title: An examination of the bidirectional relationship between functioning and symptom levels in patients with anxiety disorders in the CALM study.
abstract: BACKGROUND
  Patients with anxiety disorders suffer marked functional impairment in their activities of daily living. Many studies have documented that improvements in anxiety symptom severity predict functioning improvements. However, no studies have investigated how improvements in functioning simultaneously predict symptom reduction. We hypothesized that symptom levels at a given time point will predict functioning at the subsequent time point, and simultaneously that functioning at a given time point will predict symptom levels at a subsequent time point.
  
  
  METHODS
  Patients were recruited from primary-care centers for the Coordinated Anxiety Learning and Management (CALM) study and were randomized to receive either computer-assisted cognitive-behavioral therapy and/or medication management (ITV) or usual care (UC). A cross-lagged panel design examined the relationship between functional impairment and anxiety and depression symptom severity at baseline, 6-, 12-, and 18-month follow-up assessments.
  
  
  RESULTS
  Prospective prediction of functioning from symptoms and symptoms from functioning were both important in modeling these associations. Anxiety and depression predicted functioning as strongly as functioning predicted anxiety and depression. There were some differences in these associations between UC and ITV. Where differences emerged, the UC group was best modeled with prospective paths predicting functioning from symptoms, whereas symptoms and functioning were both important predictors in the ITV group.
  
  
  CONCLUSIONS
  Treatment outcome is best captured by measures of functional impairment as well as symptom severity. Implications for treatment are discussed, as well as future directions of research.
authors.affiliation: Department of Psychology,University of California,Los Angeles,USA.
authors.forename: L A
authors.initials: LA
authors.lastname: Brown
authors.affiliation: Department of Psychology,University of California,Los Angeles,USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Krull
authors.affiliation: University of Washington at Harborview Medical Center,Center for Healthcare Improvement for Addictions,Mental Illness, andMedically Vulnerable Populations (CHAMMP),Seattle,WA,USA.
authors.forename: P
authors.initials: P
authors.lastname: Roy-Byrne
authors.affiliation: RAND Corporation,Santa Monica,CA,USA.
authors.forename: C D
authors.initials: CD
authors.lastname: Sherbourne
authors.affiliation: Department of Psychiatry and Department of Family & Preventive Medicine,University of California,San Diego,USA.
authors.forename: M B
authors.initials: MB
authors.lastname: Stein
authors.affiliation: South Central VA Mental Illness Research Education and Clinical Center,North Little Rock,AK,USA.
authors.forename: G
authors.initials: G
authors.lastname: Sullivan
authors.affiliation: Department of Psychology,University of California,Los Angeles,USA.
authors.forename: R D
authors.initials: RD
authors.lastname: Rose
authors.affiliation: Department of Psychiatry & Biobehavioral Sciences,University of California,Los Angeles,USA.
authors.forename: A
authors.initials: A
authors.lastname: Bystritsky
authors.affiliation: Department of Psychology,University of California,Los Angeles,USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Craske
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D014151:Anti-Anxiety Agents / Q000627:therapeutic use*; D001008:Anxiety Disorders / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D056344:Executive Function; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D011446:Prospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D014151:Anti-Anxiety Agents
keywords: Anxiety; functioning; primary care