Unspecified Anxiety Disorder Diagnosis Significantly Decreases Treatment for Veterans

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By Annette M. Boyle

HOUSTON — About 40% of veterans with anxiety disorders receive a “placeholder” diagnosis that often remains with them indefinitely — and dramatically reduces the likelihood they ever will receive appropriate care, according to a new study.

Only 12% of veterans with a diagnosis of unspecified anxiety disorder (anxiety NOS) received a more-specific diagnosis within a year. Because of the way treatment guidelines are tied to specific diagnosis, providers are often left uncertain as to how to proceed with those patients.

Most forms of anxiety have similar treatments, so a nonspecific diagnosis might not seem significant; however, it cuts in half the likelihood that a patient will receive treatment. Two-thirds of patients with the most common specific anxiety diagnoses receive mental health services, while less than a third of those with unspecified anxiety do.

Exposure therapy is effective treatment for some types of anxiety. In this photo, Col. Michael J. Roy, MD, (left), of Walter Reed National Military Medical Center in Bethesda, Md., conducts a demonstration with Sgt. Lenearo Ashford, of a combat simulator that represents one of the new forms of treatment. Army photo

Exposure therapy is effective treatment for some types of anxiety. In this photo, Col. Michael J. Roy, MD, (left), of Walter Reed National Military Medical Center in Bethesda, Md., conducts a demonstration with Sgt. Lenearo Ashford, of a combat simulator that represents one of the new forms of treatment. Army photo

“A diagnosis of anxiety NOS is appropriate when clinically significant symptoms of anxiety are present, but they don’t meet the diagnostic criteria for a specific anxiety disorder,” said Terri Barrera, PhD, of the Michael E. DeBakey VA Medical Center in Houston. If providers lack sufficient information to make a more-specific diagnosis, though, they should schedule a timely follow-up evaluation so they can determine the type of anxiety the patient has or to whom they should be referred for more detailed assessment, she said.

About one-third of veterans suffer from anxiety in any given year, roughly twice the rate of the general population. Anxiety in veterans is commonly related to post-traumatic stress syndrome (PTSD), but it also can occur with obsessive-compulsive disorder (OCD) or phobias. Social settings may trigger anxiety, or a person with generalized anxiety disorder may find many situations quite stressful.

Anxiety disorders can cause significant functional impairment and are associated with high rates of psychiatric and medical comorbidities and suicide, so proper identification and treatment often have significant long-term impact on patient well-being.

Barrera and colleagues at Boston University looked at VA patient data for veterans who received a new anxiety disorder diagnosis between Oct. 1, 2009, and Sept. 30, 2010. During the year, 180,646 patients (62%) received a specific anxiety disorder diagnosis, while 111,598 (38%) were diagnosed with anxiety NOS.

The study, published in General Hospital Psychiatry, found that two-thirds of anxiety NOS diagnoses occurred in primary-care settings compared with only 18% in specialty mental health settings. PTSD accounted for 55% of diagnoses. General anxiety disorder (8%) and panic disorder (5%) were the next most common accompanying diagnoses. 1

The study found that anxiety NOS diagnosis occurred most often with female patients, those who were older and who lacked other specific comorbid diagnoses such as substance-use disorders or bipolar disorder or service-connected disabilities. The researchers noted that the differences in diagnosis may indicate a disparity in care and less-comprehensive diagnostic evaluations for patients with these characteristics.

First-line treatments for all forms of anxiety include cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), but the therapies may be delivered differently based on the type of anxiety present. “For instance, the Va/DoD guidelines endorse two specific types of CBT for the treatment of PTSD (cognitive processing therapy and prolonged exposure), whereas exposure and response prevention is the gold standard CBT treatment for OCD,” Barrera told U.S. Medicine.

Veterans with anxiety NOS were less likely to receive either psychotherapy or medication treatments, perhaps because of provider uncertainty about the proper referral.

Many treatments within the VA/DoD are tied to specific diagnoses, making the path to follow with an NOS diagnosis a little murky for a primary-care provider. The authors noted that “the growing body of research on transdiagnostic anxiety treatments, which use common principles of disorder-specific, evidence-based treatments to target a range of related disorders, may hold promise for anxiety NOS.” Currently, however, no defined treatments for and few case studies on unspecified anxiety disorders exist to guide providers.

Availability of appropriate specialists also might pose challenges. “Referrals for specific types of providers should be largely dependent on patient treatment preferences, but they may also be limited due to the availability of treatment alternatives” in smaller hospitals or clinics, Barrera said. “Although services vary between VA facilities, many larger hospitals have specialty clinics for PTSD and/or anxiety whose providers are trained in the focused treatments for PTSD, OCD, panic disorder and other anxiety conditions.”

To help providers properly identify anxiety, Barrera recommends brief screenings for anxiety, as other studies have shown that about 50% of patients with anxiety go undiagnosed in primary-care settings.

The VA’s primary care mental health initiative also might play an important role by providing a ready resource for further assessment, specific diagnosis and treatment of anxiety condition. “In our study, patients who were diagnosed in integrated primary-care mental-health settings were much more likely to receive a specific anxiety disorder diagnosis and to engage in mental-health services than those diagnosed in primary care,” she noted.

Although anxiety is far more prevalent than depression, there has been less attention to improving care for anxiety disorders within VA primary-care settings, she added.

“The development of VA clinical guidelines for anxiety would go a long way in improving the detection, diagnosis and treatment of anxiety. Ideally these guidelines would include routine standardized screenings for anxiety and general recommendations for the appropriate referral of veterans with various anxiety types of severity levels,” Barrera said.

1. Barrera TL, Mott JM, Hundt NE, Mignogna J, Yu HJ, Stanley MA, Cully JA. 2. Diagnostic specificity and mental health service utilization among veterans with newly diagnosed anxiety disorders. Gen Hosp Psychiatry. 2013 Oct 22. pii:S0163-8343(13)00305-8. doi: 10.1016/j.genhosppsych.2013.10.013. [Epub ahead of print] PubMed PMID: 24268573.

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