The American Journal of Managed Care-April (2010)

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The mean Liebowitz Social Anxiety Scale score for all subjects with generalized social anxiety disorder was 74 68 for those with pure generalized social anxiety disorder and 82 for those with comorbid psychopathology. The mean age at onset of generalized social anxiety disorder was For subjects with generalized social anxiety disorder and comorbid depression, the mean age at onset of major depression was Subjects were asked which came first, generalized social anxiety disorder or the comorbid diagnosis; Generalized social anxiety disorder occurred first i.

For the remaining subjects, the comorbid diagnosis either preceded generalized social anxiety disorder The annual direct costs of health care services utilization are presented in Table 2. Subjects with pure generalized social anxiety disorder made significantly more outpatient visits than those with no diagnosis but not more than subjects with pure major depression. Subjects with generalized social anxiety disorder and comorbid psychopathology also made significantly more clinic visits than those with no diagnosis.

Similar findings were observed for total medical expenditures, but only the differences between generalized social anxiety disorder subjects with comorbid psychopathology and subjects with no diagnosis were statistically significant. Analysis of wages indicated that severity of generalized social anxiety disorder i.

Severity of generalized social anxiety disorder was not associated with different rates of employment or hours of work.

The patient-centered medical home in the Veterans Health Administration. - PubMed - NCBI

Compared with the no-diagnosis group, subjects with pure generalized social anxiety disorder had significantly greater impairment in work and home productivity and significantly greater overall work impairment Table 3. Subjects with generalized social anxiety disorder and comorbid psychopathology missed a greater percentage of work time because of health than did those in the no-diagnosis group. Subjects with pure major depression had significantly greater impairment than did subjects with pure generalized social anxiety disorder in terms of percentage of work hours missed, work productivity, home productivity, and overall work impairment.

Current disability associated with generalized social anxiety disorder was measured with the Liebowitz Self-Rated Disability Scale and the Sheehan Disability Scale. On the Liebowitz Self-Rated Disability Scale, subjects with pure generalized social anxiety disorder rated themselves significantly more impaired in terms of current moderate alcohol use, family relations, romantic relationships, and social network than did those with no diagnosis Table 3. Subjects with generalized social anxiety disorder and comorbid psychopathology also reported significantly greater impairment in these domains as well as in employment than did those with no diagnosis.

Subjects with major depression alone were significantly more impaired than subjects with pure generalized social anxiety disorder in terms of employment, family relations, romantic relationships, and desire to live Table 3. However, when asked about lifetime disability, there were no significant differences between subjects with depression and those with pure generalized social anxiety disorder. On the Sheehan Disability Scale, the highest disability scores across all categories of work, social life, family functioning, and total disability were observed in subjects with generalized social anxiety disorder and comorbid psychopathology Table 3.

In addition, Sheehan Disability Scale scores indicated significantly greater impairment for subjects with pure generalized social anxiety disorder compared with subjects who had no diagnosis. Subjects with pure generalized social anxiety disorder reported significantly lower health-related quality of life than those with no diagnosis on all subscales of the Short-Form General Health Survey except physical functioning, bodily pain, limitations in role functioning resulting from physical problems, and the standardized physical component Table 3.

Subjects with generalized social anxiety disorder and comorbid psychopathology also showed significantly greater impairment than those with no diagnosis on all the Short-Form General Health Survey subscales except the standardized physical component. Subjects with pure major depression exhibited greater impairment than did subjects with pure generalized social anxiety disorder on all subscales.

During the month before participating in the survey, a significantly greater percentage of subjects with pure generalized social anxiety disorder than of subjects with no diagnosis endorsed thoughts that they would be better off dead or thoughts of suicide Among subjects with pure generalized social anxiety disorder, Generalized social anxiety disorder is among the most prevalent—albeit underrecognized and undertreated—psychiatric disorders in the community.

This study is the first to our knowledge to report direct and indirect costs of generalized social anxiety disorder in managed care. The demographic profile is congruent with other social anxiety disorder samples. The median age at onset of generalized social anxiety disorder The slight overrepresentation of female subjects is similar to other epidemiological studies.

Moreover, most subjects in this survey had generalized social anxiety disorder that was of a severity similar to that of patients seeking treatment. For example, the Liebowitz Social Anxiety Scale mean score of 74 in this population is comparable to the mean baseline pretreatment Liebowitz Social Anxiety Scale score Pure generalized social anxiety disorder was associated with significantly lower health-related quality of life and substantially impaired occupational functioning. However, subjects with generalized social anxiety disorder and comorbid psychopathology were even more impaired.

Lifetime suicide attempt rates were as great in subjects with pure generalized social anxiety disorder as they were in subjects with current major depression.


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This is in contrast to the findings of Schneier and associates 3 , who did not find higher suicide attempt rates in patients with social anxiety disorder. Unlike our study, Schneier et al. Our finding that generalized social anxiety disorder is associated with substantial indirect costs is consistent with the recent economic analysis of the National Comorbidity Survey Generalized social anxiety disorder is also associated with substantially decreased hourly wages and higher health service utilization.

We computed the impact of generalized social anxiety disorder on educational and occupational attainment, controlling for age and gender Figure 2. In addition, the probability that a person with average-severity generalized social anxiety disorder holds a technical, professional, or managerial job is 14 percentage points lower than that of an otherwise healthy individual.

Combined with our observation that generalized social anxiety disorder can begin in preadolescence, these findings underscore the profound effect on lifetime achievement.

We recognize several limitations of this study. All participants were members of the Dean Health Plan. To be a member, one must be employed or directly related to an employee member.

The patient-centered medical home in the Veterans Health Administration.

As a result, this population is less likely to include individuals with generalized social anxiety disorder that is severe enough to preclude employment, thus understating the total impact of generalized social anxiety disorder in the community. In the ECA database, Because of the substantial comorbidity in our population and the unclear extent of the contribution of generalized social anxiety disorder to effects in subjects with comorbid diagnoses, it is difficult to assess the overall effect of generalized social anxiety disorder.

However, generalized social anxiety disorder was the psychiatric disorder that occurred first in Some forms of comorbidity e. We attempted to separately analyze subjects with pure generalized social anxiety disorder and to use regression analysis to control for psychiatric comorbidity.

In addition, some of the impact of generalized social anxiety disorder could have been associated with psychiatric comorbidity e. There is a probable sampling bias in the study, since a greater percentage of subjects agreeing to be contacted than of subjects who asked not to be contacted screened positive for social anxiety disorder An adjustment was made to compensate for this sampling bias in calculating the overall prevalence rate of generalized social anxiety disorder.

For the same reason, the no-diagnosis group may include individuals with more psychopathology than the true underlying population. It is also possible that individuals who screened positive for social anxiety disorder were more likely to return the questionnaire, although it is not possible to adjust for this bias. An important secondary outcome is the development of a brief and psychometrically sound screening tool for generalized social anxiety disorder. The three-item version actually improved the sensitivity and specificity over the longer version and should provide a valuable tool for both research and clinical care.

We found that generalized social anxiety disorder is prevalent and severe in a managed care population but is undiagnosed and undertreated. Generalized social anxiety disorder is associated with lower health-related quality of life, a higher rate of lifetime suicide attempts, diminished educational and occupational attainment, and higher utilization of health care resources. The magnitude of these effects and the societal burden of generalized social anxiety disorder are similar to those of depression. Because our findings suggest that generalized social anxiety disorder in managed care populations is similar in quality and severity to generalized social anxiety disorder studied in research treatment settings, it would be worthwhile to study whether interventions that have been shown to be efficacious in the research environment can be translated effectively to primary care patients.

Given the chronic nature of generalized social anxiety disorder in this managed care sample and the likelihood that associated functional impairment may take longer to respond to treatment than symptoms alone do, long-term trials are needed to most meaningfully assess the impact of treatment. Such studies will help determine if the psychiatric comorbidity, reduced quality of life, impaired social and occupational functioning, and greater health care utilization associated with generalized social anxiety disorder can be substantially improved through the use of established treatments.

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