title: Implementation of the CALM intervention for anxiety disorders: a qualitative study.
abstract: BACKGROUND
  Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) []) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed?
  
  
  METHODS
  Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes.
  
  
  RESULTS
  Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS.
  
  
  CONCLUSIONS
  The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.
authors.affiliation: Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA. currangeoffreym@uams.edu
authors.forename: Geoffrey M
authors.initials: GM
authors.lastname: Curran
authors.forename: Greer
authors.initials: G
authors.lastname: Sullivan
authors.forename: Peter
authors.initials: P
authors.lastname: Mendel
authors.forename: Michelle G
authors.initials: MG
authors.lastname: Craske
authors.forename: Cathy D
authors.initials: CD
authors.lastname: Sherbourne
authors.forename: Murray B
authors.initials: MB
authors.lastname: Stein
authors.forename: Ashley
authors.initials: A
authors.lastname: McDaniel
authors.forename: Peter
authors.initials: P
authors.lastname: Roy-Byrne
mesh_terms: D001008:Anxiety Disorders / Q000188:drug therapy / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000458:organization & administration*; D003131:Combined Modality Therapy / Q000379:methods*; D003142:Communication; D003153:Community Health Services; D003299:Cooperative Behavior; D004059:Diffusion of Innovation; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration; D009042:Motivation; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration; D010820:Physicians / Q000523:psychology* / Q000592:standards; D011320:Primary Health Care; D036301:Qualitative Research; D012959:Socioeconomic Factors; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy*