Flexible Treatment Intervention Significantly Better Than Usual Care for Anxiety Disorders in Primary Care

Pam Harrison

May 19, 2010

May 19, 2010 — A flexible program designed to treat 4 common anxiety disorders in primary care leads to significantly greater improvement in anxiety symptoms and functional disability compared with usual care, new research suggests.

Peter Roy-Byrne, MD, University of Washington School of Medicine, Seattle, and colleagues found that at 12 months, 63.6% of patients randomized to the Coordinated Anxiety Learning and Management (CALM) program responded to treatment compared with 44.6% of those who received usual care. Some 51.4% of CALM recipients were also in remission at the same assessment point compared with 33.2% of usual care recipients.

"One of the challenges of delivering different evidence-based treatments in primary care is that there are too many different programs, and physicians were telling us that they wanted one program for psychiatry," Dr. Roy-Byrne told Medscape Psychiatry.

"Since anxiety disorders have a lot in common, we designed a specialized cognitive behavior program, which was very simple to deliver and which makes it much easier to train people to do, and it allowed us to look at multiple disorders in a single, manageable way," he added.

The study is published in the May 19 mental health theme issue of the Journal of the American Medical Association.

Lower Anxiety Scores

Between June 2006 and April 2008, 1004 patients with anxiety disorders with or without major depression received treatment for 2 to 12 months. The CALM model addresses the 4 most common anxiety disorders, including panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress disorder with or without comorbid depression.

The CALM modality also allows patients to choose their preferred treatment modality, including pharmacotherapy, cognitive behavioral therapy (CBT), or both, plus it allows for additional treatment when needed.

Patients in the CALM group initially received their preferred treatment for 10 to 12 weeks, whereas patients in the usual care group continued to be treated by their physician in the usual manner with medication, brief counseling, or referral to a mental health specialist.

The primary outcome measure was a generic measure of 2 key components of all anxiety disorders, psychic and somatic anxiety, assessed by the 12-item Brief Symptom Inventory (BSI-12) subscales for anxiety and somatization.

BSI-12 scores were significantly lower for patients in the CALM group at 6 months, with a mean difference of −2.49 points (P < .001), as well as at 12 months, at a mean difference of −2.63 points (P < .001), and again at 18 months, at a mean difference of −1.63 points (P = .05).

At 18 months, more patients at 64.6% randomized to the CALM intervention had responded to treatment compared with 51.4% of those assigned to usual care, whereas 51% and 36.7% of patients in the CALM vs usual care groups were in remission.

"Outcome measures for patients in the intervention group were significantly better for all other measures, except physical health and satisfaction with medical care," the investigators add.

Table. Proportion of Patients Achieving Response/Remission From Baseline

  CALM, % Usual Care, % No. Needed to Treat P Value
Response at 12 months 63.6 44.6 5.27 <.001
Remission at 12 months 51.4 33.2 5.50 <.001

CALM = Coordinated Anxiety Learning and Management

More Than Medication

The CALM intervention, especially the CBT component of it, which was developed by Michelle Craske, PhD, is probably the reason the intervention proved much more effective than usual care.

"Nobody gets anything but medication or maybe some very nonspecific counseling in primary care for the most part," said Dr. Roy-Byrne.

On the other hand, the CALM program was not developed for trained therapists but for nurses and allied healthcare practitioners who had clinical experience but who knew nothing about CBT.

This suggests that the program can both teach psychotherapy to unskilled healthcare practitioners and teach them to do it effectively, said Dr. Roy-Byrne. Barriers to more widespread implementation of the CALM program are largely issues of reimbursement, he added.

However, some insurers have worked out a mechanism by which collaborative care for the treatment of depression is being reimbursed, and these same mechanisms could be put into place for the treatment of anxiety disorders in primary care.

"We know that CBT is an important component in the treatment of anxiety and that it is at least as good as medication in most studies and it may even have more long-lasting effects, so this kind of collaborative approach has been around for a few decades, we just adopted it for anxiety disorders," he said.

Dr. Roy-Byrne received research grant support from the National Institutes of Health and has served as a paid member of advisory boards for Jazz Pharmaceuticals and Solvay Pharmaceuticals on one occasion each. He also received honoraria for CME-sponsored speaking engagements from the American Psychiatric Association, the Anxiety Disorders Association of America, CME LLC, CMP Media, Current Medical Directions, Imedex, Massachusetts General Hospital Academy, and PRIMEDIA Healthcare.

JAMA. 2010;303:1921-1928.

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