Adequacy of treatment received by primary care patients with anxiety disorders

Brief modular anxiety intervention for primary care: Hybrid I pilot randomized controlled trial of feasibility, acceptability, effectiveness, and implementation potential

BACKGROUND

Anxiety is highly prevalent, but undertreated, in primary care. Brief, non-pharmacological interventions are needed. Modular Anxiety Skills Training (MAST), a cognitive-behavioral anxiety intervention, was developed for primary care and tailored for a Veteran sample (MAST-V). The purpose of this mixed methods pilot study was to evaluate MAST-V's feasibility, acceptability, and implementation potential, and preliminarily examine its effectiveness compared to Primary Care Behavioral Health (PCBH) usual care.

METHODS

This hybrid I randomized controlled trial (conducted 2019-2021) assigned 35 primary care patients (Mage = 47, 17 % female, 27 % racial/ethnic minority) with clinically significant anxiety symptoms to receive MAST-V or PCBH usual care. Participants completed validated measures of anxiety symptoms and functional impairment at 0, 4, 8, 12, and 16 weeks.

RESULTS

Participants attended more sessions in MAST-V than usual care. After necessary adjustments to reduce session duration, MAST-V will likely fit within PCBH practice parameters. Participants in both conditions valued treatment, but treatment satisfaction, credibility, and therapeutic alliance were higher for MAST-V. Study therapists achieved high treatment fidelity and rated MAST-V as highly feasible, acceptable, and appropriate for PCBH. They identified ways to address potential barriers to implementation. MAST-V was more effective than usual care in reducing anxiety symptoms and impairment.

LIMITATIONS

This was a small pilot study at a single site using study therapists. Results should be considered preliminary until replicated in a full-scale clinical trial.

CONCLUSIONS

This brief modular anxiety intervention, which was designed with implementation in mind, may help to address the anxiety treatment gap in primary care.

The prevalence of anxiety in adult endocrinology outpatients: A systematic review and meta-analysis

INTRODUCTION

Anxiety disorders and anxiety symptoms are common mental disorders in the medically unwell and have significant impacts on patients' quality of life and engagement with psychiatric and medical services. Several systematic reviews have examined the prevalence of anxiety in specific endocrinology settings with estimates varying significantly from study to study. No meta-analysis has examined anxiety rates across the endocrinology outpatient setting. The aim of this meta-analysis is to provide endocrinologists with a precise estimate of the prevalence of anxiety - and impacting factors - in their outpatient clinics.

METHOD

PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched to identify studies that assessed anxiety prevalence in endocrinology outpatients published up to 23 January 2023. This was part of a larger systematic review search of anxiety prevalence in common medical outpatient clinics. Data characteristics were extracted independently by two investigators. Studies of patients 16 years and older and representative of the clinic were included. The point prevalence of anxiety or anxiety symptoms was measured using validated self-report questionnaires or structured interviews. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Pooled estimates were analysed under the random-effects model and subgroup analyses on relevant variables were conducted under a mixed-effects model. Heterogeneity was assessed using the I2 statistic.

RESULTS

Fifty-nine studies with a total of 25,176 participants across 37 countries were included in this study. The overall pooled prevalence of anxiety or anxiety symptoms was 25·1% (95%CI 21·4-29·2; 6372/25,176; n = 59). Subgroup analyses revealed no difference in prevalence between outpatients with diabetes mellitus compared to other grouped endocrine disorders. Generalized Anxiety Disorder (GAD) was the most frequent clinical diagnosis 11·7% (95%CI 8·1-16·7; I2=87·93%; 443/4604; n = 17), while panic disorder was significantly higher in the non-diabetes group 9·5% (95%CI 5·9-14·9; I2=57·28%; 56/588; n = 8), compared to the diabetes group 5·2% (95%CI 3·7-7·3; I2=32·18%; 184/3669; n = 6). Estimates of prevalence were higher when assessed with a self-report scale 32·4% (95%CI 25·6-40·0; I2=96·06%; 1565/4675; n = 21) compared to diagnostic interview 17·6% (95%CI 12·2-24·7; I2=94·39%; 636/5168; n = 21). Outpatients in developing countries had higher rates of anxiety than those in developed countries. Female diabetes patients reported higher rates of anxiety compared to males.

CONCLUSION

Our study provides evidence that anxiety occurs frequently amongst endocrinology outpatients and at a higher rate than is estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective management strategies be developed to support endocrinologists in identifying and treating these conditions in their outpatient clinics.

Barriers to and facilitators of using evidence-based, cognitive-behavioral anxiety interventions in integrated primary care practice

Cognitive-behavioral treatment for anxiety disorders and symptoms remains underutilized in integrated primary care (IPC), in part because the many treatments developed for specialty care are not readily translated to this unique setting. The objective of this study was to identify barriers and facilitators to behavioral health providers (BHPs) delivering evidence-based cognitive--behavioral anxiety interventions within IPC practice. We conducted semistructured interviews with a national sample of 18 BHPs (50% psychologists, 33% social workers, 17% registered nurses) working in IPC in the Veterans Health Administration. We assessed barriers to and facilitators of using psychoeducation, exposure, cognitive therapy, relaxation training, mindfulness/meditation, Acceptance and Commitment Therapy-based interventions, and problem-solving therapy. Qualitative coding and conventional content analysis revealed barriers and facilitators at three levels: IPC, provider, and patient. Themes suggested key barriers of poor fit with the IPC model, BHP training deficits, and lack of patient buy-in, and key facilitators of good perceived fit of the intervention (e.g., scope, duration) with the IPC model, BHPs feeling well equipped, and utility for patients. BHPs select interventions based on fit for the individual patient. Some results were consistent with prior work from specialty care, but the IPC model itself introduces significant implementation challenges. BHPs would benefit from flexible intervention options and training on IPC treatment goals and how to deliver the essence of evidence-based interventions in small doses. Our findings will help to inform adaptation of behavioral anxiety interventions to better fit IPC practice and development of beneficial training and resources for BHPs to reduce implementation challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient factors associated with receipt of psychological and pharmacological treatments among individuals with common mental disorders in a Swedish primary care setting

BACKGROUND

Psychological and pharmacological therapies are the recommended first-line treatments for common mental disorders (CMDs) but may not be universally accessible or utilised.

AIMS

To determine the extent to which primary care patients with CMDs receive treatment and the impact of sociodemographic, work-related and clinical factors on treatment receipt.

METHOD

National registers were used to identify all Stockholm County residents aged 19-64 years who had received at least one CMD diagnosis (depression, anxiety, stress-related) in primary care between 2014 and 2018. Individuals were followed from the date of their first observed CMD diagnosis until the end of 2019 to determine treatment receipt. Associations between patient factors and treatment group were examined using multinomial logistic regression.

RESULTS

Among 223 271 individuals with CMDs, 30.6% received pharmacotherapy only, 16.5% received psychological therapy only, 43.1% received both and 9.8% had no treatment. The odds of receiving any treatment were lower among males (odds ratio (OR) range = 0.76 to 0.92, 95% CI_{[minimum, maximum]} 0.74 to 0.95), individuals born outside of Sweden (OR range = 0.67 to 0.93, 95% CI_{[minimum, maximum]} 0.65 to 0.99) and those with stress-related disorders only (OR range = 0.21 to 0.51, 95% CI_{[minimum, maximum]} 0.20 to 0.53). Among the patient factors examined, CMD diagnostic group, prior treatment in secondary psychiatric care and age made the largest contributions to the model (R² difference: 16.05%, 1.72% and 1.61%, respectively).

CONCLUSIONS

Although over 90% of primary care patients with CMDs received pharmacological and/or psychological therapy, specific patient groups were less likely to receive treatment.

Feasibility of a video-delivered mental health course for primary care patients: a single-group prospective cohort study

BACKGROUND

In many health care systems, primary care is tasked with offering psychological treatment for common mental disorders. Resources are often limited, which complicates widespread dissemination of traditional psychological treatments. Stepped care models where the less resource-intensive interventions are delivered first, can be employed, but often do not eliminate the need for a thorough diagnostic assessment, which can be time-consuming, has the potential to bottleneck patient intake, and can add to waiting times. Novel low-threshold formats are needed to improve access to mental health care in the primary care setting.

METHODS

This was a single-group prospective cohort study (N = 91). We assessed the feasibility of a video-delivered course as a first-line intervention for patients seeking help for mental health problems at a primary care center. The course had a transdiagnostic approach, suitable for both depression and anxiety disorders, and was based on cognitive behavioral techniques. Patients in need of psychosocial assessment, which usually entailed a four- to six-week wait, were referred by physicians or triage nurses. Study participants could start within a week, without the need for conventional diagnostic assessment, and were informed that they would be offered assessment after the course if needed. Key feasibility outcomes included participant satisfaction, attendance rates, the proportion of participants in need of additional clinical intervention after the course, and the rate of clinically significant improvement in anxiety and depression symptoms.

RESULTS

Participants scored a mean of 21.8 (SD = 4.0, 9-32, n = 86) on the Client Satisfaction Questionnaire-8; just below our target of 22. The mean attendance rate was 5.0/6 lectures (SD = 1.6, range: 0-6, n = 91). Forty-six percent (37/81) reported experiencing no need of further clinical intervention after the course. The rate of clinically significant improvement was 59% (27/46) for anxiety and 48% (22/46) for depression. No serious adverse event was reported.

CONCLUSIONS

Delivering a low-threshold online video-delivered mental health course in primary care appears to be feasible. Adjustments to further improve patient satisfaction are warranted, such as offering the choice of participating online or face-to-face.

TRIAL REGISTRATION

(ClinicalTrials.gov NCT04522713) August 21, 2020.

Changes in treatment outcomes in patients undergoing an integrated psychosomatic inpatient treatment: Results from a cohort study

Objective

In Germany, multimodal psychosomatic inpatient treatment can be initiated for patients with substantial mental disorders (e.g., depression, anxiety, somatoform disorders) and comorbid physical disease. However, studies investigating changes in psychological and functional treatment outcomes, and predictors of long-term treatment effects in patients undergoing psychosomatic inpatient treatment are needed.

Methods

This cohort study analyzed 160 patients aged ≥18 who were treated on an integrated psychosomatic inpatient unit at the University of Göttingen Medical Center. Its aim was to analyze changes in psychological and functional outcomes, and to identify predictors of long-term improvements in health-related quality of life (HRQoL) in patients with comorbid mental and physical illness who were undergoing integrated inpatient psychosomatic treatment. Assessments were completed at admission, discharge, and 12- or 24-month follow-up. Outcomes included physical complaints [Giessen Subjective Complaints List (GBB-24)], psychological symptoms [Brief Symptom Inventory (BSI)], and HRQoL [European Quality of Life Questionnaire (EQ-5D)].

Results

One-hundred sixty inpatients were included (mean age = 53.1 ± 12.6; 53.8% female). There were significant, medium- to large-sized improvements in psychological symptoms (BSI-Global Severity Index; d = -0.83, p < 0.001), physical symptom burden (d = -0.94, p < 0.001), and HRQoL (d = 0.65, p < 0.001) from admission to discharge, and significant, small- to medium-sized greater improvements in all psychological outcomes from admission to follow-up (BSI-GSI: d = -0.54, p < 0.001; GBB-24 total symptom burden: d = -0.39, p < 0.001; EQ-5D: d = 0.52, p < 0.001). Furthermore, better improvement in HRQoL during hospitalization (partial η2 = 0.386; p < 0.001) was associated with higher HRQoL at follow-up. Finally, intake of antidepressant at discharge was associated with impaired HRQoL at follow-up (η2 = 0.053; p = 0.03).

Conclusion

There were significant short- and long-term improvements in psychological symptoms, physical complaints, and HRQoL after treatment on an integrated psychosomatic inpatient unit in patients with mental disorders and a comorbid physical disease.

Health care system and patient costs associated with receipt of minimally adequate treatment for depression and anxiety disorders in older adults

BACKGROUND

Depression and anxiety disorders in older adults are associated with a great burden. Research has shown that less than 50% of adults receive adequate treatment in primary care settings for these disorders. Rare are the studies however assessing adequate treatment in older adults and associated costs from the societal perspective. Given the episodic nature of common mental disorders, this study aims to assess the three-year costs from a restricted societal perspective (including health system and patient perspectives) associated with receipt of minimally adequate treatment for depression and anxiety disorders in older adults consulting in primary care.

METHODS

This primary care cohort study included 358 older adults aged 65 years and older with either a self-reported or physician diagnosis of depression or an anxiety disorder covered under Quebec's public drug plan. Receipt of minimally adequate treatment was assessed according to Canadian guidelines and relevant reports. Outpatient and inpatient service use, medication costs and physician billing fees were obtained from provincial administrative databases. Unit costs were calculated using provincial financial and activity reports and relevant literature. A propensity score was created to estimate the probability of receiving minimally adequate treatment and the inverse probability was used as a weight in analyses. Generalized linear models, with gamma distribution and log link, were conducted to assess the association between receipt of minimally adequate treatment and costs.

RESULTS

Overall, receipt of minimally adequate treatment was associated with increased three-year costs averaging $5752, $536, $6266 for the health system, patient and societal perspectives, respectively, compared to those not receiving minimally adequate treatment. From the health system perspective, participants receiving minimally adequate treatment had higher costs related to emergency department (ED) (difference: $457, p = 0.001) and outpatient visits (difference: $620, p < 0.001), inpatient stays (difference: $2564, p = 0.025), drug prescriptions (difference: $1243, p = 0.002) and physician fees (difference: $1224, p < 0.001). From the patient perspective, receipt of minimally adequate treatment was associated with higher costs related to loss of productivity related to ED (difference: $213, p < 0.001) and outpatient visits (difference: $89, p < 0.001).

CONCLUSIONS

Older adults receiving minimally adequate treatment for depression and anxiety disorders incurred higher societal costs reaching $2089 annually compared to older adults not receiving minimally adequate treatment. The main cost drivers were attributable to hospitalizations and prescription drug costs.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model

BACKGROUND

While multiple treatments for pediatric anxiety and obsessive compulsive disorder (OCD) are efficacious, little is known about their cost-effectiveness. In response, we sought to provide relevant information through systematic review and cost-effectiveness simulation.

METHODS

We evaluated the cost-effectiveness of treatment for pediatric anxiety and OCD in two ways. First, we conducted a systematic review following PRISMA guidelines. Second, we evaluated cost-effectiveness for antidepressant medication, cognitive behavioral therapy, and their combination via a simulation that integrated information from the Truven MarketScan database and the NIMH National Database for Clinical Trials Related to Mental Illness.

RESULTS

Both systematic review and simulation found antidepressant medication and cognitive behavioral therapy to be cost-effective for pediatric anxiety and OCD. Antidepressant medication was the least costly approach, and cognitive behavioral therapy provided additional cost-effectiveness, especially for OCD.

LIMITATIONS

During systematic review, relatively few articles provided information about both costs and effectiveness. While there was a notable margin of error to support multiple interventions as cost-effective, limited prior research decreased precision of point estimates and comparisons between interventions.

CONCLUSIONS

Both antidepressant medication and cognitive behavioral therapy were found to be cost-effective for pediatric anxiety and OCD. Results supported investment from third party payers, who serve as critical gatekeepers that can increase treatment dissemination. However, more precise information would better inform the exact amount of investment needed, especially with regard to selection decisions between active interventions. Cost-effectiveness research would benefit from systematic collection of data on treatment costs and quality of life in future clinical trials.

Development of a cognitive bias modification intervention for anxiety disorders in primary care

OBJECTIVES

There is a great need for low-intensity, scalable treatments in primary care, where most anxious patients first present for treatment. We describe Stage IA treatment development and a Stage IB feasibility trial of cognitive bias modification (CBM) for transdiagnostic anxiety in primary care.

METHODS

The online intervention, Mental Habits, comprised eight sessions of a personalized CBM targeting attention and interpretation biases. Coaches assisted patients in using the website, monitored progress via a dashboard, and shared information with primary care providers. We evaluated Mental Habits in an open trial (N = 14) and a randomized controlled trial (RCT) (N = 40) in primary care patients with anxiety disorders.

RESULTS

We compared results to a priori benchmarks of clinically meaningful outcomes. In the open trial, Mental Habits met feasibility, acceptability, and efficacy benchmarks. In the pilot RCT, there was greater dropout at one study site which ultimately closed. In the intent-to-treat analyses, Mental Habits met the benchmark for self-report, but not the interview measure of anxiety. Symptom Tracking did not meet the benchmark for self-report or interview measures of anxiety. In per-protocol analyses, Mental Habits exceeded the benchmark for both self-report and interview measures, whereas Symptom Tracking met the benchmark for self-report. Interpretation bias improved in the Mental Habits group, but not in Symptom Tracking. No effects were observed for attention bias.

CONCLUSION

The online CBM intervention demonstrated good acceptability and, when delivered at a stable primary care clinic, preliminary effectiveness in primary care. A larger RCT is warranted to test effectiveness.

PRACTITIONER POINTS

A personalized, transdiagnostic Cognitive Bias Modification (CBM) intervention for anxiety in primary care is acceptable to primary care patients with social anxiety disorder, generalized anxiety disorder, and/or panic disorder /agoraphobia. With training and supervision from licensed mental health clinicians, bachelor's-level coaches can assist primary care patients to self-administer CBM. Offering a low-intensity, self-directed anxiety intervention in primary care can greatly expand the reach of anxiety treatment, with minimal need for additional resources. Interpretation bias may be an important clinical target for primary care patients with anxiety.

Anxiety in the Medically Ill: A Systematic Review of the Literature

BACKGROUND

Although anxiety is highly represented in the medically ill and its occurrence has relevant clinical implications, it often remains undetected and not properly treated. This systematic review aimed to report on anxiety, either symptom or disorder, in patients who suffer from a medical illness.

METHODS

English-language papers reporting on anxiety in medically ill adults were evaluated. PubMed, PsycINFO, Web of Science, and Cochrane databases were systematically searched from inception to June 2021. Search term was "anxiety" combined using the Boolean "AND" operator with "medically ill/chronic illness/illness/disorder/disease." Risk of bias was assessed via the Joanna Briggs Institute (JBI) Critical Appraisal Tools-Checklist for Prevalence Studies. The PRISMA guidelines were followed.

RESULTS

Of 100,848 citations reviewed, 329 studies met inclusion criteria. Moderate or severe anxious symptoms were common among patients with cardiovascular, respiratory, central nervous system, gastrointestinal, genitourinary, endocrine, musculoskeletal system or connective tissue, dermatological diseases, cancer, AIDS and COVID-19 infections. The most common anxiety disorder was generalized anxiety disorder, observed among patients with cardiovascular, respiratory, central nervous system, dermatologic diseases, cancer, primary aldosteronism, amenorrhea, and COVID-19 infection. Panic disorder was described for cardiovascular, respiratory, dermatology diseases. Social anxiety was found for cardiovascular, respiratory, rheumatoid diseases. Specific phobias were relatively common in irritable bowel syndrome, gastroesophageal reflux, end-stage renal disease.

CONCLUSION

Anxiety is a major challenge in medical settings. Recognition and proper assessment of anxiety in patients who suffer from a medical illness is necessary for an appropriate management. Future reviews are warranted in order also to clarify the causal and temporal relationship between anxiety and organic illness.

Anxiety treatment preferences among veteran primary care patients: Demographic, mental health, and treatment-related correlates

INTRODUCTION

Anxiety symptoms are common, yet undertreated, among primary care patients. Accommodating patient treatment preferences improves engagement and retention. In contrast to depression, little is known about primary care patients' preferences for anxiety treatment.

METHOD

Participants were 144 veterans experiencing anxiety symptoms but not receiving psychotherapy who were recruited from primary care. Preferences for 11 anxiety treatment attributes (method; location; type; format; provider; frequency, length, and number of appointments; psychotherapy orientation; symptom focus; and topic/skill) and demographic, mental health (e.g., anxiety symptom severity), and treatment-related (e.g., psychotherapy history) variables were assessed via mailed survey. We used chi-square goodness of fit tests to identify patient preferences for each attribute and multivariate multinomial logistic regression models to explore demographic, mental health, and treatment-related correlates of treatment preferences.

RESULTS

Patient preferences were largely consistent with integrated primary care models, particularly Primary Care Behavioral Health, with a few exceptions. Patients preferred longer appointments (e.g., 45-60 minutes) and a longer duration of treatment (e.g., ≥13 appointments) than is typically offered in primary care. Several variables, particularly education level, perceived need for help, anxiety symptom severity, and attitudes toward psychotherapy, were repeatedly associated with preferences for various anxiety treatment attributes.

DISCUSSION

Results from this study suggest that patients tend to have distinct preferences for anxiety treatment in primary care that are largely consistent with common integrated primary care models. Results also identify several variables that may be associated with specific preferences, which may help match patients to their preferred type of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Treatment adequacy and remission of depression and anxiety disorders and quality of life in primary care older adults

BACKGROUND

Studies on the long-term outcomes of receiving adequate treatment for depression and anxiety disorders are scarce. The aims of this study were to assess the association between adequacy of care and remission of common mental disorders (CMD) and change in quality of life among a population of older adults consulting in primary care.

METHODS

The study was conducted among 225 older adults with a CMD who participated in the longitudinal ESA-Services study. Adequacy of care was assessed using administrative and self-reported data and was based on Canadian guidelines and relevant literature. CMD were measured at baseline and follow-up using self-reported measures (DSM-5 criteria) and physician diagnostic codes (International Classification of Diseases, 9^th and 10^th revisions) for depression and anxiety disorders. The remission of CMD was defined by the presence of at least one disorder at baseline and absence at follow-up. Quality of life was measured at baseline and follow-up using a visual analog scale and the Satisfaction With Life Scale. To estimate the probability to receive adequate/inadequate care, a propensity score was calculated, and analyses were weighted by the inverse probability. Weighted multivariable analyses were carried out to assess the remission of CMD and change in quality of life as a function of adequacy of care controlling for individual and health system factors.

RESULTS

Results showed that 40% of older adults received adequate care for CMD and 55% were in remission at follow-up. Adequacy of care was associated with remission of CMD (AOR: 0.66; CI 0.45-0.97; p-value: 0.032). Participants receiving adequate care had an improvement between baseline and follow-up of 0.7 (beta: 0.69, CI 0.18; 1.20, p = 0.008) point on the Satisfaction With Life Scale, while a marginal association was observed with improvement in HRQOL (beta: 2.83, CI 0.12; 5.79, p = 0.060).

CONCLUSION

The findings contribute to the rare observational studies on the association between adequacy of care for CMD and long-term treatment effects. Future studies on population effectiveness should focus on patient indicators of quality of care which may better predict long-term outcomes for patients with depression and anxiety.

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial

AIM

To compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.

METHODS

Participants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.

RESULTS

Participants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.

CONCLUSIONS

Internet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.

Cognitive Behavioral Therapy for Anxiety Disorders: Outcomes From a Multi-State, Multi-Site Primary Care Practice

BACKGROUND

Anxiety disorders are among the most common mental health conditions. Individuals with anxiety typically seek services in primary, rather than specialty, care. While there is significant evidence supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for anxiety disorders, there have been no naturalistic studies reporting anxiety-specific treatment outcomes in primary care.

METHODS

Participants (N = 1,589) were recruited from a multi-state, multi-site primary care practice, with 491 participants endorsing moderate to severe anxiety at baseline and engaging in at least one CBT session. Data was drawn from a psychotherapy tracking database.

RESULTS

Among participants with moderate to severe anxiety who engaged in CBT, a significant decrease in anxiety and depression symptoms was observed over the course of psychotherapy (p< .001, d = 0.57-0.95). Rates of reliable change, response, and remission varied across diagnostic categories. The use of CBT interventions also varied across diagnoses in line with evidence-based treatment recommendations.

DISCUSSION

Short-term CBT delivered in primary care is associated with significant improvements in anxiety and depression symptoms among participants with anxiety disorders. These findings support the use of a population-based approach to anxiety disorders treatment and suggest that evidence-based CBT can be implemented in the real-world setting.

Clinical considerations in designing brief exposure interventions for primary care behavioral health settings

INTRODUCTION

Prevalence rates of anxiety disorders and symptoms in primary care (PC) settings are very high. Behavioral health consultants in primary care behavioral health (PCBH) settings enable increased access to evidence-based anxiety treatment. Despite strong extant support for exposure-based therapy for anxiety disorders, the use of exposure to treat anxiety in PC settings is low. Although barriers to exposure therapy (ET) may be exacerbated in PC settings, many anxiety presentations in PC warrant an exposure-based approach to treatment. Thus, exploration of feasibility and efficacy of ET in PC represents a critical area for advancing evidence-based treatment of anxiety symptoms.

METHODS

The current article addresses this gap through the presentation of two case examples of ET conducted in PCBH. Theoretical and practical information regarding the implementation of exposure using a brief (≤ 30 min), time-limited (4-6 visit) approached are presented.

RESULTS

Results from the case examples demonstrate feasibility of conducting exposure in a brief format consistent with a PCBH approach. Additionally, patient outcomes presented suggest that ET conducted in PCBH reduces anxiety symptoms and may facilitate referral to specialty care settings.

DISCUSSION

Exposure may offer promise in improving the quality of anxiety treatment in PC. Future work documenting both effectiveness and implementation outcomes of exposure in PC in clinical work and research trials is needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Learning gains from a one-day training in acceptance-based behavior therapy

The primary method of training for individual licensed mental health professionals is continuing education (CE). Despite the promise of CE as a vehicle for training clinicians in evidence-based practices, only a handful of studies have examined the efficacy of trainings delivered in the CE context. Moreover, these studies have focused on a few very specific therapeutic approaches. There is a growing body of evidence supporting Acceptance-based Behavior Therapy (ABBT) as a treatment for generalized anxiety disorder (GAD) and related disorders. Training workshops aimed at disseminating ABBT are regularly conducted across and outside the United States, yet the effectiveness of these trainings is unknown. The goal of this study was to examine learning outcomes among licensed mental health professionals following a six-hour CE training in ABBT. Data were collected at baseline, post-training, and at three-month follow-up. Participants demonstrated a statistically significant increase in learning on an ABBT Knowledge Questionnaire and in their coded responses to client scenarios from baseline to follow-up, although there was a significant decline in knowledge between post and follow-up. Beyond baseline ABBT knowledge, attitude towards evidence-based practice was the only predictor of change in knowledge over time.

Sex Differences in Anxiety Disorders in Older Adults

PURPOSE OF REVIEW

Anxiety disorders are the most prevalent mental disorders. Although prevalence estimates are lower in males than females, the disability associated with anxiety disorders has been increasing in males. This review focuses on recent research studying sex differences in anxiety disorders and associated symptoms in older adults.

RECENT FINDINGS

Females are close to three times more likely than males to report most anxiety disorders. Heterogeneity exists in sex-specific lifetime and past-year estimates. Age-appropriate instruments such as the CIDI65+ show higher estimates than previous research. The profiles of females and males with anxiety with respect to depressive and somatization symptoms are different. Age-appropriate standardized mental disorder instruments have been developed and may be useful to overcome the challenges of observed heterogeneity in anxiety disorders and allow for future cross-country comparisons and a better description of the epidemiology and biopsychosocial factors associated with different types of anxiety disorders in older adults.

A randomized controlled pilot study evaluating Worry Less, Live More: The Mindful Way Through Anxiety Workbook

Effective interventions for generalized anxiety exist, but barriers to treatment prevent their broad dissemination. Commercially available self-help materials may help bridge this gap, but few have been empirically evaluated. This study compared self-reported change in generalized anxiety symptomology and associated problems between community members with excessive worry who were randomly assigned to receive the Worry Less, Live More: The Mindful Way through Anxiety Workbook (n = 35) and those in a delayed condition (n = 29). Participants in the workbook condition reported significantly greater reductions between baseline and 11-week follow-up in self-reported worry (η ² =.15), general anxiety/tension (η ² =.13), and anxiety (η ² =.24) than those in the delayed condition, although no statistically significant differences across condition on changes in depression, functional impairment or acceptance were detected. This pilot study provides support for continued research examining the efficacy of acceptance-based behavioral therapy delivered in a self-help format.

Guided Digital Cognitive Behavioral Program for Anxiety in Primary Care: Propensity-Matched Controlled Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is the gold standard treatment for adult anxiety disorders but is often not readily available in a scalable manner in many clinical settings.

OBJECTIVE

This study examines the feasibility, acceptability, and effectiveness of a coach-facilitated digital cognitive behavioral program for anxious adults in primary care.

METHODS

In an open trial, patients who screened positive for anxiety (General Anxiety Disorder-7 [GAD7] score ≥5) were offered the digital cognitive behavioral program (active group, n=593). Primary outcomes included anxiety, quality of life (QoL), and ambulatory medical use over 6 months. Intent-to-treat (ITT) and modified intent-to-treat (mITT) analyses were completed. Subsequently, we compared the outcomes of participants with those of a matched control group receiving primary care as usual (CAU; n=316).

RESULTS

More than half of the patients downloaded the cognitive behavioral mobile app program and about 60% of these were considered engaged, which was defined as completion of ≥3 techniques. The active group demonstrated medium size effects on reducing anxiety symptoms (effect size d=0.44; P<.001) and improving mental health QoL (d=0.49; P<.001) and showed significantly improved physical health QoL (d=0.39; P=.002) and a decreased likelihood of high utilization of outpatient medical care (odds ratio=0.49; P<.001). The active group did not significantly outperform the CAU group in anxiety reduction or QoL improvement (d=0.20; P=.07). However, intent-to-treat analysis showed that the active group had a significantly lower likelihood of high utilization of outpatient medical care than the enhanced CAU group (P<.0001; odds ratio=0.09).

CONCLUSIONS

A coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable. Primary care patients prescribed a digital cognitive behavioral program for anxiety experienced significant improvements in anxiety symptoms, QoL, and reduced medical utilization. This effect was observed even among patients with chronic medical conditions and behavioral health comorbidities. Although the primary outcomes in the active group did not improve significantly more than the CAU group, health care utilization declined, and some secondary outcomes improved in participants who engaged in the program compared to the CAU group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03186872; https://clinicaltrials.gov/ct2/show/NCT03186872.

Altered Neurobiological Processing of Unintentional Social Norm Violations: A Multiplex, Multigenerational Functional Magnetic Resonance Imaging Study on Social Anxiety Endophenotypes

BACKGROUND

Patients with social anxiety disorder (SAD) fear negative evaluation in social situations. Specifically, previous work indicated that social anxiety is associated with increased medial prefrontal cortex activation in response to unintentional social norm (SN) transgressions, accompanied by increased embarrassment ratings for such SN violations. Here, we used data from the multiplex, multigenerational LFLSAD (Leiden Family Lab study on Social Anxiety Disorder), which involved two generations of families genetically enriched for SAD, and investigated whether these neurobiological and behavioral correlates of unintentional SN processing are SAD endophenotypes. Of four endophenotype criteria, we examined two: first, the cosegregation of these characteristics with social anxiety (SA) within families of SAD probands (criterion 4), and second, the heritability of the candidate endophenotypes (criterion 3).

METHODS

Participants (n = 110, age range 9.0-61.5 years, eight families) performed the revised Social Norm Processing Task; functional magnetic resonance imaging data and behavioral ratings related to this paradigm were used to examine whether brain activation in response to processing unintentional SN violations and ratings of embarrassment were associated with SA levels. Next, heritability of these measurements was estimated.

RESULTS

As expected, voxelwise functional magnetic resonance imaging analyses revealed positive associations between SA levels and brain activation in the medial prefrontal cortex and medial temporal gyrus, superior temporal gyrus, and superior temporal sulcus, and these brain activation levels displayed moderate to moderately high heritability. Furthermore, although SA levels correlated positively with behavioral ratings of embarrassment for SN transgressions, these behavioral characteristics were not heritable.

CONCLUSIONS

These results show, for the first time, that brain responses in the medial prefrontal cortex and medial temporal gyrus, superior temporal gyrus, and superior temporal sulcus, related to processing unintentional SN violations, provide a neurobiological candidate endophenotype of SAD.

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis

PURPOSE

Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care.

METHODS

We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool.

RESULTS

Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness.

LIMITATIONS

The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety.

CONCLUSIONS

E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.

Cultural modifications of cognitive behavioural treatment of social anxiety among culturally diverse clients: a systematic literature review

The aim of this study was to conduct a systematic literature review to ascertain whether cognitive behavioural therapy (CBT) for social anxiety disorder (SAD) can be successfully used in non-Western contexts and demonstrate sufficient effectiveness. This area is largely under-researched with conflicting evidence presented in quantitative studies, with virtually no qualitative studies published. This review utilized realist review methodology and focused on qualitative case studies presented by clinicians. A systematic search of EBSCO HOST, The Cochrane Library Database, Google, Google Scholar and reference mining, using various combinations of terms relating to: (1) CBT, (2) social anxiety and (3) cultural diversity were employed. Seven case studies of cultural adaptations of CBT treatment for culturally diverse SAD sufferers were included. The treatment outcomes were generally promising in all cases (reporting significant decrease of SAD symptoms, maintained over time) and the success of therapy was often attributed to culturally specific modifications introduced. CBT can be an acceptable and effective treatment for culturally diverse SAD sufferers with ‘modest’ modifications, without major diversions from the original CBT models and protocols, but this finding must be treated with caution and more methodologically rigorous research (qualitative and quantitative) is needed to more fully understand what works, for whom and in what circumstances.

Treatment adequacy for social anxiety disorder in primary care patients

OBJECTIVES

There is a gap between clinical practice guidelines for social anxiety disorder and clinical practice that needs to be addressed to ensure the delivery of evidence-based treatments. The objectives of this study were: 1) to describe mental health service utilization in a cohort of primary care patients with social anxiety disorder; 2) to examine treatment adequacy for pharmacotherapy and psychotherapy according to indicators based on clinical practice guidelines; and 3) to explore correlates of treatment adequacy.

METHOD

The "Dialogue" project (Quebec, Canada) is a large study conducted in 67 primary care clinics. After a mental health screening in primary care (n = 14 833), participants with anxiety or depressive symptoms took part in a telephone/web structured interview on mental health symptoms and service utilization (n = 1956). This study included 289 participants meeting DSM-IV criteria for social anxiety disorder.

RESULTS

Overall, 86.2% of participants reported consulting for mental health reasons over the past 12 months. Only 23.6% of our sample reported the detection of social anxiety disorder by a healthcare professional in the past 12 months. Approximately 2 in 5 respondents with social anxiety disorder reported receiving pharmacotherapy or psychotherapy meeting our treatment adequacy indicators. Antidepressant medication was the most common treatment. Logistic regression models showed that the detection of major depression (OR = 4.651; 95% CI: 2.559-8.453) or other anxiety disorder(s) (OR = 2.957; 95% CI: 1.555-5.625) were associated with receiving any adequate treatment, but the detection of social anxiety disorder itself was not (OR = 1.420; 95% CI: 0.696-2.899).

CONCLUSION

Low rates of detection and treatment adequacy based on our indicators demonstrate that efforts must be made to ensure the quality of care for individuals with social anxiety disorder in primary care.

Variation in out of pocket health care costs for individuals with anxiety disorders by type of insurance coverage

PURPOSE

Given that out-of-pocket (OOP) costs impact adherence to treatment and recent and proposed changes to the health insurance system that impact OOP costs, it is imperative to understand the OOP cost burden faced by individuals with anxiety disorders depending upon type of insurance coverage. The objective of this study was to determine the annual OOP cost burden faced by individuals with anxiety disorders and the variation of these costs by type of insurance coverage.

METHODS

Using weighted nationally representative data from the 2011-2014 Medical Expenditure Panel Surveys, total OOP health care costs were assessed for all respondents who indicated that they had an anxiety disorder (N = 9985). Total OOP health care costs were also calculated separately by type of insurance.

RESULTS

Average annual OOP costs among individuals with anxiety was $1152. The highest OOP cost were incurred by individuals with private fee-for-service (FFS) insurance ($1356/year, 4.1% of annual income), while individuals enrolled in HMOs with dual Medicare/Medicaid had the lowest OOP cost ($129/year, 6.8% of annual income). Individuals without insurance had high OOP cost burden ($1309/year, 12.5% of annual income).

CONCLUSION

Individuals with anxiety disorders have a wide range of OOP cost depending upon their insurance coverage. Those with anxiety should carefully consider their choice of insurance coverage if interested in minimizing OOP costs.

The association between different domains of quality of life and symptoms in primary care patients with emotional disorders

Despite the importance of quality of life (QoL) in primary care patients with emotional disorders, the specific influence of the symptoms of these disorders and the sociodemographic characteristics of patients on the various QoL domains has received scant attention. The aim of the present study of primary care patients with emotional disorders was to analyse the associations between four different QoL domains and the most prevalent clinical symptoms (i.e., depression, anxiety and somatization), while controlling for sociodemographic variables. A total of 1241 participants from 28 primary care centres in Spain were assessed with the following instruments: the Patient Health Questionnaire (PHQ)-9 to evaluate depression; the Generalized Anxiety Disorder Scale (GAD)-7 for anxiety; PHQ-15 for somatization; and the World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) to assess four broad QoL domains: physical health, psychological health, social relationships, and environment. The associations between the symptoms and QoL domains were examined using hierarchical regression analyses. Adjusted QoL mean values as a function of the number of overlapping diagnoses were calculated. The contribution of sociodemographic variables to most QoL domains was modest, explaining anywhere from 2% to 11% of the variance. However, adding the clinical variables increased the variance explained by 12% to 40% depending on the specific QoL domain. Depression was the strongest predictor for all domains. The number of overlapping diagnoses adversely affected all QoL domains, with each additional diagnosis reducing the main QoL subscales by 5 to 10 points. In primary care patients with a diagnostic impression of an emotional disorders as identified by their treating GP, clinical symptoms explained more of the variance in QoL than sociodemographic factors such as age, sex, level of education, marital status, work status, and income. Given the strong relationship between depressive symptoms and QoL, treatment of depression may constitute a key therapeutic target to improve QoL in people with emotional disorders in primary care.

Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research

Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.

Treating Pediatric Anxiety: Initial Use of SSRIs and Other Antianxiety Prescription Medications

OBJECTIVE

Multiple pharmacotherapies for treating anxiety disorders exist, including selective serotonin reuptake inhibitors (SSRIs), the recommended first-line pharmacotherapy for pediatric anxiety. We sought to describe initial antianxiety medication use in children and estimate how long antianxiety medications were continued.

METHODS

In a large commercial claims database, we identified children (3-17 years) initiating prescription antianxiety medication from 2004 to 2014 with a recent anxiety diagnosis (ICD-9-CM = 293.84, 300.0x, 300.2x, 300.3x, 309.21, 309.81, 313.23). We estimated the proportion of children initiating each medication class across the study period and used multivariable regression to evaluate factors associated with initiation with an SSRI. We evaluated treatment length for each initial medication class.

RESULTS

Of 84,500 children initiating antianxiety medication, 70% initiated with an SSRI (63% [95% CI, 62%-63%] SSRI alone, 7% [95% CI, 7%-7%] SSRI + another antianxiety medication). Non-SSRI medications initiated included benzodiazepines (8%), non-SSRI antidepressants (7%), hydroxyzine (4%), and atypical antipsychotics (3%). Anxiety disorder, age, provider type, and comorbid diagnoses were associated with initial medication class. The proportion of children refilling their initial medication ranged from 19% (95% CI, 18%-20%) of hydroxyzine initiators and 25% (95% CI, 24%-26%) of benzodiazepine initiators to 81% (95% CI, 80%-81%) of SSRI initiators. Over half (55%, 95% CI, 55%-56%) of SSRI initiators continued SSRI treatment for 6 months.

CONCLUSIONS

SSRIs are the most commonly used first-line medication for pediatric anxiety disorders, with about half of SSRI initiators continuing treatment for 6 months. Still, a third began therapy on a non-SSRI medication, for which there is limited evidence of effectiveness for pediatric anxiety, and a notable proportion of children initiated with 2 antianxiety medication classes.

Anxiety Management in Primary Care: Implementing the National Institute of Clinical Excellence Guidelines

More than 40 million Americans suffer from anxiety disorders, ranking them as one of the most common mental health disorders in America. The purpose of this pilot study was to educate providers on the National Institute Clinical Excellence (NICE) anxiety guidelines and monitor providers' perceived competence in managing anxiety. Results showed perceived competence increased significantly pre-intervention to immediately post-intervention (p=0.001), and data revealed the scores did not change significantly immediately post-to six-weeks post (p=0.170). Providers who implemented the guidelines into practice had significantly higher scores (p=0.026) than those who did not implement the guidelines.

Incentives and disincentives for treating of depression and anxiety in Ontario Family Health Teams: protocol for a grounded theory study

INTRODUCTION

There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016.

METHODS AND ANALYSIS

An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation.

ETHICS AND DISSEMINATION

The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality.

The Met allele of BDNF Val66Met polymorphism is associated with increased BDNF levels in generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) is a common psychiatric disorder characterized by long-term worry, tension, nervousness, fidgeting, and symptoms of autonomic system hyperactivity. The neurobiology of this disorder is still unclear, although it has been shown consistently that the environment and the genetic profile could increase its risk. We examined whether a polymorphism in the brain-derived neurotrophic factor (BDNF) gene, which plays a role in neuroplasticity and memory, could increase the vulnerability to this disorder.

PARTICIPANTS AND METHODS

In our study, 816 participants from a population-based study were genotyped by qPCR for the BDNF functional variant rs6265 (Val66Met) and the BDNF serum levels were measured by ELISA.

RESULTS

Our results showed a significant association between the Met allele and risk for GAD (P=0.014), but no differences were observed in the serum levels of BDNF according to diagnosis (P=0.531) or genotype distribution (P=0.197). However, after stratification according to the GAD diagnosis, the Met allele was associated significantly with an increase in serum BDNF levels compared with the Val/Val genotype in GAD participants (F=3.93; P=0.048). The logistic regression analysis confirmed the independent association of Met allele as a risk factor for development of GAD after adjusting for confounder variables (β=0.528; 95% confidence interval: 0.320-0.871; P=0.012).

CONCLUSION

These results suggest that BDNF could be involved in the neurobiology of GAD and might represent a useful marker associated with the disease.

Treatment adequacy of anxiety disorders among young adults in Finland

BACKGROUND

Anxiety disorders are common in early adulthood, but general population studies concerning the treatment adequacy of anxiety disorders taking into account appropriate pharmacological and psychological treatment are scarce. The aims of this study were to examine treatments received for anxiety disorders in a Finnish general population sample of young adults, and to define factors associated with receiving minimally adequate treatment and with dropping out from treatment.

METHODS

A questionnaire containing several mental health screens was sent to a nationally representative two-stage cluster sample of 1894 Finns aged 19 to 34 years. All screen positives and a random sample of screen negatives were invited to a mental health assessment including a SCID interview. For the final diagnostic assessment, case records from mental health treatments for the same sample were obtained. This article investigates treatment received, treatment adequacy and dropouts from treatment of 79 participants with a lifetime anxiety disorder (excluding those with a single specific phobia). Based on all available information, receiving antidepressant or buspirone medication for at least 2 months with at least four visits with any type of physician or at least eight sessions of psychotherapy within 12 months or at least 4 days of hospitalization were regarded as minimally adequate treatment for anxiety disorders. Treatment dropout was rated if the patient discontinued the visits by his own decision despite having an adequate treatment strategy according to the case records.

RESULTS

Of participants with anxiety disorders (excluding those with a single specific phobia), 41.8 % had received minimally adequate treatment. In the multivariate analysis, comorbid substance use disorder was associated with antidepressant or buspirone medication lasting at least 2 months. Those who were currently married or cohabiting had lower odds of having at least four visits with a physician a year. None of these factors were associated with the final outcome of minimally adequate treatment or treatment dropout. Participants with comorbid personality disorders received and misused benzodiazepines more often than others.

CONCLUSIONS

More efforts are needed to provide adequate treatment for young adults with anxiety disorders. Attention should be paid to benzodiazepine prescribing to individuals with personality disorders.

Shifts in the care for patients presenting in primary care with anxiety; stepped collaborative care parameters from more than a decade

BACKGROUND

The mental health burden on primary care is substantial and increasing. Anxiety is a major contributor. Stepped collaborative care (SCC) is implemented worldwide to improve patient outcomes, but long term real-world evaluations of SCC do not exist. Using routinely used electronic medical records from more than a decade, we investigated changes in anxiety prevalences, whether physicians made distinction between non-severe and severe anxiety, and whether these groups were referred and treated differently, both non-pharmacologically and pharmacologically.

METHODS

Retrospective assessment of anxiety care parameters recorded by 54 general practitioners between 2003 and 2014, in the electronic medical records of a dynamic population of 49,841-69,413 primary care patients.

RESULTS

Substantial shifts in anxiety care parameters have occurred. The prevalence of anxiety symptoms doubled to 0.9% and of anxiety disorders almost tripled to 1.1%. Use of ICPC codes seemed comprehensive and use of instruments to support in anxiety level differentiation increased to 13% of anxiety symptom and 7% of anxiety disorder patients in 2014. Minimal interventions were used more frequently, especially for anxiety symptoms (OR 21 [95% CI 5.1-85]). The antidepressant prescription rates decreased significantly for anxiety symptoms (OR 0.5 [95% CI 0.4-0.8]) and anxiety disorders (OR 0.6 [95% CI 0.4-0.8]). More patients were referred to psychologists and psychiatrists.

CONCLUSIONS

We found shifts in anxiety care parameters that follow the principles of SCC. Future primary care research should comprehensively assess the use of the SCC range of therapeutic options, tailored to patients with all different anxiety severity levels.

The efficacy and pattern of use of a computer-assisted programme for the treatment of anxiety: a naturalistic study using mixed methods in primary care in Spain

BACKGROUND

Naturalistic studies to assess the efficacy and pattern of use of computer-delivered psychotherapy programmes in real daily clinical conditions are infrequent. Anxiety disorders are the most common mental disorders, and many of them do not receive adequate management, especially in primary care settings. The objective of this study is to assess the efficacy of an internet-delivered programme for anxiety in primary care.

METHODS

Multicentre, naturalistic study. Patients with generalised anxiety disorder were recruited (N=229). The generalised anxiety disorder 7-item scale (GAD-7) was the only outcome measured. Qualitative methods were used to analyse patient-therapist interactions.

RESULTS

Only 13.5% of patients completed the programme. Analysis per intent-to-treat using Last Observation Carried Forward showed a significant GAD-7 decrease post-treatment (-2.17: SD=4.77; p=0.001) (Cohen׳s d=0.43) with a correlation between the number of sessions and decrease in anxiety (Rho=-0.34, p=0.001). The analysis per protocol showed significantly decreased GAD-7 (-4.13; SD=6.82; p=0.002) (d=0.80). Withdrawal was related to low programme friendliness, lack of a partner, and higher education. Only 17.47% of the patients consulted their therapists. Facilitators were patient demand for information and sufficient time. Barriers were lack of motivation and lack of connection with the programme.

LIMITATIONS

The main limitations of this study included the use of an open trial design, the lack of follow-up, and the inclusion of only one outcome (GAD-7).

CONCLUSIONS

To our knowledge, this is the first study with computer-delivered psychotherapy (CDP) on GAD. CDP for anxiety is efficacious in naturalistic environments. Specific facilitators and barriers should be considered.

Pharmacotherapy of anxiety disorders in German-speaking countries: current status and changes between 1994 and 2011

Over the past years, international treatment guidelines have been established for the treatment of anxiety disorders. Nevertheless, little is known as to whether the actual inpatient treatment follows these guidelines. The main goal of this study was to answer the question whether patients with anxiety disorder are treated according to treatment guidelines. A total of 2,573 psychiatric inpatients with the diagnosis of anxiety disorder (920 men, 1,653 women) were identified on the basis of the data of the international drug safety programme in psychiatry AMSP. Of these patients, 25.3% presented with phobia, 26.6% with panic disorder, 18.7% with generalized anxiety disorder (GAD), and 29.4% with other diagnoses of anxiety. In all of the patients, 12.7% did not receive any psychotropic medication and 22.9% were not treated with antidepressants. Only 59.3% of patients with GAD, 73.9% of patients with panic disorder, and 52.1% of patients with phobia were treated according to diagnostic guidelines. The majority (60.3%) of all patients received one or two psychotropic drugs, and only 3.7% received five or more psychotropic drugs. In two groups of patients (one group with phobia and one with panic disorder), the annual prescription rate of antidepressants significantly increased over time. The prescription rate for anticonvulsants in patients with GAD increased from 0% in 1997 to 41.7% in 2011, and for antipsychotics, from 40.7% in 1997 to 47.2% in 2011. In particular, patients with GAD were commonly treated with antipsychotics.

Epidemiology of generalized anxiety disorder in Canadian military personnel

Introduction: This study examined the prevalence, clinical characteristics, help seeking patterns, and military experiences associated with past-year generalized anxiety disorder (GAD) using a representative sample of military personnel. Methods: Data were from the Canadian Community Health Survey–Canadian Forces Supplement ( n = 5,115 Regular Force, n = 3,286 Reserve Force), conducted by Statistics Canada on behalf of the Department of National Defence in 2002. GAD and other mental disorders were assessed using the World Mental Health Composite International Diagnostic Interview. Clinical features of GAD of interest included mean age of onset and episode length, symptoms, degree of impairment and co-occurring disorders, and perceived need for help and help seeking. Multivariate logistic regression models were conducted to examine the sociodemographic, military characteristics, and mental disorders correlated with past-year GAD. Results: Past-year and lifetime prevalence rates of GAD were 1.7% and 4.4%, respectively. The majority of military personnel with past-year GAD reported being severely impaired at work and in their relationships and social life. Those with past-year GAD, relative to those without it, had higher odds of having another mental disorder. Of military personnel with past-year GAD, 72.2% had sought help. Regular Force personnel, relative to reservists, had higher odds of having past-year GAD, as did individuals who witnessed atrocities. Discussion: GAD is modestly prevalent in the Canadian military and is associated with considerable functional impairment. Nevertheless, high rates of help seeking for GAD may speak to the availability, accessibility, and acceptability of mental health care in the Canadian Armed Forces.