An intervention in primary care settings that allowed a choice of cognitive behavior therapy, medication, or both, along with computer-assisted treatment support for patients with common anxiety disorders, resulted in greater improvement in anxiety symptoms and functional disability compared to usual care, according to a study in the May 19 issue of JAMA, a theme issue on mental health.

"Improving 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. The effectiveness of one approach, collaborative care, is well established for primary care depression, but has been infrequently studied for anxiety disorders, despite their common occurrence in primary care," the authors write.

Peter Roy-Byrne, M.D., of the University of Washington School of Medicine, Seattle and colleagues conducted a study to examine whether a flexible treatment delivery intervention in primary care would be better than usual care (UC) in reducing symptoms of anxiety and in improving certain measures of functioning, health-related quality of life, and quality of care delivered for the 4 most common anxiety disorders: panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress disorder (PTSD). The intervention the researchers designed, Coordinated Anxiety Learning and Management (CALM), allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by non-expert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. "In this way, CALM seeks to accommodate the complexity of real-world clinical settings, while maximizing fidelity to the evidence-base in the context of a broad range of patients, clinicians, practice settings, and payers," the authors write.

The randomized controlled effectiveness trial of CALM compared with usual care took place in 17 primary care clinics in 4 U.S. cities. Between June 2006 and April 2008, 1,004 patients with anxiety disorders (with or without major depression), ages 18 to 75 years, were enrolled and subsequently received treatment for 3 to 12 months. Follow-up assessments at 6,12, and 18 months after the beginning of the trial were completed in October 2009. Anxiety symptoms were measured with the 12 item Brief Symptom Inventory (BSI-12).

The researchers found that the scores on measures of anxiety symptoms were significantly lower for patients in the intervention group at 6 months, 12 months and 18 months. "At 12 months, response and remission rates (CALM vs. UC) were 63.66 percent vs. 44.68 percent, and 51.49 percent vs. 33.28 percent, with a number needed to treat of 5.27 for response and 5.50 for remission."

"The flexibility of treatment (e.g., variation in number and type of sessions, and in criteria for continuing further treatment, use of both telephone and in-person contact), the targeting of multiple disorders, and the clinical effectiveness across a range of patients and clinics suggest that the CALM treatment delivery model should be broadly applicable in primary care. However, implementation of this model will require reimbursement mechanisms for care management that are not currently available," the authors write.

"Nonetheless, the success of the model tested here demonstrates that addressing multiple common mental disorders in the context of one delivery model is feasible and effective and could serve as a template for the development of unified approaches to management of the multiple psychiatric comorbidities that are the rule rather than the exception in both the general population and in clinical practice."