Nancy A. Melville

April 18, 2017

SAN FRANCISCO – A behavioral therapy program for the treatment of anxiety in primary care yields benefits to a large patient population who often receive suboptimal treatment – if any at all.

"We know anxiety disorders are much more likely to show up in a primary care setting long before they end up in a specialty mental health setting, and usually that delay can be several years. So, it's an important opportunity to try to treat these anxiety patients right at the primary care level," Craig N. Sawchuk, PhD, of the Mayo Clinic, in Rochester, Minnesota, told delegates attending the Anxiety and Depression Association of America (ADAA) Conference 2017.

The Mayo Clinic's Integrated Behavioral Health psychotherapy program, which is embedded in the system's primary care settings, focuses on providing short-term, evidence-based cognitive-behavioral therapy (CBT) in one to 10 sessions.

One aspect of the program that makes it unique is the detailed tracking of evidence-based interventions and patient outcomes on a session-by-session basis.

Dr Sawchuk described data from June 2014 through February 2017 on five primary care clinics in Rochester, Minnesota.

Of the 928 patients diagnosed with primary anxiety in the sample, 562 received one or more CBT sessions. Treatments included cognitive interventions (85%), exposure therapy (67%), behavioral activation (50%), motivational engagement (45%), skill building (44%), and relaxation (24%).

Patients attended an average of 3.65 sessions over 13.67 weeks. Significant improvements were found from the initial visit to the final session (for all, P < .001) in scores on the Generalized Anxiety Disorder–7 (GAD-7) and the Patient Health Questionnaire–9 (PHQ-9). For the entire sample, the rate of response on the GAD-7 was 35%, and the rate of remission was 23%.

Significant Commitment Required

The tracking data were further stratified according to type of anxiety disorder. In a sample of 298 patients treated specifically for generalized anxiety disorder (GAD), the most common treatment offered was cognitive intervention (90%), followed by exposure therapy (64%) and skill building (47%). Those patients attended an average of 3.24 sessions. Changes on the GAD-7 and PHQ-9 were both significant (all P < .001); 37% of patients achieved response on the GAD-7, and 24% achieved remission.

For those treated for panic disorder (n = 35), the majority received exposure therapy (87%), followed by cognitive (71%), motivational (42%), and relaxation (13%) interventions. The patients attended an average of 3.08 sessions. Significant improvements were seen in scores on the GAD-7 (P < .007) and the PHQ-9 (P < .009); 31% achieved response on the GAD-7, and 13% achieved remission.

Among 43 patients with obsessive-compulsive disorder, interventions included exposure therapy (80%), cognitive therapy (74%), and skill building (37%). The average number of sessions was 5.46. Significant improvements were found on the GAD-7 (P < .001) but not the PHQ-9. GAD-7 response and remission rates were 33% and 22%, respectively.

For patients with posttraumatic stress disorder (PTSD) (n = 26), cognitive therapy was the most common intervention (80%), followed by exposure therapy (70%) and behavioral activation (60%). Patients with PTSD attended the highest average number of sessions (6.10). Changes in scores on the GAD-7 (P < .007) and PHQ-9 (P < .04) were both significant; 23% of patients achieved response on the GAD-7, and 13% achieved remission.

In comparing the results with the Coordinated Anxiety Learning and Management (CALM) trial from 2010, the rates of response and remission for patients with specific anxiety disorders in the Mayo Clinic's sample were lower.

Unlike the findings from the CALM study, the Mayo study's findings are not representative of a highly structured, controlled research study. Instead, they reflect routine practice, which has very little, if any, selection or exclusion criteria, Dr Sawchuk said.

"Routine practice studies such as ours may also result in shorter courses of care than research-funded studies," he told Medscape Medical News.

The improvements are an important indicator of progress that can be made with the inclusion of mental health services in primary care. A critical aspect of that provision is training in evidence-based practices, Dr Sawchuk noted.

The Mayo Clinic conducts weekly psychotherapy case consultations with all primary care psychotherapy providers and monthly psychotherapy training seminars on specific evidence-based approaches, which helps to prevent the tendency for providers to drift back to therapy practices that may not be effective.

"These [efforts] require a significant investment on the part of the institution to allow for protected time for skill development," Dr Sawchuk said.

Serious Lack of Evidence-Based Care

The payoff is an emphasis on evidence-based care, which, particularly for anxiety disorders, is sorely lacking, not just in primary care but among mental health providers in general, he said.

"We know that the interventions known to be least effective for anxiety, such as distraction and, to some degree, relaxation, are in fact used the most frequently, while strategies known to be the most effective – exposure-based interventions ― are used the least, so there is a tremendous quality control issue."

With panic disorder, for example, evidence strongly favors the benefits of exposure therapy, which involves gradual but repeated confrontation of the triggers of the patient's fears.

"Our mantra is to get those patients to exposure therapy as soon as possible," Dr Sawchuk noted.

Research suggests that the use of exposure therapy among providers is low. This may be due to the fact that some providers are not trained in exposure therapy or that providers have fears or misconceptions about the approach, Dr Sawchuk said.

"[Misconceptions] can include that exposure therapy can be harmful, or feel it's not good to make patients upset," he said.

In addition, exposure therapy may require more time and effort than is typically available in primary care practices.

"Some patients may need a bit more help with the groundwork of preparing themselves to do exposures, [such as] motivational engagement exercises.

"However, this is the best treatment we can offer, and therefore, it's our duty to make sure that consumers are made aware of and have access to such treatments."

Praise for Mayo Program

In previous research, Risa B. Weisberg, PhD, and colleagues reported findings that underscore the low utilization of exposure therapy in primary care.

"We found that while a third of patients were receiving psychotherapy, only 13% were getting cognitive techniques, and only 5% received exposure therapy," Dr Weisberg told Medscape Medical News. Dr Weisbert is assistant chief of psychology at the VA Boston Healthcare System and is professor of psychiatry at the Boston University School of Medicine.

She echoed the problem that some practitioners are not comfortable providing exposure therapy.

"Many therapists avoid engaging their patients in exposure, as this treatment technique inherently involves encouraging your patient to become distressed and uncomfortable – which is distressing and uncomfortable to many providers," said Dr Weisberg, who is not involved in the Mayo Clinic program.

Consequently, many turn to the easier option of writing a prescription, as was demonstrated in a study from 2007 by Dr Weisberg's team.

"We found that nearly half of primary care patients with anxiety disorders weren't receiving any treatment; 21% were receiving only pharmacotherapy; 24.5% were receiving both medications and psychotherapy of some sort; and 7% were getting only psychotherapy. So, overall, pharmacotherapy was more common than psychotherapy," she said.

Dr Weisberg underscored the value of the Mayo Clinic's program in addressing many of these shortcomings.

"The wonderful thing about what Mayo Clinic is currently doing is that they are providing in-depth training and continued support to their primary care behavioral providers on how to best treat anxiety," she said.

"Many healthcare systems assume that professionals hired into clinical positions will know which treatments are most effective and how to implement them.

"Mayo Clinic isn't making this assumption – they are providing this training."

The authors and Dr Weisberg have disclosed no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2017. Presented April 7, 2017.

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