Why Aren’t We Getting Better?

Experts say that anxiety is highly treatable. So why aren't more people getting better?

Taylor worked as a therapist in a group practice, which was furnished in a Wayfair-sourced, minimalist style that provoked my envy. Everywhere you looked there were structurally unsound blue velvet sofas, wobbly faux-driftwood coffee tables, and framed, old-timey maps with zero significance. I left the practice every week thinking, with great resolve, “I just need to buy more house plants, and then my apartment will be beautiful like my therapist’s office.”

I had never seen a therapist who was as demographically similar to me as Taylor. She was a PhD student. She did not yet have her license, and was practicing under the supervision of a more experienced therapist. She sat in her office, Ugg boots off, fuzzy socks rolled over her yoga pants, a giant Starbucks-branded tumbler on her desk. We had probably learned to apply flicks of eyeliner from the same YouTube videos. When we scrolled through social media, we received the same targeted ads.

Our similarities proved too beguiling for us both. When I spoke about my relationship, Taylor spoke about her relationship. When I described my anxiety, Taylor noted points of comparison with her own. When I said that I wanted children but had some concerns, she said that she had children and honestly, it was pretty doable. She had been diagnosed with ADHD as an adult. She asked if I was familiar with the idea that many women have lifelong ADHD which has been overlooked. I was familiar. Taylor suspected that I was also one of these women. Even though Taylor was most of the way through with a PhD in clinical psychology, I felt strongly that we had both learned about this matter on TikTok.

Sometimes Taylor offered insightful reframing of my thinking, though I can no longer remember many examples of this. Together, we helped her achieve the appropriate number of hours of clinical supervision to get her license.

In an early session, Taylor off-handedly referred to my anxiety as “treatment resistant.” I was shocked and hurt. No therapist, psychiatrist, or primary care doctor had used this language with me before. She meant, I guess, that I had been diagnosed with an anxiety disorder years earlier, and that despite going to therapy and taking daily medication I still had an anxiety disorder. Her words collapsed my years of attempting to relieve my anxiety into exercises in failure.

I comforted myself that Taylor’s indelicacy spelled an uphill battle for her in her chosen profession of helping people. But eventually I heard the bracing clarity in Taylor’s words: I had an anxiety disorder, and it wasn’t getting better, despite following the general recommendations for someone with my disorder (get a therapist, take medication, download various apps filled with mistranslated Zen koans.)

This is the question I am trying to explore in my writing and reporting: if anxiety disorders are so common, and if they are regarded as “highly treatable,” and if they are subject to less stigma than they once were, why aren’t more people who have anxiety disorders getting better? By “better” I mean—why aren’t more people experiencing a reduction of symptoms, and even remission?

To put it more simply: why aren’t I better? And for the many, many other people who feel this way, is change possible?

Anxiety disorders: a slog!

Let’s first establish that a lot of people have anxiety disorders, and that for many people, these disorders do not abate for years, if ever. At this point, I am sorry to say, I have no choice but to cite some statistics.

About 20% of Americans have an anxiety disorder at any given time. The lifelong prevalence of anxiety disorders in the U.S. is closer to 30%. Hidden in that second, painfully high percentage is a sliver of hope: anxiety disorders can come and go.

How often do they come and go? In the early 2000s, researchers at Harvard and other institutions that are always motivating fictional tweens to write inspiring application essays, spent two years doing comprehensive, sit-down interviews with a cross section of over 9,000 Americans about their mental health. This was the National Comorbidity Survey Replication, or NCS-R.

Around 600 of these interview subjects reported having symptoms of Generalized Anxiety Disorder for more than a year. During the two year study, about 41% of those 600 people “experienced full remission” at one point. That means that nearly 60% of people still had an anxiety disorder after two years! And many of the people who did experience remission during the survey subsequently had a “recurrence of symptoms” during the survey period.

That’s just Generalized Anxiety Disorder, which is only one member of a family of anxiety disorders that includes phobias, social anxiety disorder, panic disorder, and others. With panic disorder (PD) and with panic disorder with agoraphobia (PDA) one analysis found that people with PD have a 75% chance of remission in three years, 67% for people with PDA. Of the people who experienced remission, 12% of people with PD relapsed, and about 21% of people with PDA did. Estimates for remission from Social Anxiety Disorder are 50% for full remission, 79% for partial remission.

Personally, seeing these numbers severed from real lives causes me to feel sleepy. To put a human face on these numbers, I think about the people I’ve interviewed who get panic attacks. I think most of them would say that even partial remission—say, going from weekly to quarterly panic attacks—would be a quality of life increase on par with moving to a Nordic country or adopting a perfectly behaved, model-gorgeous Golden Retriever. Still, if approximately a quarter of people with Panic Disorder don’t achieve remission in three years, I think it’s worth asking—could they have achieved remission if they had better access to treatment? Or if they had access to better treatment? Or if they just knew more about what kind of treatment to seek?

The studies I listed tell us that a lot of people with anxiety disorders do get better, and many don’t, and that a lot of people get better for a while, and then suffer again. What they don’t tell us is how many of those people were able to get treatment at all.

The problem with “asking for help”

For a few years, the cause of destigmatizing mental health care has given politicians, celebrities, and medical professionals the opportunity to plead with the public to “ask for help” when we need it. That’s good! They should keep doing this! I hope Demi Lovato is writing a poignant ballad about this as we speak! For a lot of people, though, there is no one to ask.

More than 2 in 5 Americans who needed mental health care in the previous year did not receive care, a 2022 Harris Poll found. (As a point of comparison, 1 in 5 said the same thing about medical care.) The top reasons: cost, and inability to find a reasonably located provider.

Insurance won’t save you from this problem. More than 40% of adults who have insurance and who describe their mental health as “fair or poor” were unable to get mental health care or medication when they needed it at least once in the last year, a 2023 survey from KFF found.

Poor people struggle to access mental health care. Middle class people struggle to access mental health care. Even relatively rich people often struggle to access mental health care. In a high cost of living area, even a white collar salary will only stretch so far to accommodate months or years of weekly therapy with a practitioner who does not take insurance.

Americans congratulate ourselves on stigmatizing mental health less than we once did.But actually accessing mental health care remains a luxury. An even greater luxury is accessing quality mental health care. That brings us to our next problem. If you are able to “get help” for your anxiety disorder, it won’t necessarily help you.

What treatment did I resist?

A few months after Taylor became my therapist, she told me that she was moving to another city. She understood, she said, that this could mark a painful disruption in my mental health care. She wanted to do everything she could to make the transition as smooth as possible for me. She would be willing to meet with me over Zoom for a period to help me adjust. But I experienced no difference in my life whatsoever when I stopped seeing Taylor.

Taylor identified me as a person who has “treatment resistant” anxiety. I’m not sure that she was right. The first line treatments for anxiety disorders are Cognitive Behavioral Therapy and SSRIs. One estimate is that 60% of people with anxiety disorders see a significant positive response to these treatments. A more recent study that followed adults with anxiety disorders and depression found that, ten years after receiving a full course of CBT, 63% were in remission from their anxiety disorders.

Despite constant claims from researchers and clinicians that CBT is the gold standard treatment for people with anxiety disorders, there is little research on how many people who have anxiety disorders actually get Cognitive Behavioral Therapy. It’s also not clear how many therapists in the U.S. actually use CBT in their practice. Taylor, for example, did not use CBT.

Most people who pursue treatment for anxiety disorders never find out if they’re in the roughly 40% of people who have a significant positive response to SSRIs and CBT because they do not get a full course of those treatments. Peter Roy-Byrne, a professor of psychiatry at the University of Washington, writes about the difference between “true treatment resistance” and “pseudo-resistance.” He explains:

“Patients with “pseudo-resistance” have not actually received sufficient treatment, either because the type of treatment was wrong (ie, ineffective for the anxiety diagnosis), the “dose” (for medication) or the way the treatment was delivered (for psychotherapy) was insufficient, or the patient was nonadherent (failing to take medication or perhaps failing to engage sufficiently in the psychological treatment, eg, not doing CBT homework).”

Who actually gets enough high-quality, consistent treatment that they find out that they are actually “treatment resistant”? Not too many people. In one survey of 1,000 Americans who were diagnosed with anxiety by primary care doctors, the majority received anti-anxiety medication, and nearly half received “some counseling with at least 1 element of CBT.” Only about a fifth received the real, rigorous CBT that has high rates of relieving anxiety. Less than 10% of patients had received both appropriate counseling and appropriate medication doses.

“Delivering CBT with high fidelity is much more difficult than prescribing medication effectively,” Roy-Byrne notes. SSRIs AND SNRIS are at least pretty effective, but as Roy-Byrne points out, many clinicians’ “failure to prescribe a sufficient dose and, even more often, to wait an adequate duration before giving up” means that a lot of anxious people don’t get to reap the benefits of their SSRI.

For many, seeking help for anxiety means getting an SSRI. For some people, it also means finding the first practitioner who you can afford and has a friendly face and an opening in their schedule. It means working with that therapist until you feel better, or run out of money, or life gets in the way. For a number of people, this combination gives them their life back.

Everyone else is wandering around buying journals and self-medicating with other substances and Googling “tae kwon do for anxiety” and hoping it goes away soon. Many of these persistently anxious people people have, according to Alexander Bystritsky, the former director of the UCLA anxiety disorders program, a “very poor quality of life and have highest rate of suicidal attempts than any other disorders.”

Even to me, a person who has perhaps too strong an identification with my own anxiety, it is hard to accept that anxiety disorders cause that extreme level of suffering. In the popular imagination, an anxiety disorder is whatever Larry David has. Bystritsky’s claims are nicely illustrated by Andrew Solomon, who said, comparing his experiences with anxiety and depression:

If someone told me I had to be depressed for the next month, I would say that as long as I knew it was temporary, I could do it. But if someone told me I had to have acute anxiety for the next month, I would kill myself, because every second of it is intolerably awful. It is the constant feeling of being terrified and not knowing what you’re afraid of.

Let’s name a few overarching problems here:

1. In America, many people cannot get the mental health care they need.

2. Many people who do access mental health care for anxiety do not improve sufficiently, or at all.

And one more problem, which I’ve written about a few times: these conditions push people to engage in generic wellness and self-care practices, which usually means buying products, some of which are based on junk science. (But they’re fun!)

In college, instead of drinking alcohol or having sex, I often watched the TV show Grey’s Anatomy. I was in New York City, so spectacular art was being born yards away from me at any given time, and I was always being like, “These doctors are so good at surgery! I hope they kiss soon!”

Every few episodes, the surgeons on the show were faced with a tumor that was exceptionally rare and massive. Seeing the tumor on CT scans caused their beautifully sculpted faces to contort, and their large and interestingly shaped eyes to widen in awe. They itched to extract the tumor, and they knew that the odds of their success were low.

My anxiety disorder puzzles me because—I felt in college and I feel now—it is nothing like those tumors. It is not rare or special or complex. It is the same thing that is plaguing millions of other people, that is employing all of these therapists and counselors and psychiatrists, that is inspiring memes that launch a thousand “it me” comments. My anxiety disorder is treatable. Probably, so is yours.

If yours is also not getting better, it could be because of the three issues I named above: lack of access, lack of high quality, competent care, and lack of buy-in on your part that results in reaching for shoddy, quick-fix solutions.

I want to demonstrate that the situation I and so many other people find ourselves in is common, wrong, and fixable.

People often say, “The definition of insanity is doing the same thing over and over and expecting different results.” And then other people often say, “No, that is not the definition of insanity, someone just made that up and people seem to find it comforting.” Encouraging people who suffer from anxiety to pursue treatment is good advice. It is certainly better than the advice that preceded it, which was, “You’re fine, stop complaining.”

But it is frustrating—it even feels cruel—to hear well-meaning people and institutions bleat the same advice about anxiety disorders without considering the somewhat obvious pitfalls that cause these solutions to fail or not even reach so many people.

When I think about the hours I spent with Taylor, I think, of course: “When will I get a blue velvet sofa and other charming home decor items?” But I also think that both of us needed better therapists, and a clearer plan for our care.

And I remain hopeful that those things are still in our future.