Could social phobia slow your patient’s recovery?

Study finds 8.2% of HMO members have GSP
• Your patient consistently refuses to attend a substance-abuse support group.
• Your workers’ compensation client is increasingly reluctant to return to work.
• Your patient appears unwilling to keep follow-up appointments.

If just one of those scenarios strikes a familiar chord, it may be time to ask yourself whether your noncompliant patient may be suffering in silence from a disabling psychiatric disorder.

More than 10 million Americans suffer from generalized social phobia (GSP) disorder. It is the third most common psychiatric illness in the United States, following closely behind depression and alcoholism. Despite its prevalence, only 5% of patients with social anxiety disorder receive some form of treatment. (See box, p. 82, for a list of studies on social phobia disorder.)

"Most patients with social anxiety disorder go untreated because the symptoms don’t shout at you like those of depression or panic attacks," notes Jonathan R.T. Davidson, MD, professor in the department of psychiatry and behavioral science at Duke University Medical Center in Durham, NC, and director of the Anxiety and Traumatic Stress Program. "These people are quiet and reticent. Doctors aren’t trained to take them seriously."

Study data released

Left untreated, GSP can be socially and economically devastating to individuals and society. In addition, from a case management perspective, one study found that 70% to 80% of patients with GSP suffer from additional psychiatric conditions that add to the cost of treatment.

A study of more than 9,000 members of a large health maintenance organization found an 8.2% prevalence rate of GSP. The study was presented by Davidson and several colleagues at the 37th annual Meeting of the American College of Neuropsychopharm acology in Las Croabas, Puerto Rico, late last year. Compared with HMO members without GSP, patients with GSP had significantly more missed work hours, lower work and home productivity, greater overall disability, and more limitations on education. (See box, below, for more data from the study.)

These behaviors should cause case managers to investigate the possibility of GSP, Davidson says (see assessment tool for social anxiety disorder inserted in this issue):

    • Absenteeism at critical times. "If you have a workers’ comp client who fails to show up for an important evaluation or return-to-work conference, it may be a form of avoidance that is the hallmark of this disease," he says.
    • Excessive sweating.
    • Nervous trembling.
    • Blushing easily.
    • Avoiding eye contact. "People with social anxiety disorder feel very uncomfortable making eye contact, especially with authority figures," Davidson says.
    • Substance abuse. "People with this disorder often use alcohol as a form of self-treatment. This tends to be more prevalent in men than women."

The good news is that social anxiety disorder is easily treatable, he notes. "These patients are easy and pleasant to work with. They want to please others and are grateful for any improvement."

Several classes of drugs are very effective in the treatment of social anxiety disorder, including selective serotonin reuptake inhibitors, monamine oxidase inhibitors, and benzodiazepines. In addition, patients sometimes benefit from cognitive or behavioral therapy, says Davidson.

Not only are effective treatments available, but most patients have remarkable improvement within three months of treatment. "If you have a patient who has been on drug therapy for social anxiety disorder for more than 12 months without improvement, you need to investigate why," he tells case managers. "There are great economic advantages in providing maximum health benefits and facilitating access to treatment for patients with social anxiety disorder," he says. "We must treat this as a real illness."

Profile of a phobia

A study of more than 9,000 members of a large health maintenance organization presented recently at the 37th Annual Meeting of the Ameri can College of Neuropsychopharmacology in Las Croabas, Puerto Rico, revealed this profile of individuals with generalized social phobia (GSP):

    • The mean age of patients was 42.81 years.

    • The mean age of onset was 12.71 years.

    • Nearly 29% of GSP patients had a mental health visit in the past 12 months.

    • Nearly 30% of GSP patients had filled at least one antidepressant prescription.

    • GSP patients were 10% less likely to graduate from college than HMO members without GSP.

    • Nearly 25% of GSP patients reported a lifetime history of suicide attempts compared to 5% of HMO members without GSP.

    • Patients with GSP had total health care utilization of $2,466 compared to $1,959 for HMO members without GSP during the same reporting period, for a difference of $685.

    • Roughly 44% of GSP patients had a comorbid diagnosis on the tool to measure mental health and substance abuse. In 70% of GSP patients, the onset of GSP preceded the onset of the comorbid disorder.

    • Only 0.5% of the 8.2% of HMO members identified with GSP had a diagnosis of social phobia in the HMO’s administrative database.

Source: Katzelnick DJ, Kobak KA, Helstad CP, Greist JH, Davidson J, et al. The direct and indirect costs of social phobia in managed care patients. Presented at the 37th annual Meeting of the American College of Neuropsycho pharm a cology. Las Croabas, Puerto Rico; Dec. 14-18, 1998.