Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care

Abstract

MPROVING 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. 1 The effectiveness of one approach, collaborative care, is well established for primary care depression, 2-5 but has been infrequently studied for anxiety disorders, 6,7 despite their common occurrence in primary care. 8 The multiplicity of anxiety disorders and the fact that anxious patients are less likely to seek 9 and harder to engage 10 in treatment may be contributing factors. Furthermore, whereas effective treatment for both anxiety and depressive disorders relies in part on pharmacotherapy, psychosocial treatments such as cognitive behavioral therapy (CBT) are important for pa-tients who are anxious. Not only do these patients strongly prefer psychological treatment over medications, 10,11 but also CBT may have ad-Author Affiliations are listed at the end of this article.

Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial

“…But PTSD treatment is less routine in primary care and its care is more challenging because of barriers at the patient, physician and practice levels. 4,[21][22][23] The Coordinated Anxiety Learning and Management (CALM) trial 24 found that, for patients with PTSD recruited from private and mostly academic medical settings, improvement in outcomes was no different relative to usual care. 25 The Re-Engineering Systems for the Primary Care of PTSD (RESPECT-PTSD) trial for veterans with PTSD did not find an intervention effect for symptoms or functioning.…”

Implementation of Collaborative Depression Management at Community-Based Primary Care Clinics: An Evaluation

“…(1–6) The IMPACT trial, one exemplar of collaborative care, demonstrated significant improvement in depression outcomes among elderly patients with cost savings in the long-term. (3) These promising results have engendered considerable national interest in the dissemination of integrated models, and the corresponding need to understand how to implement such models in real-world settings.…”

Collaborative Care for Anxiety: What’s Inside the Black Box and How Can It Be Improved?

“…The only question is when, how much and whether at some point patients need to be seen in the specialty rather than the primary care setting. This study seems to have used specialty care more than other collaborative care studies (in the large CALM study 6 about half the usual care patients had a specialty care visit), suggesting that it adopted more of a hybrid primary care-specialty care model than other collaborative care studies.…”

“…Yet the effect size observed in this study was similar to that seen in the largest primary care anxiety study, which used more costly personnel and in-clinic visits and delivered in-person CBT as part of the intervention. 6 How were these small to mid-sized intervention effects achieved with such a bare-bones intervention?…”

“…It has been shown that treatments targeted to one anxiety disorder likely affect other comorbid anxiety disorders as well as depression. 6 While only a portion of prior collaborative care studies of depression have reported anxiety outcomes, virtually all collaborative care studies of anxiety have reported depression outcomes. Not surprisingly, the outcomes across both sets of symptoms have been similar.…”