A quality improvement project aimed at adapting primary care to ensure the delivery of evidence-based psychotherapy for adult anxiety

Abstract

Primary care patients frequently present with anxiety with prevalence ratios up to 30%. Brief cognitive–behavioural therapy (CBT) has been shown in meta-analytic studies to have a strong effect size in the treatment of anxiety. However, in surveys of anxious primary care patients, nearly 80% indicated that they had not received CBT. In 2010, a model of CBT (Coordinated Anxiety Learning and Management (CALM)) adapted to primary care for adult anxiety was published based on results of a randomised controlled trial. This project aimed to integrate an adaptation of CALM into one primary care practice, using results from the published research as a benchmark with the secondary intent to spread a successful model to other practices. A quality improvement approach was used to translate the CALM model of CBT for anxiety into one primary care clinic. Plan-Do-Study-Act steps are highlighted as important steps towards our goal of comparing our outcomes with benchmarks from original research. Patients with anxiety as measured by a score of 10 or higher on the Generalized Anxiety Disorder 7 item scale (GAD-7) were offered CBT as delivered by licensed social workers with support by a PhD psychologist. Outcomes were tracked and entered into an electronic registry, which became a critical tool upon which to adapt and improve our delivery of psychotherapy to our patient population. Challenges and adaptations to the model are discussed. Our 6-month response rates on the GAD-7 were 51%, which was comparable with that of the original research (57%). Quality improvement methods were critical in discovering which adaptations were needed before spread. Among these, embedding a process of measurement and data entry and ongoing feedback to patients and therapists using this data are critical step towards sustaining and improving the delivery of CBT in primary care.

Internet-Based Cognitive Behavioral Therapy With Real-Time Therapist Support via Videoconference for Patients With Obsessive-Compulsive Disorder, Panic Disorder, and Social Anxiety Disorder: Pilot Single-Arm Trial

“…In this study, the treatment response rate for the GAD-7 was 45% (13/29). The response rates of PHQ-9 and GAD-7 in this study were similar to those in a prior study [89]. Taken together, our results suggest that videoconference-delivered CBT for OCD, PD, and SAD might secondarily ameliorate symptoms for generalized anxiety and depression.…”

“…There were significant differences in changes between the OCD and PD groups (OCD: P =.002; PD: P =.006; SAD: P =.10) at week 16. A previous study reported a response rate in GAD-7 of 50.9% following a computerized CBT program, for 1062 adults who had GAD-7 scores of 10 or more at baseline [89] including 75 patients with GAD, 47 with PD, 40 with SAD, and 18 with PTSD. In this study, the treatment response rate for the GAD-7 was 45% (13/29).…”

Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

“…Several methodological approaches were identified to generate data from existing programs : naturalistic, open, or "phase 4" studies [ 11 , 44 , 45 , 62 , 70 – 72 ], observational studies from routine care [ 73 ], implementation or program evaluation studies [ 49 , 74 – 78 ], and quality improvement research [ 79 ]. While the degree of overlap between these methodologies is beyond this review’s scope, their variety in published studies highlights the recognized importance of learning from existing programs.…”

“…Documents analyzed included reports on existing programs aiming to improve access to CBT for anxiety disorders through treatment modalities such as telephone CBT [ 74 ], internet-delivered CBT [ 70 – 73 , 75 , 77 , 78 ], and transdiagnostic group CBT. Some studies reported on an implemented training program [ 76 ], an approach to collaborative care [ 79 ], or CBT practices in primary care settings [ 44 ]. Other existing programs had the broader aim of improving access to various mental health services (including CBT) through a national-level endeavor [ 81 , 82 ].…”

“…On the one hand, clinical psychologists and other therapists should be adequately trained in CBT and other EBPTs when graduating [ 45 , 46 , 76 , 117 , 118 ]. On the other hand, training clinicians to deliver CBT when they are already in a clinical position can be invaluable to improve local capacity, especially in primary care or for underserved locations and populations [ 56 , 66 , 68 , 79 , 113 , 119 ]. For active practitioners, mitigating the direct and indirect training costs is crucial to getting them involved [ 83 , 85 ], notably through online training programs [ 91 , 117 – 120 ].…”