Flexible treatment intervention associated with greater improvement in anxiety symptoms

Peter Roy-Byrne, M.D., of the Uni­versity of Washington School of Medicine, Seattle, presented the findings of the study at a JAMA media briefing on mental health.

"Improving the quality of mental health care requires continued efforts to move evidence-based treatments of proven efficacy into real-world practice settings with wide variability in patient characteristics and clinician skill. The effectiveness of one approach, collaborative care, is well established for primary care depres­sion, but has been infrequently studied for anxiety disorders, despite their common occurrence in primary care," the authors write.

Dr. Roy-Byrne and colleagues conducted a study to examine whether a flexible treatment delivery intervention in primary care would be better than usual care (UC) in reduc­ing symptoms of anxiety and in improving certain measures of functioning, health-related quality of life, and quality of care de­livered for the 4 most common anxiety disorders -- panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress dis­order (PTSD). The intervention the researchers designed, Coordinated Anxiety Learning and Management (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. "In this way, CALM seeks to accommodate the complexity of real-world clinical settings, while maximiz­ing fidelity to the evidence-base in the context of a broad range of patients, cli­nicians, practice settings, and payers," the authors write.

The randomized controlled effectiveness trial of CALM compared with usual care took place in 17 primary care clinics in 4 U.S. cities. Between June 2006 and April 2008, 1,004 patients with anxiety disorders (with or without major depression), ages 18 to 75 years, were enrolled and subsequently received treatment for 3 to 12 months. Follow-up assessments at 6,12, and 18 months after the beginning of the trial were completed in October 2009. Anxiety symptoms were measured with the 12 item Brief Symptom Inventory (BSI-12).

The researchers found that the scores on measures of anxiety symptoms were significantly lower for patients in the intervention group at 6 months, 12 months and 18 months. "At 12 months, response and remission rates (CALM vs. UC) were 63.66 percent vs. 44.68 percent, and 51.49 percent vs. 33.28 percent, with a number needed to treat of 5.27 for response and 5.50 for remission."

"The flexibility of treatment (e.g., varia­tion in number and type of sessions, and in criteria for continuing further treat­ment, use of both telephone and in-person contact), the targeting of multiple disorders, and the clinical ef­fectiveness across a range of patients and clinics suggest that the CALM treat­ment delivery model should be broadly applicable in primary care. However, implementation of this model will re­quire reimbursement mechanisms for care management that are not cur­rently available," the authors write.

"Nonetheless, the success of the model tested here demonstrates that addressing mul­tiple common mental disorders in the context of one delivery model is fea­sible and effective and could serve as a template for the development of uni­fied approaches to management of the multiple psychiatric comorbidities that are the rule rather than the exception in both the general population and in clinical practice."