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

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

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

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

Harvard Medical School

Madelyn R. Frumkin Massachusetts General Hospital, Boston, Massachusetts

Sophie A. Palitz and Michaela B. Swee Temple University

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

Harvard Medical School

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

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

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

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

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

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

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

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

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

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

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

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

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

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