Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care

Abstract

Context: Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered.

Objective: To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD).

Design: A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments.

Setting: Seventeen US primary care clinics.

Patients: Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up.

Interventions: CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC.

Main outcome measures: Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores.

Results: CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders.

Conclusions: CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

Figures

Figure 1. Consort Diagram

Figure 2. Response and remission rates for principal anxiety disorder of GAD, PD, SAD and PTSD

GADPD GAD ITV Response PD ITV Response GAD UC Response PD UC Response GAD ITV Remission PD ITV Remission GAD UC Remission PD UC RemissionSADPTSD SAD ITV Response PTSD ITV Response SAD UC Response PTSD UC Response SAD ITV Remission PTSD ITV Remission SAD UC Remission PTSD UC Remission Description: Figure 2 examines the response and remission rates of the ITV (intervention condition) and the UC (usual care condition). Response was defined as a reduction of 40% or more on each of the scales used. Remission was defined by using cut-off scores when available (PDSS: ≤ 7; SPIN: ≤ 18) or an indication of no more than mild severity averaged across items (PCL-C: ≤ 34; GADSS: ≤ 6; OASIS: ≤ 5).