Incremental benefits and cost of coordinated anxiety learning and management for anxiety treatment in primary care

Abstract

Background: Improving the quality of mental health care requires integrating successful research interventions into 'real-world' practice settings. Coordinated Anxiety Learning and Management (CALM) is a treatment-delivery model for anxiety disorders encountered in primary care. CALM offers cognitive behavioral therapy (CBT), medication, or both; non-expert care managers assisting primary care clinicians with adherence promotion and medication optimization; computer-assisted CBT delivery; and outcome monitoring. This study describes incremental benefits, costs and net benefits of CALM versus usual care (UC).

Method: The CALM randomized, controlled effectiveness trial was conducted in 17 primary care clinics in four US cities from 2006 to 2009. Of 1062 eligible patients, 1004 English- or Spanish-speaking patients aged 18-75 years with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) and/or post-traumatic stress disorder (PTSD) with or without major depression were randomized. Anxiety-free days (AFDs), quality-adjusted life years (QALYs) and expenditures for out-patient visits, emergency room (ER) visits, in-patient stays and psychiatric medications were estimated based on blinded telephone assessments at baseline, 6, 12 and 18 months.

Results: Over 18 months, CALM participants, on average, experienced 57.1 more AFDs [95% confidence interval (CI) 31-83] and $245 additional medical expenses (95% CI $-733 to $1223). The mean incremental net benefit (INB) of CALM versus UC was positive when an AFD was valued ≥$4. For QALYs based on the Short-Form Health Survey-12 (SF-12) and the EuroQol EQ-5D, the mean INB was positive at ≥$5000.

Conclusions: Compared with UC, CALM provides significant benefits with modest increases in health-care expenditures.

Trial registration: ClinicalTrials.gov NCT00347269.

Conflict of interest statement

DECLARATION OF INTEREST

Dr Roy-Byrne reported receiving research grant support from the National Institutes of Health; having served as a paid member of advisory boards for Jazz Pharmaceuticals and Solvay Pharmaceuticals (1 meeting for each); having received honoraria for CME-sponsored speaking from the American Psychiatric Association, Anxiety Disorders Association of America, CME LLC, CMP Media, Current Medical Directions, Imedex, Massachusetts General Hospital Academy, and PRIMEDIA Healthcare; and serving as editor in chief for Journal Watch Psychiatry (Massachusetts Medical Society), Depression and Anxiety (Wiley-Liss Inc), and UpToDate in Psychiatry (UpToDate Inc). Dr Roy-Byrne reported also serving as an expert witness on multiple legal cases related to anxiety; none involving pharmaceutical companies or specific psychopharmacology issues.

Dr Craske reported receiving research grant support from the National Institutes of Health and having received honoraria for sponsored speaking from the Anxiety Disorders Association of America.

Dr Stein reported receiving or having received research support from the US Department of Defense, Eli Lilly, GlaxoSmithKline, Hoffmann-La Roche, National Institutes of Health, and the US Veterans Affairs Research Program; and is currently or has been a paid consultant for AstraZeneca, Avera Pharmaceuticals, BrainCells Inc, Bristol-Myers Squibb, Comprehensive NeuroScience, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Hoffmann-La Roche, Jazz Pharmaceuticals, Johnson & Johnson, Mindsite, Pfizer, Sepracor, and Transcept Pharmaceuticals. Dr Stein is paid for editorial work on the journal Depression and Anxiety and UpToDate in Psychiatry (UpToDate Inc).

No other author reported financial disclosures or conflicts of interest.

Figures

Figure 1

Incremental Net Benefit of CALM compared to Usual Care for anxiety-free days. The Incremental Net Benefit varies with the $ value assigned to each additional anxiety-free day.