Flexible anxiety treatment delivers better than usual care
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Treating anxiety-related disorders with or without depression via a flexible treatment regimen in a primary care setting may result in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up, according to study results.
Researchers conducted a randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with usual care in 17 primary care clinics in four U.S. cities. Patients were referred to the study by their internists or family practitioners and all had anxiety disorders (panic, generalized anxiety, social anxiety, or post-traumatic stress).
CALM allows patients to choose cognitive behavioral therapy (CBT), medication, or both. It includes 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.
Between June 2006 and April 2008, 1,004 patients with anxiety disorders (with or without major depression) received treatment for three to 12 months. Blinded follow-up assessments at six, 12 and 18 months after baseline were completed in October 2009 using a 12-item Brief Symptom Inventory (BSI-12) score. Secondary outcomes included response (>50% reduction from pretreatment BSI-12 score) or remission (total BSI-12 score <6).
A significantly greater improvement in global anxiety symptoms was found for CALM over usual care, measured by medication, counseling or referral to a mental health specialist. The mean differences in BSI-12 between groups were −2.49 (95% 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 six, 12 and 18 months, respectively.
At 12 months, response and remission rates (CALM vs. usual care) were 63.66% (95% CI, 58.95% to 68.37%) versus 44.68% (95% CI, 39.76% to 49.59%), and 51.49% (95% CI, 46.60% to 56.38%) versus 33.28% (95% CI, 28.62% to 37.93%), with a number needed to treat of 5.27 (95% CI, 4.18 to 7.13) for response and 5.50 (95% CI, 4.32 to 7.55) for remission. The number needed to treat was within the range of other treatments considered effective, and effects lasted for at least a year, study authors concluded. The study was published in the May 19 Journal of the American Medical Association.
Flexibility in the number and types of session, criteria for continuing therapy, targeting multiple disorders, and effectiveness across a range of primary care settings suggest the model could be applied elsewhere. Study limitations include a patient population referred by their doctors, one-third of whom had failed at least one drug regimen and who were relatively well-educated. Because the treatment was a blend, it is not known which components resulted in efficacy.