Coordinated Treatment Approach Improves Anxiety Symptoms
• Science Update
A coordinated, multi-component treatment approach was more effective in treating anxiety disorders than usual care found in primary care settings, according to an NIMH-funded study published May 19, 2010, in a special issue of the Journal of the American Medical Association devoted to mental health.
Research has found that a collaborative care approach, in which one care manager coordinates a team of treatment providers, is effective in treating depression. However, research is limited on whether the same type of approach could work to treat anxiety disorders, which are commonly treated in primary care settings.
In response, Peter Roy-Byrne, M.D., of the University of Washington Seattle, and colleagues designed a flexible collaborative treatment model for anxiety disorders—Coordinated Anxiety Learning and Management (CALM)—and compared it to usual care. CALM included cognitive behavioral therapy (CBT) that was tailored to any one of four anxiety disorders—panic disorder, generalized anxiety disorder, social anxiety disorder or post traumatic stress disorder. It also included strategies to improve medication delivery and adherence. Of the 1,004 participants recruited from 17 primary care clinics in four U.S. cities, half were randomized to CALM and were allowed to choose whether they received CBT, medication, or both. The other participants were referred to usual care which could include medication, brief counseling with a physician, or referral to a mental health specialist. All participants were diagnosed with at least one of the four anxiety disorders addressed in the CBT program.
CALM participants received their initial treatment for 10 to 12 weeks. Those who still had symptoms after 12 weeks could receive additional CBT or medication, or both. They then received monthly follow-up phone calls to reinforce CBT skills or medication management advice for up to a year.
CALM relied on a computerized program to help train care managers in CBT techniques and ensure consistency of care. The computer program employed CBT principles common to all anxiety disorders, but included specific techniques designed to address the four anxiety disorders in the study, thus allowing for personalized treatment.
Care managers also encouraged participants to stay in treatment and monitored their reactions to medication, relaying any observations and suggestions for changes to the primary care provider. CALM tracked participants' progress and outcomes through a web-based monitoring system as well.
Results of the Study
Participants in the CALM group showed significantly greater symptom improvement than those receiving usual care. After 12 months, about 63.6 percent receiving CALM had responded to treatment compared to 44.7 percent in usual care, and 51.5 percent receiving CALM had remitted compared to 33 percent in usual care.
CBT appeared to be the most popular treatment choice among those in the CALM group—57 percent chose CBT and medication combination treatment, and 34 percent chose CBT-only treatment, while 9 percent chose medication-only treatment. This preference is consistent with research that finds those with anxiety disorders tend to favor psychosocial treatment approaches over medication to treat their illness, said the researchers.
Because CALM included flexible treatment options, targeted multiple anxiety disorders, and was effective across a range of patients and clinics, it is broadly applicable in primary care settings. It could serve as a model for developing effective collaborative care of people with anxiety disorders as well as those with coexisting psychiatric disorders like depression, a situation commonly found in clinical settings.
Research is needed to determine how the strategy could best be implemented in primary care settings. In addition, a cost analysis of CALM is needed to determine whether it is a financially feasible option for payers and clinical settings.
Roy-Byrne P, Craske MG, Sullivan G, Rose RD, Edlund MJ, Lang AJ, Bystritsky A, Welch SS, Chavira DA, Golinelli D, Campbell-Sills, L, Sherbourne CD, Stein MB. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial. Journal of the American Medical Association. 19 May 2010. 303(19).