Effectiveness of Online Collaborative Care for Treating Mood and Anxiety Disorders in Primary Care: A Randomized Clinical Trial

Abstract

Importance: Collaborative care for depression and anxiety is superior to usual care from primary care physicians for these conditions; however, challenges limit its provision in routine practice and at scale. Advances in technology may overcome these barriers but have yet to be tested.

Objective: To examine the effectiveness of combining an internet support group (ISG) with an online computerized cognitive behavioral therapy (CCBT) provided via a collaborative care program for treating depression and anxiety vs CCBT alone and whether providing CCBT in this manner is more effective than usual care.

Design, setting, and participants: In this 3-arm randomized clinical trial with blinded outcome assessments, primary care physicians from 26 primary care practices in Pittsburgh, Pennsylvania, referred 2884 patients aged 18 to 75 years in response to an electronic medical record prompt from August 2012 to September 2014. Overall, 704 patients (24.4%) met all eligibility criteria and were randomized to CCBT alone (n = 301), CCBT+ISG (n = 302), or usual care (n = 101). Intent-to-treat analyses were conducted November 2015 to January 2017.

Interventions: Six months of guided access to an 8-session CCBT program provided by care managers who informed primary care physicians of their patients' progress and promoted patient engagement with our online programs.

Main outcomes and measures: Mental health-related quality of life (12-Item Short-Form Health Survey Mental Health Composite Scale) and depression and anxiety symptoms (Patient-Reported Outcomes Measurement Information System) at 6-month follow-up, with treatment durability assessed 6 months later.

Results: Of the 704 randomized patients, 562 patients (79.8%) were female, and the mean (SD) age was 42.7 (14.3) years. A total of 604 patients (85.8%) completed our primary 6-month outcome assessment. At 6-month assessment, 254 of 301 patients (84.4%) receiving CCBT alone started the program (mean [SD] sessions completed, 5.4 [2.8]), and 228 of 302 patients (75.5%) in the CCBT+ISG cohort logged into the ISG at least once, of whom 141 (61.8%) provided 1 or more comments or posts (mean, 10.5; median [range], 3 [1-306]). Patients receiving CCBT+ISG reported similar 6-month improvements in mental health-related quality of life, mood, and anxiety symptoms compared with patients receiving CCBT alone. However, compared with patients receiving usual care, patients in the CCBT alone cohort reported significant 6-month effect size improvements in mood (effect size, 0.31; 95% CI, 0.09-0.53) and anxiety (effect size, 0.26; 95% CI, 0.05-0.48) that persisted 6 months later, and completing more CCBT sessions produced greater effect size improvements in mental health-related quality of life and symptoms.

Conclusions and relevance: While providing moderated access to an ISG provided no additional benefit over guided CCBT at improving mental health-related quality of life, mood, and anxiety symptoms, guided CCBT alone is more effective than usual care for these conditions.

Trial registration: clinicaltrials.gov Identifier: NCT01482806.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Karp has received medication supplies for investigator-initiated trials from Indivior and Pfizer. No other disclosures were reported.

Figures

Figure 1.. Flowchart of Participants

Participants were referred by primary care physicians (PCPs) between August 2012 and September 2014. CCBT indicates computerized cognitive behavioral therapy; GAD-7, 7-Item Generalized Anxiety Disorder Scale; ISG, internet support group; MH, mental health; MHS, mental health specialist; PHQ-9, 9-Item Patient Health Questionnaire.

Figure 2.. Estimated Scores by Baseline Treatment Assignment

Linear mixed models adjusted for time, study arm, time-by-study arm, age strata, and clinic size. A, Estimated scores for the 12-Item Short-Form Health Survey Mental Health Composite Scale (SF-12 MCS). B, Estimated scores for the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scale. At 6 months, patients receiving computerized cognitive behavioral therapy (CCBT) alone vs usual care reported a −2.43 (95% CI, −4.16 to −0.69;P = .006) improvement. C, Estimated scores for the PROMIS Anxiety scale. At 6 months, patients receiving CCBT alone vs usual care reported a −2.30 (95% CI, −4.21 to −0.4; P = .02) improvement. The vertical line at 6 months indicates the end of care manager–led CCBT and our primary outcome point. The following 6 months were naturalistic follow-up to observe the durability of our interventions. The error bars indicate 95% CIs. ISG indicates internet support group.

Figure 3.. Forest Plot of Between-Group Differences and Effect Sizes for the 12-Item Short-Form Health Survey Mental Health Composite Scale

CCBT indicates computerized cognitive behavioral therapy; GAD-7, 7-Item Generalized Anxiety Disorder Scale; ISG, internet support group; PCP, primary care physician; PHQ-9, 9-Item Patient Health Questionnaire; UC, usual care.