An intervention in primary care settings that allowed a choice of cognitive behavior therapy, medication, or both, along with computer-assisted treatment support for patients with common anxiety disorders, resulted in greater improvement in anxiety symptoms and functional disability compared to usual care, according to a study in the May 19 issue of JAMA, a theme issue on mental health.
Peter Roy-Byrne, M.D., of the Uni-versity of Washington School of Medicine, Seattle, presented the findings of the study at a JAMA media briefing on mental health.
"Improving the quality of mental health care requires continued efforts to move evidence-based treatments of proven efficacy into real-world practice settings with wide variability in patient characteristics and clinician skill. The effectiveness of one approach, collaborative care, is well established for primary care depres-sion, but has been infrequently studied for anxiety disorders, despite their common occurrence in primary care," the authors write.
Dr. Roy-Byrne and colleagues conducted a study to examine whether a flexible treatment delivery intervention in primary care would be better than usual care (UC) in reduc-ing symptoms of anxiety and in improving certain measures of functioning, health-related quality of life, and quality of care de-livered for the 4 most common anxiety disorders-panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress dis-order (PTSD). The intervention the researchers designed, Coordinated Anxiety Learning and Management (CALM), allowed choice of cognitive behavioral therapy (CBT), medi-cation, or both; included real-time Web-based outcomes monitoring to optimize treat-ment decisions; and a computer-assisted program to optimize delivery of CBT by non-expert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. "In this way, CALM seeks to accommodate the complexity of real-world clinical settings, while maximiz-ing fidelity to the evidence-base in the context of a broad range of patients, cli-nicians, practice settings, and payers," the authors write.
The randomized controlled effectiveness trial of CALM compared with usual care took place in 17 primary care clinics in 4 U.S. cities. Between June 2006 and April 2008, 1,004 patients with anxiety disorders (with or without major depression), ages 18 to 75 years, were enrolled and subsequently received treatment for 3 to 12 months. Follow-up assessments at 6,12, and 18 months after the beginning of the trial were completed in October 2009. Anxiety symptoms were measured with the 12 item Brief Symptom Inventory (BSI-12).
The researchers found that the scores on measures of anxiety symptoms were significantly lower for patients in the intervention group at 6 months, 12 months and 18 months. "At 12 months, response and remission rates (CALM vs. UC) were 63.66 percent vs. 44.68 percent, and 51.49 percent vs. 33.28 percent, with a number needed to treat of 5.27 for response and 5.50 for remission."
"The flexibility of treatment (e.g., varia-tion in number and type of sessions, and in criteria for continuing further treat-ment, use of both telephone and in-person contact), the targeting of multiple disorders, and the clinical ef-fectiveness across a range of patients and clinics suggest that the CALM treat-ment delivery model should be broadly applicable in primary care. However, implementation of this model will re-quire reimbursement mechanisms for care management that are not cur-rently available," the authors write.
"Nonetheless, the success of the model tested here demonstrates that addressing mul-tiple common mental disorders in the context of one delivery model is fea-sible and effective and could serve as a template for the development of uni-fied approaches to management of the multiple psychiatric comorbidities that are the rule rather than the exception in both the general population and in clinical practice."
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