The Oxford dictionary defines anxiety as a “feeling of worry, nervousness, or unease about something with an uncertain outcome”. Most of us experience anxiety at some point in our lives; this is generally momentary and resolves as the stressor abates. When it becomes a constant presence in our lives and is associated with avoidant behaviour and functional limitation, it turns into an anxiety disorder.
Most anxiety disorders start early in childhood or adolescence and restrict normal living. The average age of onset can be as low as 11 years of age.1 They form a significant burden of mental illness in the world and are the sixth leading cause of disability among all physical and mental illnesses.2 According to the Centers for Disease Control, one out of every six (approximately 16%) adults suffer from mild to severe anxiety. About 3% of these suffer from severe anxiety. The spectrum of anxiety disorders includes phobias, generalised anxiety disorder, social phobia panic attacks/disorder, obsessive-compulsive disorder and agoraphobia with the first three being the most prevalent.3
Women are at two to three times greater risk than men. Prevalence rates are highest in young adults and tend to decrease with age.4 These disorders when left untreated give rise to other mental health disorders and often co-exist with depression. The presence of parental mental illness, use of cigarettes, alcohol, and socially avoidant behaviours increase the risk of having an anxiety disorder.5 Physical co-morbidities like hypertension, heart disease, asthma, and diabetes may increase the risk of anxiety disorders.4,6,7
By and large anxiety disorders are underdiagnosed and undertreated.1 The reasons for these include factors both at the provider and patient levels. Patients often present with somatic symptoms like fatigue, sleep disturbance, loss of appetite, poor concentration, and palpitations which mask the underlying anxiety. Symptoms of a panic attack often prompt patients to seek urgent or emergent care.
While health-seeking behaviour for anxiety disorders may be higher,6 optimum utilisation of resources is inadequate i.e., the provider addresses the somatic complaints but the underlying anxiety disorder takes longer to diagnose. Stigma, and socio-economic factors also pose challenges in seeking care especially for patients with generalised and social anxiety disorders.8 Healthcare professionals often fail to diagnose and treat social anxiety disorder.9
Diagnosis of anxiety disorders is therefore challenging. Patients presenting with multiple physical complaints of a chronic nature with normal exam findings and investigations should alert healthcare providers to the presence of an anxiety disorder.
Once diagnosed, treatment should depend on the functional impact anxiety has on the life of the individual. Cognitive behaviour therapy and selective serotonin receptor inhibitors (SSRIs) form the frontline treatment. Anxiety disorders are often managed with anxiolytics like benzodiazepines. While they provide instant relief and are helpful at the start of treatment till SSRI therapeutic effects begin, their use becomes habitual, leading to dependence and tolerance to effects. The role of benzodiazepines as sole agents in the management of anxiety, therefore, needs to be carefully considered. Most literature recommends using benzodiazepines in treatment initiation (short-term) along with SSRIs.9,10 Considered seemingly innocuous, mortality rates are higher among benzodiazepine users.11
It is important to note that anxiety disorders have increased by 25% during the COVID-19 pandemic.12 The economic and social consequences of this pandemic may cause this rise to persist and burden an already stressed mental health system. Other traumatic events, natural disasters, and geopolitical unrest also increase the risk of anxiety disorders.1
The chronic nature of this illness makes primary care physicians best suited to diagnose and manage anxiety disorders to help ease disease burden and improve patient well-being. It appears that healthcare providers give less attention to anxiety disorders as compared to depressive disorders. It is therefore important to increase awareness of the prevalence and functional impact of anxiety disorders in primary care.13
In a developing country like Pakistan, this becomes even more important where only 400-500 psychiatrists provide care to a population of 220 million. Furthermore anxiety rates in Pakistan are higher than global numbers where women, those with low literacy, socio-economic status multimorbidity are at the greatest risk.14
According to the World Health Organisation Pakistan has a large primary care workforce with 5000 basic health units and 6000 rural care centres. It is here that primary care providers encounter patients with anxiety disorders that present for acute and chronic illnesses. These encounters provide the best opportunity to screen for anxiety disorders.
Moreover, the Lancet commission on global mental health also highlights the need to improve the capacity building of non-psychiatrist healthcare providers for community-based care of mental health disorders.15 Of these, anxiety disorders can be easily diagnosed and managed by primary care providers. Community healthcare providers like midwives and lady health visitors can also play an important role in increasing community awareness, diagnosis, and referral.
It is therefore time that primary care providers in Pakistan understand the significant impact of anxiety disorders on the health and well-being of their patients. Understanding their role in the diagnosis and management of anxiety disorders will reduce the burden of this commonly overlooked condition.
The authors declared no competing interest.
AUTHOR’ S CONTRIBUTION:
SS: Wrote the manuscript, added references, and reviewed the manuscript.