Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.
BACKGROUND
Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders.


OBJECTIVE
To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC).


METHODS
A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009.


METHODS
CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications.


METHODS
Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6).


RESULTS
A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission.


CONCLUSIONS
For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up.


BACKGROUND
clinicaltrials.gov Identifier: NCT00347269.
Roy-Byrne
Peter
P
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations, Seattle, Washington 98104, USA. roybyrne@u.washington.edu
Craske
Michelle G
MG
Sullivan
Greer
G
Rose
Raphael D
RD
Edlund
Mark J
MJ
Lang
Ariel J
AJ
Bystritsky
Alexander
A
Welch
Stacy Shaw
SS
Chavira
Denise A
DA
Golinelli
Daniela
D
Campbell-Sills
Laura
L
Sherbourne
Cathy D
CD
Stein
Murray B
MB
D000328:Adult; D001008:Anxiety Disorders / Q000628:therapy*; D015928:Cognitive Behavioral Therapy; D003131:Combined Modality Therapy; D004358:Drug Therapy; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D011569:Psychiatric Status Rating Scales; D011787:Quality of Health Care; D011788:Quality of Life; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy*; D016896:Treatment Outcome