler, Olfson, & Berglund, 1998). This delay in treatment,
coupled with underutilization of mental health services and the overutilization of medical services,
results in protracted personal and economic costs.
Moreover, even when patients do present for treatment, the range of effective treatment options for
anxiety and mood disorders is typically not presented to patients. For example, among panic disorder,
which is more frequently detected than other anxiety disorders (Kessler et al., 1998), Roy-Byrne et al.
(1999) found that only 22% received adequate and appropriate medications and only 12% received
cognitive behavioral therapy (CBT), the most consistently supported effective intervention for this
disorder (see Barlow, 2002). This is consistent with findings of the Harvard Anxiety Research Program,
which reported that less than 20% of anxiety patients were receiving CBT (Goisman, Warshaw, &
Keller, 1999).
Most patients who do present for treatment are managed with pharmacotherapy alone (e.g., Olfson et
al., 2002; Wang et al., 2000) rather than with other evidence-based psychotherapies. This practice occurs
despite numerous reviews and meta-analyses supporting the efficacy of psychotherapy compared to no-
treatment and placebo control groups (e.g., Howard, Kopta, Krause, & Orlinsky, 1986; Lambert &
Bergin, 1994). In a survey of over 3500 members of mental health patient advocacy groups for mood
and anxiety disorders, 88% reported receiving a treatment recommendation of pharmacotherapy, while
only 39% received recommendations for psychotherapy (Wang et al., 2000). Guidelines for primary care
providers recommend psychotherapy only after failure on two antidepressant medications (Agency for
Health Care Policy and Research, 1993). This is particularly disturbing in view of the consistent findings
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616588
demonstrating poor breadth and maintenance of gains in pharmacotherapy (anxiety: Liebowitz et al.,
1999; depression: Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998), greater undesirable side effects
with psychotropic medications (e.g., Healy, 2003), greater treatment adherence problems in pharmaco-
therapy (Wang et al., 2000), and the strong data supporting the prophylactic benefits of psychotherapy.
For example, the use of CBT in depression has been shown to significantly reduce relapse rates over
pharmacotherapy alone (30% relapse in CBT versus 60% in pharmacotherapy; Gloaguen, Cottraux,
Cucherat, & Blackburn, 1998). CBT has also yielded greater response rates relative to pharmacotherapy
in the treatment of panic disorder, social anxiety, generalized anxiety disorder, and posttraumatic stress
disorder (Barlow, Gorman, Shear, & Woods, 2000; Gould, Otto, & Pollack, 1995; Gould, Otto, Pollack,
& Yap, 1997). CBT also appears to be a better tolerated treatment, as evidence by lower dropout and
treatment refusal rates than pharmacotherapy (Gould et al., 1997; Hofmann et al., 1998). Moreover,
many patients are adverse to medication treatment of anxiety and depression. For example, while the
number of general community respondents indicating they would be willing to take medication for
depression increased from 12% in 1986 to 28% in 2000 (Langer, 2000; as cited in Olfson et al., 2002),
the number who would not be willing was more than two thirds. In addition, psychotherapy can be brief
and as such has also been found to be more cost effective in the long term than pharmacotherapy
(Hollon, Thase, & Markowitz, 2002; Otto, Pollack, & Maki, 2000).
While a substantial body of research supports the efficacy of psychotherapy for anxiety and
depression (e.g., Chambless et al., 1996; Clark, 1997; Ladouceur et al., 2000; Lambert & Bergin,
1994; Westra & Stewart, 1998), these treatments are highly underutilized and perhaps increasingly so.
For example, a recent study reported a threefold increase in the number of people receiving outpatient
treatment for depression from 1987 to 1997 (Olfson et al., 2002). While promising, the number of
psychotropic medication prescriptions among those treated increased from 45% to 79%, while treatment
with psychotherapy declined from 71% to 60% over this same time period. This finding may be largely
attributable to an increase in the identification of depression in primary care. When one considers the
highly recurrent nature of depression (Kupfer et al., 1996) and the low probability of spontaneous
remission in anxiety disorders (Keller et al., 1994), psychotherapies, especially brief treatments,
represent important and cost-effective options for anxiety and depression management. As such, there
is a great need for increased awareness of effective treatments among patients and providers alike and
increased availability of such treatments.
It is evident from this review that a gross undertreatment of anxiety and depressive disorders currently
exists among adults and children. Only a minority of afflicted individuals access effective treatment and
there are numerous personal, provider, and systemic barriers that contribute to this treatment gap. We
now turn to a discussion of the various possible barriers that may account for the underutilization of
treatment for anxiety and depression.
4. Barriers to accessing effective treatment for anxiety and depressive disorders
Barriers to obtaining effective mental health services include individual factors (e.g., help-seeking
behavior), provider factors (e.g., detection), and systemic factors (e.g., availability of effective treatment),
which will each be described in turn. Giel, Koeter, and Ormel (1990) have identified the following levels
of filtering to occur in the course of an individual obtaining treatment: Level 1, individual factors (the
person in the community makes a decision to consult with a professional); Level 2, provider factors (the
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 589
person presents to a general practitioner and the physician has to identify the problem); Level 3, systemic
factors (the physician has to help the patient access mental health care); and Level 4, the patient obtains
effective mental health treatment. In light of the structure of the present health care system, it is apparent
that the primary care physician plays a central role in this filtering process. The variables that influence
each of these levels are discussed below and summarized in Table 1.
4.1. Barriers at the individual level
Health care seeking is a multidimensional phenomenon (Strosahl, 2002), with numerous factors likely
influencing an individual’s decision to seek professional assistance. These include a willingness to
disclose problems, fear of stigma and embarrassment, lack of time for treatment, negative stereotypes of
treatments, presence of comorbid medical problems, cultural factors, and demographic and geographic
variables (Christiana et al., 2000; Giel et al., 1990; Hunter & Peterson, 2001). In a national sample of
2713 individuals with posttraumatic stress disorder, Koenen, Goodwin, Struening, Hellman, and
Table 1
Barriers for accessing effective treatment for anxiety and depression
Level Barrier
Individual Willingness to disclose problems
Fear of stigma and embarrassment
Lack of time for treatment
Negative stereotypes of treatment
Presence of comorbid medical problems
Cultural factors
Demographic factors (age, marital status)
Geographic influences
Desire to handle problems on one’s own
Lack of awareness of available treatment
Minimizing severity of problems
Degree of distress and disruption of symptoms
Readiness for change
Provider Underdetection within primary care sector
Lack of knowledge of mental health problems
Preoccupation with possible organic pathology
Skill in assessing mental health difficulties
Busyness and structure of practice
Willingness to diagnose and treat mental health issues
Stigma regarding discussing mental health issues
Somatizing patient presentation style
Level of distress in presentation
Systemic Limited physician access to mental health services
Lack of awareness of range of effective treatment options
Primary care guidelines emphasizing pharmacotherapy
Limited availability of specialty mental health providers
Lack of integration of mental health services in primary care
Low rates of provision of evidence-based care in mental health services
Limited training in evidence-based care among mental health training programs
Limited response rates to empirically supported treatments
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616590
Guardino (2003) identified enabling (e.g., geographic location), predisposing (e.g., demographic
characteristics), and need factors to influence both treatment seeking and readiness. Predisposing factors
related to help-seeking behavior included being ages 45–64 years and separated or divorced. Other
factors likely to influence treatment seeking may include an individual’s perception that such treatment is
likely to be of benefit (Dozois & Westra, 2003) and financial costs associated with treatment, particularly
in the United States where there is a nonpublic health care system. Christiana et al. (2000) surveyed
members of patient mental health advocacy groups and found that the most common factors associated
with delays in treatment seeking were a desire to handle the problem on one’s own and lack of awareness
of available treatments.
Mojtabai et al. (2002) argued that many people do not seek assistance because they view their
problems as transient and minimize their severity. Moreover, the degree of individual distress seems to
contribute to seeking mental health care (Giel et al., 1990). Research on anxiety disorders, for example,
has suggested that the severity and presence of comorbid disorders predicts help-seeking behavior
(Goodwin, Koenen, Hellman, Guardino, & Struening, 2002; Koenen et al., 2003). In a national study of
posttraumatic stress disorder, the level of interference of anxiety symptoms and the comorbid diagnosis
of panic disorder were related to treatment seeking (Koenen et al., 2003). Others have identified timeline
(acute versus chronic), consequences, and controllability of depressive symptoms as playing a
significant role in accessing treatment (Brown et al., 2001). In addition, an individual’s perception of
the nature and cause of symptoms (i.e., somatic versus emotional) may be an important determinant of
help-seeking (Brown et al., 2001; Moeller-Leimkuehler, 2002).
The probability of help-seeking behavior for anxiety and depressive disorders has also shown to be
highest during the first year of onset and declines thereafter (Kessler et al., 1998), supporting the
importance of early detection. However, even when individuals do seek treatment, numerous factors may
influence their commitment and response to treatment. In a study of treatment initiation for adults with
social anxiety (Coles, Turk, Jindra, & Heimberg, 2002), only 15% of individuals who made telephone
inquiries to a specialty mental health clinic actually entered treatment. Pretreatment attrition occurred at
multiple levels, including failure to schedule an initial interview, failure to attend the initial interview,
and failure to start treatment after receiving the diagnosis of social anxiety disorder. These investigators
found that severity and demographic variables were unrelated to treatment entry, suggesting the
importance of other variables to treatment utilization. Readiness for change is an individual difference
variable being investigated more recently that may play an important role in help seeking (Prochaska,
1994). Studies have noted that less than 20% of individuals with a health or mental health problem are in
a stage of change where they are prepared to take action on the problem (O’Hare, 1996; Prochaska,
1994).
4.2. Barriers at the provider level
Giel et al. (1990) noted that the primary care setting plays a central role in the second level of filtering
between a patient and treatment. In fact, general practitioners have been described as the gatekeepers to
mental health services (Ormel, Koeter, van den Brink, & van de Willige, 1991), given that the vast
majority of individuals with anxiety and depression have contact with the primary care sector (e.g.,
Depression Guideline Panel; AHCPR, 1993; Greenberg et al., 1999; Perez-Stable, Miranda, Munoz, &
Ying, 1990; Sherbourne et al., 2001; Simon, Von Korff, & Barlow, 1995). Up to 83% of individuals with
anxiety and/or depression have consulted a family physician at least once in the past year, and these
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 591
individuals are more frequent consumers of primary care services than is the general population (Ohayon
et al., 2000). Moreover, up to 50% of individuals with depression have consulted their primary care
physician about this problem (Brown & Schulberg, 1998). Regier et al. (1982) found that of those
individuals who do seek care for mental health issues more generally, 60% do so with primary care
physicians and merely 20% with mental health professionals. As many as 25% of those individuals with
panic disorder, for example, first present at hospital emergency rooms (Segee et al., 1999; Swinson,
Soulios, Cox, & Kuch, 1992), often repeatedly, and one third have seen three or more nonpsychiatric
health care professionals (Swinson et al., 1992).
Despite this high rate of presentation to health care providers, there is significant underdetection of
mood and anxiety disorders within the primary care domain (e.g., Simon et al., 1995). Studies examining
family physicians identification of mental illness consistently reveal detection rates ranging from 15% to
36% for anxiety and depression (Kessler, Lloyd, Lewis, & Gray, 1999; Lecrubier, 1998; Ustun &
Sartorius, 2002). Research has highlighted various factors that contribute to this problem, including
physician’s knowledge of mental health problems, skill in recognizing symptoms indicative of mental
illness, busyness of practice, and willingness to diagnose and treat mental health issues (Tylee, 1996).
Kendrick, Tylee, and Freeling (1996) speculate that the factors that contribute to a physician’s
underrecognition of depression include lack of knowledge regarding common symptoms and their
management, preoccupation with possible organic pathology, failure to elicit symptoms relevant to the
diagnosis, and the structure of the general practice setting (e.g., lack of a consistent health care provider,
time constraints). Providers may also assume a stigma concerning emotional issues and avoid asking
questions about depression or anxiety for fear of harming the relationship with the patient.
An individual’s symptom pattern may play an additional role in detection, as patients who display less
overt evidence of depression (i.e., look less depressed; Freeling, Rao, Paykel, Sireling, & Burton, 1985)
and somatize their distress (Goldberg & Bridges, 1988) are more likely to go unrecognized by primary
care providers. Similarly, the degree of individual distress constitutes a factor in seeking mental health
care, suggesting that the illness behavior of the patient is an important influence on the physicians’
decision to refer for mental health care (Giel et al., 1990). Although a study by Hoeper, Nycz, Kessler,
Burke, and Pierce (1984) suggests that even when information about the mental health status of patients
was given to their primary health care providers, this did not affect the management of their patients;
implying that merely ’educating’ providers is not enough to produce changes in practice.
4.3. Barriers at the systemic level
A third level of filtering that influences the probability that an individual will obtain effective
treatment is the physicians’ access to mental health care resources. Despite studies that highlight the
limits of current physician treatment for anxiety and depression (e.g., Depression Guideline Panel;
AHCPR, 1993), general practitioners remain the most common providers of mental health services
(Parslow & Jorm, 2000), spending up to one quarter of their time per week providing direct treatment for
psychiatric conditions (Howard, 1992). A lack of knowledge about the range of effective treatments,
limited expertise in psychotherapy, and limited availability of specialty mental health providers may
contribute to a physician’s decision to treat anxiety and depression with pharmacotherapy rather than
providing or referring to mental health services. Also, guidelines for primary care providers support this
method of triage and recommend psychotherapy only after failure on two antidepressant medications
(AHCPR, 1993). An additional influence contributing to higher rates of pharmacotherapy versus other
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616592
effective treatments likely includes the strong marketing of psychotropic medications (Antonuccio,
Burns, & Danton, 2002) and lack of inclusion in medical education of training in the management of
common psychiatric conditions (Hunt, Gibbons, Paraison, & Rabik, 2004).
Additional structural barriers also impact physicians’ management of patients with mood and anxiety
problems, such as the lack of integration of mental health services with primary care settings. At the
present time, specialty mental health care is a reactive system (Giel et al., 1990), waiting for the patient
to be identified and referred for treatment; a process that produces staggering delays in treatment (e.g.,
median treatment delay of 6 years for depression/dysthymia and 14 years for GAD; Kessler et al., 1998).
The failure to make mental health care available in those settings where individuals first seek assistance
(i.e., primary care settings) inhibits access and utilization of effective treatments for mood and anxiety
disorders. The separation of mental health services may also serve to maintain the publics’ fear and
misunderstanding of mental health difficulties (Hunter & Peterson, 2001).
Further systemic barriers also arise within the mental health system itself. Consider, for instance, the
relatively low rates of provision of treatments consistent with guidelines for evidence-based practice
among mood and anxiety disorders (e.g., Goisman et al., 1999). For instance, despite literature
demonstrating the efficacy of exposure therapy for anxiety disorders, a random survey of U.S.
psychologists revealed that only 17% were utilizing this method to treat posttraumatic stress disorder
(Becker, Zayfert, & Anderson, 2003). Moreover, even when professionals do provide evidence-based
treatments, specific treatment techniques may not be implemented effectively. For example, a Minnesota
survey (Freiheit, Vye, Swan, & Cady, 2004) revealed that even when psychologists report using
cognitive behavioral methods for anxiety treatment in their clinical practice, less than 25% reported
using interoceptive exposure for panic disorder and 28% endorsed using exposure and response
prevention to treat obsessive compulsive disorder. This may result partially from limitations in
professional training. The Society of Clinical Psychology Task Force on Promotion and Dissemination
of Psychological Procedures found that training in evidence-based treatments was somewhat limited
both in doctoral programs and predoctoral internships (Crits-Christoph et al., 1995). At the time of the
survey, only 59% of predoctoral clinical internship training programs provided supervision in CBT for
depression. A recent survey of graduate students in psychology programs in the United States (Karekla,
Lundgren, & Forsyth, 2004) found that 31.4% of students did not receive any coursework covering
empirically supported treatments. Similarly, both psychiatry residency programs (Accreditation Council
for Graduate Medical Education; Tomita, 2000) and social work training neglect to emphasize training
in evidence-based psychotherapy. To some degree, this may change secondary to an increased impetus
for the provision of time-limited effective treatments given managed care within the United States,
which places various external constraints (e.g., time, funding) on mental health service delivery
(Goisman et al., 1998).
4.4. Barriers at the treatment efficacy level
Even when depression and anxiety are detected, individuals often fail to receive adequate treatment,
particularly in the primary care sector where they are most likely to present (Depression Guideline Panel;
AHCPR, 1993; Perez-Stable et al., 1990; Simon et al., 1995). In a Bulletin for the World Health
Organization on the persistence of the burden of anxiety and depression, Andrews, Sanderson, Slade,
and Issakidis (2000) cite both failure to seek treatment and failure to access efficacious treatment as two
major contributors to this ongoing problem. It has been estimated that fewer than 10% of people
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 593
suffering from major depression receive a therapeutic dose of medication (Keller & Boland, 1998), and
poor breadth and maintenance of gains have been demonstrated for the pharmacological treatment of
mood disorders (Fava et al., 1998). Moreover, concerns have also been raised recently about possible
long-term adverse effects of antidepressants (Fava, 2003). Among anxiety disorders, Katschnig and
Amering (1994) reported that only 31% of panic patients recovered following a course of pharmaco-
therapy and the majority of their sample continued to have symptoms over the 6-year follow-up period.
This recovery rate is consistent with other findings of anxiolytic medications that demonstrate poor
maintenance of treatment gains (Clum, Clum, & Surls, 1993; Gould, Otto, & Pollack, 2002; Westra &
Stewart, 1998), and suggestions that the efficacy of newer antidepressant agents are seen only as long as
the medication is continued (Ballenger, Wheadon, Steiner, Bushnell, & Gergel, 1998; Figgitt &
McClellan, 2000; Sharp et al., 1996).
Despite research supporting the efficacy of psychological therapies for these disorders (e.g., Brent et
al., 1997; Chambless & Ollendick, 2001; Clarke et al., 1999), it is also increasingly clear that there is
room to improve response rates to CBT, for example (e.g., Fisher & Durham, 1999; Otto et al., 2000),
and to reduce drop out rates in psychotherapy that tend to range between 20% and 47% (McQuaid et
al., 1999). Rates of remission vary across the anxiety disorders but generally suggest that a significant
proportion of individuals fail to respond to even the most efficacious treatments, respond only partially,
or dropout prematurely. In a review and reanalysis of 11 well-controlled studies of exposure treatment
for agoraphobia, Jacobson, Wilson, and Tupper (1988) found that only 27% of subjects could be
classified as ‘‘recovered’’ at posttreatment, and 34% at follow-up, when stringent criteria were used to
define recovery. Similar findings have been reported for CBT with GAD (e.g., Fisher & Durham, 1999;
Westen & Morrison, 2001), and only 50% of individuals receiving CBT for social anxiety demon-
strated clinically significant improvements (Clark, 1997). Comparable response rates have been
obtained in treatment outcome studies with children, in which 30–40% of individuals continue to
meet criteria for a clinically significant anxiety disorder following treatment (Barrett, Dadds, Rapee, &
Ryan, 1996; Kendall, 1994). It is important to point out that outcome varies markedly depending on
how conservative the criteria are that one considers for treatment success (Brown & Barlow, 1995;
Nathan, 2001).
Among depressed children and adults who have received antidepressant or psychological treatment,
some individuals achieve a complete remission of symptoms; however, in a substantial proportion of
cases, there are enduring or fluctuating periods of residual symptoms that persist for months to years
(Keller & Boland, 1998; Rush et al., 1998; Rush & Thase, 1997). Within treated samples, the base rate
of recovery is approximately 40% within 3 months, 60% within 6 months, and 80% within 1 year
(Coryell et al., 1994). Even the most efficacious psychotherapeutic treatments for depression produce
only partial treatment response (Cuijpers, 1998; Hollon et al., 1992; Robinson, Berman, & Neimeyer,
1990). For instance, Paykel et al., (1999) reported that 25% of individuals receiving CBT remitted and
only 29% experienced a relapse. Although this was superior to clinical management (47% relapse),
there remain a significant proportion of individuals who fail to respond to treatment. As another
illustration, Elkin et al. (1989) reported a post-CBT remission rate of 51%; suggesting about one half
of the sample remained symptomatic. This is consistent with reports from meta-analytic studies of CBT
for depression, indicating that post-CBT depression scores continue to be in the mildly depressed range
(Cuijpers, 1998; Robinson et al., 1990). Thus, although psychotherapies have been demonstrated to be
effective, there remains a large proportion of individuals who do not attain significant treatment gains
or remission.
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616594
5. Strategies for bridging the gap between disorder and treatment
The previous review outlined the nature of existing barriers encountered by individuals in obtaining
effective treatment for anxiety and depression. Given such barriers and the enormity of this public health
issue, it is imperative to consider what strategies can be implemented to render access to mental health
care more accessible and effective. Potential remediative steps can be executed at multiple levels from
public and provider education, to promoting earlier detection, to increasing effective mental health care
training, and changes to the manner of care delivery. Such initiatives, which are summarized in Table 2,
are described in turn.
5.1. Increasing detection and access at the level of the individual
5.1.1. Enhancing public awareness of anxiety and depression
Interventions aimed at the individual level focus on identifying problems and increasing help-seeking
behavior among those with anxiety and depression. Public awareness and education initiatives seem to
be increasing in recent years and may assist in improving individuals’ ability to recognize the symptoms
of anxiety and depression, as well as reduce the stigma associated with mental health services (Schare,
2003; Suinn, 2003). For instance, the public currently appears to have greater knowledge about
depression and this enhanced awareness may be partially responsible for a more recent increase in
reported prevalence of depression (Angst, 1997). One example of such detection and awareness
campaigns is the national screening days for anxiety and mood disorders, which allow individuals in
the community to learn about these disorders and undergo a brief screen to detect potential problems.
Such public awareness campaigns may not only serve to increase individual help-seeking behavior but
also assist individuals in learning about and accessing available mental health resources in their
community. These and other public awareness campaigns may also be useful in by-passing some of
the other barriers that individuals encounter once a decision is made to seek treatment (e.g., systemic
barriers such as provider nondetection or failure to access evidence-based treatments).
Another example of enhancing public awareness is the increasing availability of Internet and self-
help resources (see Table 3 for some examples; Taylor, Jobson, Winzelberg, & Abascal, 2002). To the
extent that they offer valid and accurate information, Web-based treatments and education about
anxiety and depression would appear to have the advantage of broader access among sufferers (e.g.,
individuals house-bound because of anxiety or depression) and providers (e.g., Web-based guidelines
for the treatment of anxiety and depression). In fact, research has demonstrated that Internet-based
programs can reduce the length of provider-based treatment among individuals with panic disorder
and social phobia (Carlbring, Westling, Ljungstrand, Ekselius, & Anderson, 2001; Gruber, Moran,
Roth, & Taylor, 2001). Moreover, the proliferation of self-help books is a welcome development,
allowing wider dissemination of effective treatments for mood and anxiety disorders. For example,
Burns’ (1980) Feeling Good: The New Mood Therapy has been found to significantly reduce
depressive symptoms among readers (Scogin, Hamblin, & Beutler, 1987; Scogin, Jamison, Floyd,
& Chaplin, 1998). Meta-analyses (Cuijpers, 1997; Gould & Clum, 1993; Scogin, Bynum, Stephens, &
Calhoon, 1990) have shown that self-help approaches yield large overall treatment effect sizes (0.76–
1.19) and that additional therapist input may have no additional effect on participant outcomes.
Clearly, one needs to be discriminating in selecting resources in the public domain (i.e., not all self-
help books are based on evidence-based treatments), yet the availability of a number of empirically
Table 2
Strategies for bridging the gap between anxiety and depressive disorders with treatment
Level Goal of strategy Intervention
Individual 1. Enhancing public awareness Public education campaigns within the media,
school system, and other public domains;
National public screening days;
Increased Web-based and self-help resources.
2. Prevention programs Early prevention efforts targeted at identified risk factors;
Interventions with children at risk, such as those
whose parents suffer from anxiety or depression;
Integrating relapse prevention strategies
within existing treatments.
Provider 1. Improving screening and treatment Develop brief, reliable, and accurate screening
measures for general practitioners;
Educate physicians about risk factors for the disorders.
Educate medical professionals about the
assessment and treatment of the disorders;
Incorporate mental health education into
existing medical training programs.
2. Improving access to effective treatment Educate physicians on available
empirically supported treatments;
Disseminate research findings to medical journals,
textbooks, and newsletters;
Increased collaboration efforts between medical
and mental health professionals.
Systemic 1. Increased access to treatment Integrating mental health and health services;
Shared-care models of health care.
2. Increased availability of treatment Increase governmental funding for mental health services.
3. Ensuring effective delivery of treatment Greater professional school training in
empirically supported treatments;
More educational training workshops for professionals;
Adapting empirically supported treatments
to be amenable to delivery by nonspecialty
mental health providers;
Research into most effective modes of transfer of knowledge;
Infrastructure support from professional
governing boards to ensure delivery of effective treatment.
4. Ensuring provision of effective treatment Greater accountability of professionals to
provide empirically supported care;
Implementing regulated guidelines for
practice in accordance with empirically supported care;
Modifications to accreditation standards of regulating bodies;
Incentives to provide empirically supported
care from professional licensing boards and insurance agents.
5. Improving efficiency of available treatments Identification of ‘‘active’’ treatment ingredients;
Provision of brief and effective treatments.
6. Improving effectiveness of available
treatments
Clinical innovations to supplement existing treatments and
address low response rates;
Identification of individual difference variables
related to treatment response.
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 595
Table 3
Suggested self-help readings and Web site resources on CBT for anxiety and depression
Title Treatment target Source Author
The Feeling Good Handbook Depression and anxiety Penguin Books Burns (1989)
An End to Panic:
Breakthrough Techniques
for Overcoming Panic
Disorder
Panic disorder New Harbinger Zuercher-White (1998)
Dying of Embarrassment Social anxiety disorder New Harbinger Pollard et al., 1992
Mastery of Your
Anxiety and Panic II
Panic disorder The Psychological
Corporation
Barlow and
Craske (1994)
Mind over Mood Depression Guilford Books Greenberger and
Padesky (1995)
Overcoming Generalized
Anxiety Disorder
Generalized anxiety disorder New Harbinger White (1999)
Stop Obsessing: How to
Overcome Your obsessions
and Compulsions
Obsessive–compulsive
disorder
Bantam Books Foa and Wilson (1991)
www.paniccenter.net Provides 12 sessions of free
weekly program of CBT for
panic disorder and agoraphobia
www.anxieties.com Provides free step-by-step
CBT treatment plans for a
variety of anxiety disorders
including social anxiety, panic,
PTSD, and OCD
www.nimh.nih.gov/anxiety U.S. government sponsored
site with lots of educational
materials on anxiety and
useful links
(e.g., clinical trials)
www.adaa.org Lists specialty anxiety service
providers in North America
(useful links to clinical trials)
www.cmha.ca Nonprofit Canadian Web site
with extensive and broad
information on various mental
health problems
www.nmha.org Nonprofit American Web site
with very extensive and broad
information on various mental
health problems
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616596
based self-help resources may provide access to treatment, and in a more timely fashion, for those
who would otherwise not access it (e.g., individuals in rural communities, those reluctant to present
for treatment). This is particularly important in view of the large discrepancy between the number of
sufferers and the limited number of health care providers, particularly specialty mental health care
providers (Williams, 2001). In addition, these resources may also be used adjunctively with specialty
mental health care, or busy family physician practices, to reduce the amount of provider-based
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 597
treatment required. For instance, Carlbring et al. (2001) found that an Internet-delivered CBT self-help
program, with minimal therapist contact, was effective for reducing symptoms among individuals with
panic disorder.
5.1.2. The prevention of anxiety and depressive disorders
Efforts also need to be directed toward prevention and early detection/management of anxiety and
mood disorders (see Dozois & Dobson, 2004). Given the growing body of literature identifying risk
factors for the development of mood disorders (e.g., Nolen-Hoeksema & Girus, 1994; Spence, 2001),
preventative interventions need to target these specific pathways. For instance, numerous vulnerability
factors (e.g., restricted range of social roles, body image concerns, and higher risk for sexual abuse)
appear to account for the higher rates of depression observed among adolescent females (Nolen-
Hoeksema & Girus, 1994). Such knowledge allows for development of prevention initiatives, which
target interventions towards reducing the incidence of dysfunction or decreasing the impact of
environmental risks for mood disorders. For instance, Gardenswartz and Craske (2001) demonstrated
the efficacy for prevention of panic disorder (and reduction of panic symptoms at 6-month follow-up) of
a 1-day workshop geared towards individuals identified as at risk for panic disorder. While such
initiatives are emerging, greater effort in this area may assist in reducing the chronic disability and
burden currently commonplace in those with anxiety and depressive disorders. Earlier detection and
treatment may also reduce the severity and course of depression for example by minimizing the number
of subsequent depressive episodes (McQuaid et al., 1999).
Several prevention programs for children and adolescents, such as the Resourceful Adolescent Program
for adolescent girls in Canada (Collins et al., 2004) and the Queensland Early Intervention and Prevention
of Anxiety Project (Dadds, Spence, Holland, Barrett, & Laurens, 1997; Dadds et al., 1999) in Australia,
have recently been implemented in the school system. Early prevention initiatives have also been directed
at reducing the risk of developing emotional disturbance in children who have parents with mental health
difficulties. Such interventions are based on the high concordance rates observed between parents and
children for emotional distress (Beidel & Turner, 1997; Goodman & Gotlib, 1999; Hammen, 2000;
Wickramaratne & Weissman, 1998). For example, Clarke et al. (2001) conducted a randomized controlled
trial to prevent depressive episodes in offspring of adults who had been treated for depression in a health
maintenance organization. Ninety-four adolescent offspring (aged 13–18 years) of depressed parents were
randomly assigned to either treatment as usual or treatment as usual plus a 15-week CBT prevention
program. The results indicated that only 9% of CBT participants developed a depressive episode during
the 15-month follow-up interval, compared with 29% of the treatment as usual children. Although such
prevention programs yield promising results, further research is necessary to clarify the most effective
methods for directing such interventions (universal versus targeted groups) and age groups to be targeted
(early in life versus adolescence).
Given our increasing awareness that the modal course of depression and anxiety is marked by relapse,
greater efforts are also necessary to prevent relapse and recurrence of these disorders. That is, beyond
acute treatment of the disorder, efforts are needed to develop and integrate relapse prevention strategies
in existing treatments. For example, residual agoraphobic symptoms have been found to confer increased
risk for reemergence of this disorder (Fava et al., 2001). Relapse prevention efforts are particularly
necessary in light of the increased risk of depression associated with each sequential episode. Theorists
have recently attempted to account for this increased risk by suggesting a ‘‘sensitization’’ hypothesis.
That is, depressed individuals may become more ‘‘sensitized’’ the longer they experience depression or
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616598
the more frequently their episodes recur (Segal, Williams, & Teasdale, 2002; Segal, Williams, Teasdale,
& Gemar, 1996; Teasdale et al., 2000). Specifically, the threshold for the reactivation of negative
thinking patterns associated with dysphoric mood may be lowered the more an individual has
experienced depression. Consistent with this idea, the structural organization of negative self-referential
content appears to be stable even when individuals remit from their depression (Dozois & Dobson,
2001). Individuals with a greater number of past episodes of depression also appear to organize cognitive
content differently than do individuals with fewer episodes (Dozois & Dobson, 2003). Depressed
individuals may therefore benefit from strategies that help them to reallocate attention once they begin to
experience dysphoric mood (see Segal et al., 2002).
A major strength of psychotherapies is their potential to facilitate relapse prevention. A meta-analysis
(Gould et al., 1995) of long-term treatment outcome for panic disorder found that cognitive–behavioral
interventions were most successful at maintaining treatment gains at 1-year follow-up. Increasing efforts
are also being directed explicitly toward relapse prevention in depression. As one illustration,
mindfulness-based cognitive therapy treatment has relapse prevention as a prime focus (Segal et al.,
2002). Early evaluations of this treatment for individuals prone to recurrent depression, but currently
remitted, suggest favorable outcomes in reducing the probability of depressive relapse in comparison to
treatment as usual (Teasdale et al., 2000). Continuation-phase cognitive therapy (Jarrett et al., 2001) is
another recent treatment development that has demonstrated efficacy in reducing relapse in depression in
comparison to treatment as usual. Further research is necessary to also evaluate the specific pathways for
targeting relapse prevention strategies for anxiety and depression. In this regard, Joiner (2000) has
presented an interpersonal model of depression identifying multiple interpersonal variables (e.g., stress
generation, negative feedback seeking, excessive reassurance seeking, interpersonal conflict, avoidance)
that may interact in reciprocal and dynamic ways to maintain the depressive process and increase
vulnerability for the recurrence of depressive episodes. Such models have important implications for
understanding and ultimately reducing the high rate of relapse in depression.
5.2. Increasing detection and access at the level of the provider
5.2.1. Improving screening measures in primary care
Research has shown that even among those individuals who are identified as having anxiety and
depression in primary care, a low percentage are correctly diagnosed (Wittchen et al., 2002). This finding
draws attention to the important need for reliable and accurate screening instruments for anxiety and
depression. Inclusion of brief screening measures or procedures may facilitate integration into primary
care, given the multiple demands of general practitioners and busyness of a family medicine practice
(Kendrick et al., 1996). Accuracy of detection is also imperative for ensuring the provision of
appropriate treatment. Detection rates have been found to be particularly low for those individuals with
generalized anxiety disorder (0.5%; Katzelnick & Greist, 2001), despite the higher prevalence rates of
the disorder within the primary care sector (Culpepper, 2002). The importance of screening for
generalized anxiety disorder within the primary care sector seems to be particularly important given
that those individuals are more likely to develop further mental health difficulties, such as depression
(Kessler et al., 1996). Similarly, research has demonstrated that individuals with social anxiety are at risk
for developing depression and alcoholism (Lecrubier & Weiller, 1997).
Accurate detection of anxiety and depression may be improved by targeting the identified risk factors
for the disorders. For example, individuals with depression and anxiety disorders have higher number of
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 599
visits to general practitioners (e.g., Greenberg et al., 1999). Efforts directed towards screening high
utilizers of health care services would serve to increase detection, improve access to appropriate
treatment, and reduce further health care visits (Margraf & Schneider, 1995). Screening could also be
directed toward the children of individuals with anxiety and depression, given the high concordance rates
(up to 50%) of emotional distress between parents and children (e.g., Beidel & Turner, 1997; Goodman &
Gotlib, 1999).
Investigators (e.g., Hunt et al., 2004; Kramer, Simonsick, Lima, & Levac, 1992) have suggested that
efforts be made to assist primary-care physicians, residents in training, and medical students to acquire
the necessary skills for assessing mental health problems, managing patients with such difficulties, and
formulating appropriate treatment plans. Incorporating mental health educational components into
existing medical training programs may be potentially successful in this aim. Additionally, training
workshops and seminars increasingly being held for general practitioners in the community may be
useful in promoting awareness and detection of mental health problems (e.g., Defeat Depression
Campaign; Paykel, 1994).
5.2.2. Educating physicians and other mental health providers about available evidence-based
treatments
Efforts are required to challenge assumptions of biological psychiatry and educate mental health care
providers about psychosocial factors involved in the etiology and treatment of depression and anxiety
disorders. Berger (2001) has drawn attention to the reductionistic perspective of the medical model
toward mental health difficulties and the consequent marginalization of psychotherapy. Pharmacological
treatment for depression and anxiety is emphasized despite consistent research findings, demonstrating
the majority of outcome in pharmacotherapy is attributable to common factors in all treatments (i.e.,
‘placebo’ effects, such as expectancy or characteristics of the treatment provider; Greenberg, 1999;
Scovern, 1999). In particular, studies have highlighted the importance of the therapeutic alliance in
medical treatment outcomes and rather than considering such psychological variables as extraneous,
medical training should emphasize how to facilitate the doctor–patient relationship (Greenberg, 1999).
There is evidence (Pirbhai, 2003) suggesting that the medical paradigm may be shifting to emphasize
communication, such as exploring feelings about one’s illness, beliefs regarding causation, and impact of
illness on individual functioning. For instance, the BATHE method (Lieberman & Stuart, 1999) has been
introduced as a technique for improving the doctor–patient relationship by collecting information about
the psychosocial context of patients’ symptoms and providing empathic responses. Preliminary empirical
support for such models of patient care has suggested improved patient satisfaction and improved health
and mental health outcomes (Stewart, 2004).
It is also important for physicians and other mental health care providers to be aware of recent
research findings on evidence-based treatments in order to ensure the delivery of effective treatment.
This is particularly true in the case of evidence-based psychotherapies. Further dissemination of research
findings to medical journals, textbooks, newsletters, and educational training programs and/or work-
shops is necessary to improve awareness of the range of evidence-based interventions. Such dissem-
ination must include efforts to challenge professional and public assumptions about the relative efficacy
of medication and psychotherapy for treating depression and anxiety.
In regard to improving the quality of patient care, further initiatives have attempted to achieve this
aim through collaboration between mental health professionals and primary care providers. For
example, Unutzer et al. (2001) reported improved compliance with antidepressant usage over
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616600
treatment-as-usual in primary care attendees with depression who were provided with education and
follow-up with a nurse practitioner trained in mental health care. Hunter and Peterson (2001) reported
on the development of a ‘‘primary care psychology training program’’ in which the clinical skills of
assessment, behavioral analysis, behavioral therapy, and differential diagnosis were adapted to the
primary practice setting. Such educational programs may additionally serve to challenge the general
assumption within the medical profession that pharmacotherapy is the most cost-effective treatment
option for mood disorders.
5.3. Systemic changes to increase detection and access
5.3.1. Integration of mental health and health services
Strosahl (1998) proposed that the structure of general health care precludes physicians from
responding to mental health concerns in a meaningful way. The segregation of psychological and
psychiatric services from primary care results in the delivery of ineffective services. Given the
fundamental importance of the primary care setting for the treatment of anxiety and depression
(Robinson, 2002), strategies for integrating mental health services within the primary care setting are
required. Shared-care models of health care represent such an initiative, and there are currently several
models in existence to guide such procedures (e.g., Blount, 1998; Cummings, Cummings, & Johnson,
1997; Katon et al., 1995; Strosahl, 1996). These models emphasize a collaborative treatment approach,
with patients being co-managed by mental health and primary care providers, and treatment integrating
psychoeducation with regard to self-management strategies. Studies have demonstrated the efficacy of
shared-care models and suggest that the integration of mental health treatment within primary care
settings is potentially more effective than traditional treatments delivered in mental health clinics (Katon
et al., 1995; Mynors-Wallis, Gath, Day, & Baker, 2000).
A growing body of research further suggests that integrated mental health service delivery is
substantially more cost-effective than the existing health care system (Cummings, 1997; O’Donohue,
Ferguson, & Cummings, 2002; Strosahl, 1998; Strosahl & Sobel, 1996; Von Korff et al., 1998). The
additional benefits of increased patient and provider satisfaction (Katon et al., 1996), as well as improved
patient outcomes (Hellman, Budd, Borysenko, McClelland, & Benson, 1990), have been demonstrated
for shared-care models of treatment. For example, Von Korff et al. (1998) found that the costs of
integrated mental health and primary care services for depression were significantly lower than treatment
as usual (US$123 per patient versus US$317). A recent meta-analysis of 57 controlled cost offset studies
(Chiles, Lambert, & Hatch, 1999) demonstrated an average cost return of 20% for integrated behavioral
health services. Providing cost-effective treatments has become a fundamental issue in North American
in light of the rising costs of health care. In fact, the United States spends a greater percentage of its gross
national product on healthcare than any other country, with an approximate expenditure of 1.2 trillion
dollars on health care in the year 2000 (Strosahl, 2002). In regard to the treatment of mood disorders, the
cost of providing effective treatment is offset by the decrease in future medical utilization among
afflicted individuals (Strosahl, 2002; Yingling, Wuslin, Arnold, & Rouan, 1993). For example, Margraf
and Schneider (1995) reported an 81% decrease in healthcare costs for individuals with panic disorder
following 15 sessions of CBT. However, further health care initiatives are required to capitalize on such
medical cost savings pathways and facilitate the delivery of effective treatment. For instance, hospitals
and mental health clinics need to ensure that evidence-based treatments are put into practice in
community and hospital settings (Barlow, Levitt, & Bufka, 1999).
5.3.2. Increased governmental funding for mental health services
While the integration of mental health and health services will facilitate the delivery of effective
treatment, governmental funding initiatives are also necessary to ensure the availability of treatment. The
Canadian Alliance on Mental Illness and Mental Health (CAMIMH, 2003) has drawn attention to the
disproportionate governmental funding allotted to mental health resources in comparison to general health
care and the consequences of this discrepancy. For instance, Romanow and Marchildon (2003) emphasize
a need for provincial health plans to extend public coverage to evidence-based psychological interventions
in order to improve patient outcomes and present an alternative to prescription drug therapies. It is
imperative that reform takes place in health care systems within North America to increase the availability
of psychiatric and psychological services to those individuals suffering from anxiety and depression. In
Canada for example, partnerships between provincial and federal governmental health agencies may be a
step toward implementing National Action Plans for mental health reform (CAMIMH, 2003).
5.3.3. Wider availability of training in evidence-based treatments
Currently, CBT and other evidence-based treatments are not being made available to a wide range of
patients with anxiety and affective disorders (e.g., Wilson, 1997) despite the growing body of empirical
support for these treatments. Griest (2000) suggested that this discrepancy exists because there are not
enough therapists available who are competent in the provision of evidence-based psychotherapies.
Other investigators (e.g., Becker et al., 2003) have drawn attention to the need for further research to
understand practitioner perceptions of barriers to using evidence-based treatment. We have already noted
that there is a need to provide educational and training workshops for mental health and health
professionals on the provision of such treatments. In order to facilitate this training, it is also necessary
for evidence-based psychotherapies to be adapted for delivery by nonspecialty mental health care
providers and practitioners in the primary care setting. To achieve this aim, the components and requisite
amount of such training also need to be evaluated.
Increasing the amount of training in evidence-based treatments in existing doctoral psychology
training programs and predoctoral internships is further required to meet the growing public demand for
such treatment. Educational initiatives need to address professional barriers to such treatments, including
misperceptions of manual-based treatments and the important role of supervisors in providing such
training (Karekla et al., 2004; Kendall, 2002). Moreover, research also needs to be directed at the means
through which effective transfer of information can occur (Hayes, Barlow, & Nelson-Gray, 1999). For
example, work by Miller and Mount (2001) reveals that attendance at workshops has little appreciable
impact on actual skill utilization or integration into the clinical practice of attendees.
Other researchers (Calhoun, Mora, Pilkonis, & Rehm, 1998) have suggested that additional training
initiatives (e.g., the development of postdoctoral training programs) are required to ensure sufficient
expertise in evidence-based treatments. Although such initiatives may increase the level of available
training, infrastructures by professional governing boards may be necessary to ensure that effective
treatments are being delivered by service providers (Barlow et al., 1999). The Guidelines and Principles
for Accreditation of Programs in Professional Psychology (APA, 1996) is one positive impetus in this
direction, as it includes a mandate that sufficient attention be given to the empirical base of
psychological methods. However, the guidelines outline that doctoral programs have a responsibility
for giving students a sound academic background in the ‘‘science of psychology’’ but permit individual
programs to determine their own ‘‘philosophy of training.’’ Within social work, there are currently no
guidelines to ensure the inclusion of empirically based approaches in training. However, psychiatry has
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 601
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616602
recently taken steps towards improving training by including CBT as a requirement of the new
accreditation criteria for psychiatry residency programs (Beck, 2000).
5.3.4. Greater accountability to provide evidence-based care
Developing such guidelines may ensure that professionals learn the necessary skills for providing
effective treatment, but new infrastructures may be required to guarantee appropriate mental health
service delivery. Having regulated guidelines available to specify the course of treatment of mood
disorders may facilitate this process. For example, the Depression Guideline Panel (AHCPR, 1993) has
provided recommended treatment for major depressive disorder and these guidelines have become
enforced by law in some states in the United States (Barlow et al., 1999). The U.S. Congress also passed
a public law to establish the Agency for Health Care Policy and Research (Public Law 101–239, 1989)
with the mandate of enhancing the quality, appropriateness, and effectiveness of health care services.
Modifications to the accreditation standards of professional organizations (e.g., American Psychological
Association) may also serve to improve the quality of mental health services provided by holding
professionals and public agencies more accountable.
Additional systemic changes are required to reward service providers for offering evidence-based
services. For instance, insurance agencies could adjust rates of reimbursement for services dependent
upon empirical justification and professional licensing boards could offer insurance credits to providers of
evidence-based treatments. Taylor and Biglan (1998) draw attention to the impetus of financial incentives
by pointing out that agencies would ensure the use of evidence-based treatments if doing so would
increase their funding base, and clinicians would do the same if they could get on more provider lists.
5.3.5. Identification of ‘‘active’’ treatment ingredients
While evidence-based treatments need to be advocated, it is apparent that further research is required to
improve the response rates to treatment for individuals with anxiety and depression. Further treatment
dismantling studies are necessary to delineate the specific active components of broader treatment
packages (e.g., psychoeducation, cognitive restructuring) in order to streamline interventions without
sacrificing treatment potency (Telch, Smits, Brown, & Beckner, 2002). For example, behavioral
activation has been found to be a core factor in depression management (Martell, Addis, & Jacobson,
2001) and exposure is a critical treatment element for anxiety (Barlow, 2002), whereas breathing
retraining in panic disorder has been found to be nonessential (Schmidt et al., 2000; Taylor, 2001). Such
findings have served as an important step in the dissemination of psychological treatments by contributing
to the development of briefer interventions that can be made available to a wider range of patients and by
allowing existing protocols to be differentially focused on the active treatment ingredients of the protocol.
The brevity and efficiency of existing treatments is imperative in light of the rising costs of health care,
which serve to place restraints on available services. There is also evidence that providing a brief
educational intervention in the emergency room to patients presenting with panic attacks can reduce the
number of subsequent ER presentations (Dyckman, Rosenbaum, Hartmeyer, & Walter, 1999; Phoenix &
Westra, 2003). This is consistent not only with adaptations of practice toward brevity and efficiency but
also adaptations to fit delivery of care where the patient is most likely to present in the system.
5.3.6. Innovations in practice to supplement existing effective treatments
Additional theory-driven developments or adaptations of treatments are also necessary to address the
need for improved response rates in anxiety and depression. Increasing need is also being recognized for
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 603
the development of new treatments (and/or integration of existing treatments) that more widely address
the diverse presentations of clinical problems (Kohlenberg, 2003). For instance, Ladouceur et al. (2000)
reported strong preliminary support for a focal treatment targeting worry in individuals with generalized
anxiety disorder (e.g., challenging positive beliefs about worry, worry exposure, etc.). The treatment led
to superior results, relative to a waitlist control group, and there were posttreatment reductions in the
intolerance of uncertainty, a central theoretical concept of generalized anxiety disorder. Investigators
(e.g., Roemer & Orsillo, 2002) have also suggested the potential utility of mindfulness-based cognitive
therapy for the treatment of generalized anxiety disorder, and research is beginning in this area.
Innovations in clinical treatments may also improve response rates through the systematic identifi-
cation of individual difference variables related to treatment response (Hayes et al., 1999; Prochaska,
2000). For instance, individual differences in change readiness has been found to be a significant
predictor of treatment completion (panic disorder: Dozois, Westra, Collins, Fung, & Garry, 2004; general
mental health outpatients: Brogan, Prochaska, & Prochaska, 1999) and outcome (CBT outcomes in
anxiety: Dozois et al., 2004; benzodiazepine response in anxiety: Wilson, Bell-Dolan, & Betiman, 1997).
Treatments, such as motivational interviewing, have received strong empirical support in the addictions
and other health behavior domains (Burke, Arkowitz, & Dunn, 2002; Burke, Arkowitz, & Menchola,
2003; Miller, 2004). As such, they hold promise for extending response rates to existing evidence-based
treatments (Arkowitz & Westra, in press; Murphy, Rosen, Cameron, & Thompson, 2002; Taylor, 2004;
Westra, 2004).
Moreover, if variation in readiness for change is consistently associated with lower treatment seeking
and poorer outcomes to existing treatments in anxiety and depression, treatments that enhance change
readiness may be particularly amenable to population health approaches to enhancing treatment access.
For example, Prochaska et al. (Brogan et al., 1999; Prochaska, 2000; Prochaska, Norcross, &
DiClemente, 1994) report substantively higher recruitment rates for motivational enhancement treat-
ments than change-based treatments for smoking cessation. Another promising avenue to increase help
seeking may involve the adaptation of the community reinforcement treatment model developed and
supported by Miller et al. (e.g., Miller, Meyers, & Hiller-Sturmhofel, 1999; Meyers, Miller, Hill, &
Tonigan, 1999) in the addictions domain. This approach takes a systems perspective on treatment by
coaching family and supports of the person with the problem to respond in a more therapeutic way,
designed to increase motivation for change and help seeking (Wolfe & Meyers, 2004). Preliminary
findings have demonstrated the efficacy of this approach (Meyers et al., 1999). Adapting such strategies
to the management of prevalent problems such as anxiety and depression may be worthwhile in
attempting to increase treatment entry and also empowering individuals closely affected by the sufferer’s
difficulties.
6. Conclusions and future directions
This article highlighted the gaps that exist in accessing effective treatment among children and adults
with anxiety and depression. It is apparent from the magnitude and burden of these mental health
problems that this is a significant public health issue, requiring increased public, professional, and
systemic attention. Effective treatments are available for these disorders; however, increased efforts are
necessary to overcome the barriers for obtaining such treatment and improving the quality of life among
individual sufferers.
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616604
We have identified a number of factors that may influence the likelihood of seeking and accessing
treatment. However, these are merely suggestive at this stage since research on these factors, and their
interrelationships, is quite limited. More research is required on basic yet fundamental questions such as
‘Why would someone seek treatment?,’ ‘What provider or systemic factors most strongly influence the
probability of help seeking?,’ and ‘Once a person decides to seek treatment, what are the factors
influencing staying in treatment and utilization of effective symptom management strategies?.’ In other
words, we need to advance our understanding of factors influencing ‘engagement’ in treatment.
Understanding how to engage people in treatment is critical to broadening rates of treatment seeking
and utilization, particularly as investigators embark on prevention efforts. As one illustration, Barsky and
Ahern (2004) supported the efficacy of CBT for hypochondriasis in primary care. However, of the 776
individuals who screened positive for high health anxiety, over 50% either declined to participate or
could not be reached subsequent to the screening. Thus, the majority of individuals with the problem
failed to follow-up on treatment, even when it was offered.
Arguably, simply adding more techniques to our treatment repertoire or educating people about
existing techniques, while important, will likely not be sufficient to accomplish the goal of greater
utilization of effective treatment. Individual, provider, and contextual factors need to be delineated,
which influence the individual to seek out and utilize treatment. Hubble, Duncan, and Miller (1999) have
conceptualized psychotherapy outcome as influenced by client factors, relationship factors, expectancy,
and technique. This may be a useful broad framework for guiding investigations on engagement with
change strategies. For example, optimism that one can be effective in producing change (Dozois &
Westra, 2003) and treatment credibility (Chambless, Tran, & Glass, 1997) have been found to be
important determinants of psychotherapy outcome. Moreover, the impact of a positive working alliance
in psychotherapy (Bachelor & Horvath, 1999), and increasingly in medicine (Stewart, 2004), has been
consistently and strongly supported in facilitating effective treatment.
Thus, understanding the individual-seeking treatment (their hopes, resources, preferences, biases,
community, etc.) and the context in which they consider treatment (credibility of the provider and the
treatment, quality of the relationship with the provider, characteristics of the setting in which treatment is
sought) may very well be keys to bridging the gap between problem and resolution on a population-
health basis in mental health. For example, CBT has been repeatedly found in recent surveys to be more
acceptable, credible, and rated as more likely to be effective by anxiety sufferers compared with
pharmacotherapy (Walker, Vincent, Furer, Cox, & Kjernisted, 1999; Zoellner, Feeny, Cochran, & Pruitt,
2003). Since treatment credibility is related to outcome (Chambless et al., 1997), it might be
hypothesized that such factors might promote higher treatment utilization. Moreover, physicians who
are more positive and confident in the efficacy of their pharmacotherapy recommendations produce more
positive responses to treatment compared to their less confident counterparts (Fisher, Cole, Rickels, &
Uhlenhuth, 1964; Uhlenhuth et al., 1966). In all likelihood, such patient and provider factors are related
to increased expectancy of change and greater probability of utilization of treatment recommendations.
Given their crucial role in symptom relief, these factors and others merit greater empirical attention,
particularly in relation to the mechanisms and means through which they influence problem identifi-
cation, treatment seeking, and treatment utilization.
This review has served to draw attention to numerous avenues for bridging the treatment gap, and this
list is by no means exhaustive. Joint efforts are now required between professionals and governing
agencies to support efforts directed at increasing access and efficacy of mental health care for anxiety
and depression.
K.A. Collins et al. / Clinical Psychology Review 24 (2004) 583–616 605
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- Gaps in accessing treatment for anxiety and depression: Challenges for the delivery of care
- Introduction
- Prevalence, course, and burden of anxiety and depression
- Prevalence
- Course
- Burden
- Rates of access to mental health care in anxiety and depression
- Barriers to accessing effective treatment for anxiety and depressive disorders
- Barriers at the individual level
- Barriers at the provider level
- Barriers at the systemic level
- Barriers at the treatment efficacy level
- Strategies for bridging the gap between disorder and treatment
- Increasing detection and access at the level of the individual
- Enhancing public awareness of anxiety and depression
- The prevention of anxiety and depressive disorders
- Increasing detection and access at the level of the provider
- Improving screening measures in primary care
- Educating physicians and other mental health providers about available evidence-based treatments
- Systemic changes to increase detection and access
- Integration of mental health and health services
- Increased governmental funding for mental health services
- Wider availability of training in evidence-based treatments
- Greater accountability to provide evidence-based care
- Identification of active treatment ingredients
- Innovations in practice to supplement existing effective treatments
- Conclusions and future directions
- References
