Quality of and patient satisfaction with primary health care for 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.

Sequenced Treatment Effectiveness for Posttraumatic Stress (STEPS) Trial: A protocol for a pragmatic comparative effectiveness trial with baseline results

BACKGROUND

There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments.

METHOD

Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5).

RESULTS

Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline.

CONCLUSION

Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.

Curative care expenditure of outpatient anxiety disorder in Liaoning Province, 2015-2020-based on "System of Health Accounts 2011"

Introduction

Anxiety disorders are the most common mental disorder, experienced by more than a quarter of the population. This study examines total outpatient curative care expenditures (CCE) for anxiety disorders and changes in their composition based on the System of Health Accounts 2011 (SHA 2011).

Methods

This study used multi-stage stratified random from a total of 9,318,513 outpatient sample data by 920 healthcare organizations, a total of 109,703 cases of anxiety disorders from 53 sample organizations (5.76%) from 2015 to 2020. Univariate analysis, multifactor analysis and structural equation modeling (SEM) were used to explore the influential factors affecting outpatient CCE for anxiety disorders.

Results

Anxiety disorder outpatient CCE from 2015 to 2020 continued to increase from CNY 99.39million in 2015 to CNY 233.84 million in 2020, mainly concentrated in western medicine costs, 15-64 years, general hospital, generalized anxiety disorder and public financing. The results of univariate analysis showed statistically significant differences in all subgroups, and the results of multivariate analysis and SEM showed that the choice to purchase western drugs, purchase prepared Chinese drugs, choice to have a checkup, urban employees' basic medical insurance, and 0-14 years old were associated with high anxiety disorder outpatient CCE.

Conclusion

Initiatives to improve the essential drug system, reduce the out-of-pocket (OOP) ratio, and strengthen primary health care to effectively reduce the medical burden on patients.

Comparing psychological versus pharmacological treatment in emotional disorders: A network analysis

Transdiagnostic group cognitive behavioural therapy (TD-GCBT) is more effective in improving symptoms and severity of emotional disorders (EDs) than treatment as usual (TAU; usually pharmacological treatment). However, there is little research that has examined the effects of these treatments on specific symptoms. This study used Network Intervention Analysis (NIA) to investigate the direct and differential effects of TD-GCBT + TAU and TAU on specific symptoms of anxiety and depression. Data are from a multicentre randomised clinical trial (N = 1061) comparing TD-GCBT + TAU versus TAU alone for EDs. The networks included items from the PHQ-9 (depression) and GAD-7 (anxiety) questionnaire and mixed graphical models were estimated at pre-treatment, post-treatment and 3-, 6- and 12-month follow-up. Results revealed that TD-GCBT + TAU was associated with direct effects, mainly on several anxiety symptoms and depressed mood after treatment. New direct effects on other depressive symptoms emerged during the follow-up period promoted by TD-GCBT compared to TAU. Our results suggest that the improvement of anxiety symptoms after treatment might precipitate a wave of changes that favour a decrease in depressive symptomatology. NIA is a methodology that can provide fine-grained insight into the likely pathways through which treatments exert their effects.

Clinical practice for unspecified anxiety disorder in primary care

Aim

Clinicians face difficulties in making treatment decisions for unspecified anxiety disorder due to the absence of any treatment guidelines. The objective of this study was to investigate how familiar and how often primary care physicians use pharmacological and nonpharmacological approaches to manage the disorder.

Methods

A survey was conducted among 117 primary care physicians in Japan who were asked to assess the familiarity of using each treatment option for unspecified anxiety disorder on a binary response scale (0 = "unfamiliar," 1 = "familiar") and the frequency on a nine-point Likert scale (1 = "never used," 9 = "frequently used").

Results

While several benzodiazepine anxiolytics were familiar to primary care physicians, the frequencies of prescribing them, including alprazolam (4.6 ± 2.6), ethyl loflazepate (3.6 ± 2.4), and clotiazepam (3.5 ± 2.3), were low. In contrast, certain nonpharmacological options, including lifestyle changes (5.4 ± 2.3), coping strategies (5.1 ± 2.7), and psychoeducation for anxiety (5.1 ± 2.7), were more commonly utilized, but to a modest extent. When a benzodiazepine anxiolytic drug failed to be effective, primary care physicians selected the following management strategies to a relatively high degree: differential diagnosis (6.4 ± 2.4), referral to a specialist hospital (5.9 ± 2.5), lifestyle changes (5.2 ± 2.5), and switching to selective serotonin reuptake inhibitor (5.1 ± 2.4).

Conclusion

Primary care physicians exercise caution when prescribing benzodiazepine anxiolytics for unspecified anxiety disorder. Nonpharmacological interventions and switching to SSRI are modestly employed as primary treatment options and alternatives to benzodiazepine anxiolytics. To ensure the safe and effective treatment of unspecified anxiety disorder in primary care, more information should be provided from field experts.

Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial

Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Satisfaction of psychologically impaired patients with health-care services: A Saudi Arabian perspective

Psychological problems affect a sizable portion of the population, and they require special care. In the current study, we aimed to assess patient satisfaction with the healthcare system at one of the multispecialty hospitals in Riyadh, Saudi Arabia, as well as to identify potential factors that can have an impact on patient satisfaction. A validated pre-tested questionnaire including features to evaluate general hospital services (HS-6 items), nursing services (NS-3 items), pharmacy services (PS-7 items), and a standard patient satisfaction questionnaire (PSQ-18 item) was administered to patients who had been receiving therapy for their psychological disease for the past 3 months. Using binary and multiple regression analysis, the strengths of the associations between sociodemographic factors and patient satisfaction measures were evaluated. The results were expressed as adjusted odds ratios (AOR), which were deemed significant when the P value was < 0.05. Sixty-six percent of the 258 study participants were men, and sixty percent of them were between the ages of 18 and 35 years. The bulk of survey respondents (74%) were employed, married, and well-educated. Our research revealed that those who were employed (AOR, HS-2.5; NS-2.65, PS-2.32), have a higher education (AOR, HS-2.23, NS-2.63, PS-2.82), male gender (AOR, HS-1.12, NS-1.08, PS-1.86) and between the ages of 18 and 35 years (AOR, HS-1.48, NS-1.53, PS-1.67) were more likely to be satisfied with general hospital, nursing, and pharmacy services. Further, those who were married had 1.43 and 1.21 times more chance of satisfaction with the pharmacy and nursing services, respectively, compared to singles. Additionally, those with employment had odds of being satisfied that were 2.4 times higher, highly educated individuals had odds that were 2.1 times higher, participants between the ages of 18 and 35 had odds that were 1.51 times higher, and men had odds that were 1.41 times higher on the patient satisfaction questionnaire scale (PSQ-18). Overall, the study participants' satisfaction with general hospital, nursing, and pharmacy services was 70, 76.3, and 83.3%, respectively, compared to only 61.2% on the PSQ-18. Participants in the survey awarded the hospital amenities, pharmacy services, and nursing care high ratings. The medical care, however, fell short of expectations. The study's findings suggest that action needs to be taken to enhance healthcare system services, particularly in the psychological departments of the medical organization.

Can placebos reduce intrusive memories?

After traumatic experiences, intrusive memories can flash back and evoke significant distress. Here, we investigated whether the frequency and severity of intrusions can be reduced by the provision of placebo. After the (online) exposure to the trauma-film paradigm, healthy participants (N = 112) received deceptive placebo (DP), open-label placebo (OLP), or no treatment. In the DP group, participants were led to believe to receive a dopamine-modulating drug, which was supposed to disrupt the consolidation of traumatic memories, although they in fact received the same placebo tablets as the OLP group for one week. The results show that the groups did not differ in the frequency of intrusive memories after one week. However, participants receiving OLP reported a significantly reduced intensity of intrusions as compared to DP. Across groups, negative expectations about the intensity and controllability of intrusions were associated with a higher frequency of intrusions, higher distress, higher burden, and more negative appraisal. The results suggest that expectations play an important role in the emergence of intrusive memories and that some of the disabling aspects of intrusive memories can be reduced by placebo. This may carry clinical potential because placebos are an accessible, cost-effective intervention to reduce the risk of intrusive memories.

Satisfaction and associated factors among psychiatry service users at Amanuel mental specialized hospital. Addis Ababa, Ethiopia

BACKGROUND

Patient service satisfaction is the central point for the health system. Worldwide, around 450 million people suffer from mental and behavioral disorders. Clients who are dissatisfied with the service will miss appointments, abandon the treatment plan, and eventually relapse from the illness. Despite improved access to health services, the satisfaction from health institution services was decreasing from time to time and there is little information on health service consumer satisfaction.

OBJECTIVE

To assess the satisfaction and associated factors among psychiatric service consumers at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2021/2022.

METHODS AND MATERIALS

An institutional-based cross-sectional study was conducted among 420 psychiatric service users from December 15 to January 16, 2021/2022. Systematic random sampling was used. A face-face interview technique and chart review were used to collect the data and a standard and validated tool called the mental health service satisfaction scale (MHSSS) was used to measure satisfaction. The collected data was entered into EPI info version 7 and exported to SPSS version 22 for analysis. The binary logistic regression model was used to analyze the data and bivariable and multivariable logistic regression analyses were conducted to identify associated factors with satisfaction. The level of significance was reported at P < 0.05.

RESULTS

The study showed that the magnitude of patient satisfaction was 63.3% [95% CI 58.3-67.9%). Sex (AOR = 1.7, 95% CI (1.072-2.88)], educational status (AOR 4.2, 95% CI 1.64-1.8), residency [AOR = 1.8, 95% CI (1.098-3.19)], distance from the hospital [AOR 0.56, (0.34-0.93)] were significantly associated with patient satisfaction at p < 0.05.

CONCLUSION

The magnitude of patient satisfaction was high. The study showed that Sex, educational status, residence, and distance from the hospital were significantly associated with satisfaction. Prioritizing care for female patients and those coming from a distance is necessary. More ever, it is preferable to routinely and continually monitor healthcare facilities so that timely feedback can be given and problems that affect patient satisfaction can be resolved.

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).

Effectiveness of mindfulness-based cognitive therapy follow-up programs for pharmacotherapy refractory anxiety disorders: a study protocol for a randomized controlled feasibility trial

Background

Augmented mindfulness-based cognitive therapy (MBCT) with treatment as usual (mainly pharmacotherapy) is reported to be effective after treatment for anxiety disorders. However, whether its effectiveness persists in the long term is unclear.

Objective

This study aims to examine the feasibility, acceptability, and effectiveness of a follow-up program by conducting a feasibility randomized controlled trial (RCT) that compares augmented MBCT with follow-up sessions and that without follow-up sessions in preparation for a definitive RCT.

Methods

The study involves an 8-week MBCT with a 10-month follow-up. Patients aged 20 to 65 years who meet the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for panic disorder, agoraphobia, or social anxiety disorder, which is not remitted with usual treatment for at least 4 weeks, will be included in the study and randomly allocated to receive augmented MBCT with follow-up sessions or augmented MBCT without follow-up sessions. For this feasibility RCT, the primary outcomes are (1) study inclusion rate, (2) dropout rate, (3) attendance rate, and (4) mean and standard deviation of several clinical measures at 8 weeks and 5, 8, and 12 months.

Results

We started recruiting participants in January 2020, and 43 participants have been enrolled up to January 2021. The study is ongoing, and data collection will be completed by May 2022.

Conclusions

This study is novel in terms of its design, which compares augmented MBCT with and without follow-up sessions. The limitations of the trial are as follows: (1) mixed participants in terms of the delivery mode of the intervention, and (2) lack of a pharmacotherapy-alone arm. Owing to its novelty and significance, this study will provide fruitful knowledge for future definitive RCTs.

Trial Registration

UMIN Clinical Trials Registry UMIN000038626; https://tinyurl.com/2p9dtxzh

International Registered Report Identifier (IRRID)

DERR1-10.2196/33776

The Impact of Brief Interventions on Functioning Among those Demonstrating Anxiety, Depressive, and Adjustment Disorder Symptoms in Primary Care: The Effectiveness of the Primary Care Behavioral Health (PCBH) Model

Limited scalability combined with limited opportunities for patients to receive evidence-based interventions in traditional behavioral health treatment models for anxiety and depression creates a gap in access to adequate care. Primary Care Behavioral Health (PCBH) is one model of treatment in which behavioral health consultants (BHC) work directly within primary care settings, but there is limited evidence regarding the effectiveness of this model of care. The functional outcomes and appointment characteristics of Beneficiaries (N = 5402) within the military healthcare system were assessed. The study sample was predominately Caucasian, female, military dependents seen for 2 to 4 appointments. A reliable change index revealed that 17.2% showed reliable improvement and 2.4% showed reliable deterioration (p < .05). Of individuals with a severe Behavioral Health Measure-20 score at baseline, 81.5% showed some improvement at their final appointment, with 33% demonstrating reliable improvement. A mixed model analysis was used to determine the predictive value of appointment characteristics. All relations were significant (p < .001), except the between-subjects effect of appointment duration. Appointment duration revealed individuals reported worse functioning at the start of atypically long appointments. Individuals with generally longer intervals between appointments reported worse functioning, but an atypically long interval predicted better functioning at the following appointment. As it relates to number of appointments, individuals with more total appointments reported worse functioning outcomes, with generally better functioning across appointments. Overall, these data support the effectiveness of time-limited care provided through the PCBH model.

Access and attitudinal barriers to engagement in integrated primary care mental health treatment for rural populations

PURPOSE

Compared to urban areas, rural populations are less likely to engage in mental health care. Using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry, we examined the effect of rurality on engagement in mental health treatment as well as the role of potential mediators.

METHODS

Data were obtained from medical records and surveys. We defined rurality using the rural-urban commuting area codes. Baseline mediators included the Endorsed and Anticipated Stigma Inventory and the Assessment of Perceived Access to Care. Engagement outcomes included number of psychotherapy visits and self-reported medication use. We used path analysis to examine the relationship between rurality and engagement and the influence of mediating variables.

FINDINGS

Rural participants were less likely to initiate psychotherapy (OR = 0.49; adjusted P = .036), although rurality was not associated with number of psychotherapy sessions or medication use. Rurality was associated with a small elevation in negative beliefs about mental health, but this potential mediator was not associated with engagement. Rurality was negatively associated with lower perceived need for treatment (OR = 0.67, adjusted P = .040), which was in turn positively associated with initiating psychotherapy (OR = 1.99, adjusted P = .001).

CONCLUSIONS

Neither rurality itself nor the potential mediators had a large effect on engagement. Federally Qualified Health Centers offering colocated and/or integrated mental health care appear to be mostly mitigating rural-urban disparities in mental health engagement. Improving rates of psychotherapy initiation for rural patients should remain a policy goal.

Perceived quality of primary healthcare services and its association with institutional trust among caregivers of persons diagnosed with a severe mental illness in China

WHAT IS KNOWN ON THE SUBJECT

Low utilization of the family-oriented community rehabilitation services is a threatening challenge facing low- and middle- income countries. Family caregiver's trust in community healthcare providers is the precondition of service utilization and is shaped by their perceived quality of primary healthcare services from previous experience. Most of the studies concerning the relationship between perceived quality and institutional trust were conducted in western countries, resulting in limited attention paid to conditions in non-western countries. Which aspect of quality predicts institutional trust in China has not been studied yet.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

In China's context, institutional trust was generally associated with communication, worry relief and risk of privacy leak, but not with technical competence. Significant rural-urban disparity was observed: among rural respondents, institutional trust was associated with technical competence, communication and risk of privacy leak, but not with worry relief; institutional trust was only associated with worry relief in urban respondents.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Mental health nurses training or working with community healthcare workers may improve their technical and communicative competence. Priorities may differ between rural and urban areas. Mental health nurses or community healthcare workers may provide more family-oriented psycho-education to rural families, and more emotional support to urban families. Wider public anti-stigma initiatives are needed to reduce the affiliated stigma of families of persons diagnosed with a severe mental illness.

ABSTRACT

Introduction Prior studies suggested that caregiver's trust in community healthcare providers is the precondition of the utilization of community-based rehabilitation services and is shaped by their perceived quality of primary healthcare services. Nevertheless, the research conducted in non-western countries is scarce, and which aspect of quality is associated with institutional trust in China has not been studied. Aim To explore the association between perceived quality of primary healthcare services and institutional trust in China's context. Methods This cross-sectional study was conducted with 796 family caregivers from Eastern, Central and Western China between August 2018 and October 2019. Perceived quality of primary healthcare services was measured by technical competence, communication, worry relief and risk of privacy leak. Results Institutional trust was generally associated with communication, worry relief and risk of privacy leak, but not with technical competence. Among rural respondents, institutional trust was associated with technical competence, communication and risk of privacy leak, but not with worry relief. Contrary finding was observed in urban respondents. Discussion and implications for practice With rural-urban disparity considered, strategies such as improving the technical and communicative competence of community healthcare workers, providing family-oriented psycho-education and emotional support, and promoting public anti-stigma initiatives may be worth consideration.

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.

Maintaining Outcomes of Internet-Delivered Cognitive-Behavioral Therapy for Depression: A Network Analysis of Follow-Up Effects

Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments. Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained. Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention. Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT02178631.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial

BACKGROUND

Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care.

METHODS

In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis.

RESULTS

A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79].

CONCLUSIONS

Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

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).

Continuity of care is associated with satisfaction with local health care services

Background

Satisfaction is a major element in assessing quality of care. It has decreased in Finland in recent decades as well as continuity of care. We investigated which demographic, health-related, and local health care service factors, especially continuity of care, are associated with the population’s satisfaction with local health care services.

Methods

The data are part of the Health and Social Support (HeSSup) study’s follow-up questionnaire in 2012. The study is based on a random Finnish population sample. Satisfaction was studied based on the question “How satisfied are you with your local health care services?” Demographic factors, obesity, self-assessed health status, depressive mood (BDI-12 questionnaire), New York Heart Association class, and chronic diseases were asked in the questionnaire. Questions describing local health care services were also presented. We assessed the association of an assigned and named GP and the respondents’ proactivity in contacting the same doctor with satisfaction. We used crosstabulation and binary logistic regression in the analyses.

Results

The Health and Social Support study was answered in 2012 by 15,993 participants (45.4%) and majority (61.3%) was satisfied with their local health care services. An assigned and named GP (OR 1.79; 95% CI 1.67–1.92) and the respondent’s proactivity in contacting the same doctor (OR 1.23; 95% CI 1.15–1.32) were associated with satisfaction in the adjusted multivariate analysis. BDI score < 19 had the strongest association with satisfaction (OR 1.91; 95% CI 1.65–2.23). Older participants, males, and those in a relationship were more likely to be satisfied.

Conclusions

A named GP in primary care proved to have a positive correlation with patient satisfaction. Depression was associated with decreased satisfaction. A named GP indicates continuity of care, and it should be seriously considered when planning treatment for patients with chronic conditions.

Mixed methods research on satisfaction with basic medical insurance for urban and rural residents in China

Background

There have been few studies on satisfaction with integrated basic medical insurance for urban and rural residents (URRBMI), and satisfaction with URRBMI is not very high because of the complexity of its policies and differences among the insured. The aim of the present study was to explore the factors that influence satisfaction with URRBMI in China and to provide scientific suggestions to the government for how to effectively manage and improve the policy.

Methods

An explanatory sequential design of mixed methods research was used. A quantitative research using a three-stage stratified cluster sampling method was used to randomly select the guardians of pupils who participated in URRBMI (n = 1335). The quantitative research was conducted to calculate the latent variables’ scores and path coefficients between latent variables using SmartPLS3.0. With public trust, public satisfaction, and perceived quality as the target variables, important-performance analysis (IPA) was used to explore the important but underperforming factors, which were the key elements to improving satisfaction with URRBMI. A purposeful sampling strategy according to satisfaction level was used to obtain qualitative research subjects from among the quantitative research subjects. A qualitative research was conducted using semi-structured interviews, and the thematic analysis method was used to summarize the interview data.

Results

The three strongest paths were perceived quality to public satisfaction, with a total effect of 0.737 (t = 41.270, P < 0.001); perceived quality to perceived value, with a total effect of 0.676 (t = 31.964, P < 0.001); and public satisfaction to public trust, with a total effect of 0.634 (t = 31.305, P < 0.001). IPA revealed that public satisfaction and perceived quality were key factors for public trust and that perceived quality was of high importance for public satisfaction but had low performance. The policy quality was a determining factor for perceived quality. The qualitative research results showed that the most unsatisfactory aspect for the insured was the policy quality.

Conclusions

This study found that improving quality is key to improving public satisfaction with and public trust in URRBMI. The government should improve the compensation level by broadening the channel of financing for the URRBMI fund, rationally formulating reimbursement standards, and broadening the scope of the drug catalog and the medical treatment projects. The government should establish a stable financing growth mechanism and effective methods of providing health education to improve public satisfaction and public trust.

Bipolar disorder and PTSD screening and telepsychiatry diagnoses in primary care

OBJECTIVE

To describe clinical diagnoses from telepsychiatrist consultation in safety net primary care settings for adult patients screening positive for bipolar disorder, PTSD, or both.

METHODS

Patients were administered the PTSD Checklist (PCL-6) and the Composite International Diagnostic Interview 3.0 (CIDI) for bipolar disorder. Positive screening result definitions were PCL-6 score of ≥14 and CIDI positive stem question responses and score of ≥8. Patient characteristics were assessed by survey. Psychiatrists consulted in primary care via telehealth and recorded clinical diagnoses.

RESULTS

Among 767 patients attending consultation with a telepsychiatrist, 495 (65%) screened PCL-6 positive only, 249 (32%) screened both PCL-6 and CIDI positive, and 23 (3%) screened CIDI positive. Approximately two-thirds screening PCL-6 positive were diagnosed with PTSD, and most had comorbid mood disorder diagnoses, with bipolar disorder diagnosis occurring more often in those screening CIDI positive compared to negative (42% vs. 15%). Positive predictive values were 64.9% for PCL-6 and 43.8% for CIDI.

CONCLUSION

Most individuals screening positive for PTSD and/or bipolar disorder had two or more psychiatric diagnoses; misclassification exists for both instruments but was greater for CIDI. Psychiatrist consultation early in treatment for individuals screening positive on the PCL-6 and/or CIDI could help clarify diagnoses and improve treatment planning.

Perceived Patient Satisfaction and Associated Factors among Psychiatric Patients Who Attend Their Treatment at Outpatient Psychiatry Clinic, Jimma University Medical Center, Southwest Ethiopia, Jimma, 2019

Background

In health care, patient satisfaction is an attitudinal response and a pillar for quality assurance, but there is reluctance to measure it among mentally ill patients. Satisfied patients become more compliant. However, no study was done in this study area before. Therefore, this study was conducted to determine the magnitude of perceived patient satisfaction and associated factor at Jimma University Medical Center, outpatient psychiatry clinic.

Methods

Cross-sectional study design was conducted, and systematic random sampling technique was used to get study participants. The 24-item Mental Health Service Satisfaction Scale (a validated tool in Ethiopia) was used to assess patient satisfaction. Data was entered using Epi-data 3.1 and exported to the Statistical Package for the Social Sciences 22.0 for analysis. Linear regression analysis (P < 0.05) was used to identify the association between the outcome and independent variable.

Result

414 respondents participated in the study with response rate of 98%. The overall percentage of patient satisfaction was 50.3% (95% CI 48.4%-51.2%). Being male (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (Conclusion and Recommendation. This study found that half of the study participants are satisfied with the service. Distance from the hospital, current substance use, waiting time, and having good social support were identified as modifiable factors that can be improved through working with stakeholders to increase patient satisfaction.

Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics

OBJECTIVE

Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs.

INTERVENTIONS

Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly.

METHODS

Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome.

RESULTS

A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean.

DISCUSSION

We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.

Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders.

METHODS

We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings.

FINDINGS

We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs.

LIMITATIONS

Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed.

CONCLUSION

Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient- and family-centeredness of collaborative care.

Patient satisfaction and associated factors among psychiatry outpatients of St Paulo's Hospital, Ethiopia

BACKGROUND

Patient satisfaction with mental healthcare service is recognised as an important integral part of measuring the outcomes and performance of clinical service delivery. It is not well studied in Ethiopia. Therefore, it is essential to improve service in the future.

AIMS

To assess patient satisfaction and associated factors among psychiatry outpatients at St. Paulo's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted with consecutive sampling technique from May to June 2018. Data were collected using a Client Satisfaction Questionnaire (CSQ-8). Both bivariate and multivariate ordinal logistic regression analyses were used. Variables with p value <0.05 at multivariate analysis were considered statistically significant.

RESULTS

A total of 589 participants were enrolled with a response rate of 98.2%. In regard to the magnitude of patient satisfaction, 50.3% (95% CI 46.0 to 54.2) were highly satisfied, 31.0% (95% CI 27.2 to 34.8) were satisfied, and 18.7% (95% CI 15.4 to 22.1) were dissatisfied. Male sex (adjusted OR (AOR) 2.30, 95% CI 1.57 to 3.36), inability to read and write (AOR 2.23, 95% CI 1.10 to 4.66), being unemployed (AOR 1.69, 95% CI 1.15 to 2.47), obtaining services for free (AOR 1.57, 95% CI 1.11 to 2.22), and availability of medication (AOR 1.62, 95% CI 1.13 to 2.23) were significantly associated with patient satisfaction.

CONCLUSIONS

The study showed that further improvements in patient satisfaction are required. Male sex, inability to read and write, being unemployed, obtaining services free of charge, and availability of medication were significantly associated with patient satisfaction. More than half of the participants were dissatisfied with the waiting time to receive services. The provision of services within a reasonable timeframe and meeting patient expectations are helpful for good health outcomes.

Treatment of Anxiety Disorders - The Role of Pharmacists

Anxiety disorders represent the group of the most prevalent mental diseases which may have serious negative consequences for mental and social health. Anxiety is generally treated with a combination of the psychotherapeutic treatment and pharmacotherapy. Pharmacotherapy of anxiety implies the use of antidepressants, which are used as basic drugs, and an additional therapy with anxiolytics. This therapeutic approach in the treatment of anxiety disorders is accompanied by significant limitations. Adherence of anxiety patients is often insufficient due to the late onset of the effects of antidepressants, the appearance of adverse effects, the stigmatization of psychiatric patients in society and other reasons. Certain exogenous factors, such as an excessive use of coffee, smoking of marijuana, sleep disorders and personal problems, such as family problems or financial problems, can exacerbate anxiety and make it more difficult to treat it. Prolonged use of benzodiazepines, as an adjunct therapy in the treatment of anxiety, may be accompanied by the development of psycho-physical dependence. Finally, the drugs used to treat anxiety have a serious potential for the drug-drug interactions. All of these limitations may be completely or partially overcome through the active participation of Pharmacists as equal members of collaborative medical teams for the treatment of anxiety disorders.

Internet-delivered cognitive behavioral therapy for panic disorder with or without agoraphobia: a systematic review and meta-analysis

The current systematic review and meta-analysis examined the efficacy and effectiveness of internet-delivered cognitive behavioral therapy (iCBT) on panic disorder and agoraphobia symptom severity. Twenty-seven studies were identified. Results from nine randomised controlled trials (RCTs) showed that iCBT outperformed waiting list and information controls for panic (g = 1.22) and agoraphobia (g = .91) symptoms, but the quality of RCTs varied and heterogeneity was high. Results from three RCTs suggested iCBT may have similar outcomes to face-to-face CBT in reducing panic and agoraphobia symptoms. Within-group effect sizes between baseline and post-treatment were large for panic (n = 29, g = 1.16) and medium for agoraphobia symptom severity (n = 18, g = .73). Subgroup analyses of within-group pre/post treatment effect sizes showed larger within-group effect sizes for efficacy studies (n = 15) compared to effectiveness studies (n = 14) for panic severity (g = 1.38 vs. g = .98) but not agoraphobia severity. There was no impact of program length, inclusion or arousal reduction techniques, or degree of clinician support. Within-group effects of iCBT suggest the reduction in panic and agoraphobia symptom severity is maintained at 3-6 month follow-up (n = 12).

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a common and disabling illness that is often underdiagnosed and undertreated. Patients with GAD are at increased risk for suicide as well as cardiovascular-related events and death. Most patients can be diagnosed and managed by primary care physicians. Symptoms include chronic, pervasive anxiety and worry accompanied by nonspecific physical and psychological symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbances). Effective treatments include psychotherapy (often cognitive behavioral therapy) and pharmacotherapy, such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.

Comparing anxiety and depression to obesity and smoking as predictors of major medical illnesses and somatic symptoms

OBJECTIVE

Anxiety and depression predict poor physical health longitudinally, but are neglected in primary care settings compared to other risk factors such as obesity and smoking. Further, anxiety has been less commonly studied than depression, and whether anxiety has unique predictive effects for physical health is unknown. We compared anxiety and depression to obesity and smoking as predictors of physical health indices and examined unique predictive effects of anxiety and depression.

METHOD

Using data from the Health and Retirement study, a US population-based cohort study of older adults, we tested longitudinal associations of anxiety and depression symptoms with onset of self-reported physical health indices (N = 15,418; M age = 68). Medical illnesses (heart disease, stroke, arthritis, high blood pressure, diabetes, and cancer) and somatic symptoms (stomach problems, shortness of breath, dizziness, back pain, headache, pain, and eyesight difficulties) were assessed on two occasions over four years. Anxiety and depression were measured at the initial time point and tested as predictors of medical illness and somatic symptom onset.

RESULTS

Anxiety and depression symptoms predicted greater incidence of nearly all medical illnesses and somatic symptoms. Effects were as strong as or stronger than those of obesity and smoking, and anxiety and depression independently increased risk for most physical health indices assessed.

CONCLUSIONS

Findings suggest that anxiety and depression are as strongly predictive of poor future physical health as obesity and smoking and that anxiety is independently linked to poor physical health. Greater attention should be paid towards these conditions in primary care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

A pragmatic randomized controlled trial of group transdiagnostic cognitive-behaviour therapy for anxiety disorders in primary care: study protocol

BACKGROUND

Anxiety disorders are the most common mental disorders in community settings, and they are associated with significant psychological distress, functional and social impairment. While cognitive behaviour therapy (CBT) is the most consistently efficacious psychological treatment for anxiety disorders, barriers preclude widespread implementation of CBT in primary care. Transdiagnostic group CBT (tCBT) focuses on cognitive and behavioural processes and intervention strategies common to different anxiety disorders, and could be a promising alternative to conventional CBT. This study aims to examine the effectiveness of a transdiagnostic group CBT for anxiety disorders program as a complement to treatment-as-usual (TAU) in primary mental health care.

METHODS/DESIGN

The trial is a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment, and follow-up at 4, 8 and 12-months design. Treatment and control groups. a) tCBT (12 weekly 2-h group sessions following a manualized treatment protocol); b) TAU for anxiety disorders. Inclusion criteria comprise meeting DSM-5 criteria for primary Panic Disorder, Agoraphobia, Social Anxiety Disorder and/or Generalized Anxiety Disorder. Patients are recruited in three regions in the province of Quebec, Canada. The primary outcome measures are the self-reported Beck Anxiety Inventory and the clinician-administered Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5); secondary outcome measures include treatment responder status based on the ADIS-5, and self-reported instruments for specific anxiety and depression symptoms, quality of life, functioning, and service utilisation.

STATISTICAL ANALYSIS

Intention-to-treat analysis. A mixed effects regression model will be used to account for between- and within-subject variations in the analysis of the longitudinal effects of the intervention.

DISCUSSION

This rigorous evaluation of tCBT in the real world will provide invaluable information to decision makers, health care managers, clinicians and patients regarding the effectiveness of the intervention. Widespread implementation of tCBT protocols in primary care could lead to better effectiveness, efficiency, access and equity for the large number of patients suffering from anxiety disorders that are currently not obtaining evidence-based psychotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02811458 .

Initial outcomes of a real-world multi-site primary care psychotherapy program

OBJECTIVE

Although anxiety, mood, and adjustment disorders are commonly treated in primary care, little evidence exists regarding psychotherapy outcomes within this setting. The primary objective of this study was to describe outcomes of a large-scale primary care psychotherapy program.

METHODS

Patients (N = 2772) participated in cognitive behavioral therapy (CBT) as part of a multi-site primary care program. A tracking system was utilized to collect data on demographics, diagnoses, course of care, anxiety and depressive symptoms, and frequencies of psychotherapy principles used over the course of primary care CBT.

RESULTS

Anxiety disorders were most frequent, often comorbid with depression. Over two-thirds of the sample participated in at least one CBT session. Case formulation, cognitive interventions, exposure, and behavioral activation were frequently utilized approaches. Significant improvements on the GAD-7 and PHQ-9 occurred for all groups, yielding medium effect sizes (d = 0.50-0.68). Rates of reliable change (48-80%), response (35-53%), and remission (21-36%) were noted for those scoring in the moderate range of severity.

CONCLUSION

Patients suffering from anxiety, depression, and adjustment disorders can be effectively treated in primary care with CBT. Future efforts are needed to match patient characteristics with the types and timing of therapy interventions to improve clinical and functional outcomes.

Virtual Reality for Anxiety Reduction Demonstrated by Quantitative EEG: A Pilot Study

While previous research has established that virtual reality (VR) can be successfully used in the treatment of anxiety disorders, including phobias and PTSD, no research has examined changes in brain patterns associated with the use of VR for generalized anxiety management. In the current study, we compared a brief nature-based mindfulness VR experience to a resting control condition on anxious participants. Self-reported anxiety symptoms and resting-state EEG were recorded across intervals containing quiet rest or the VR intervention. EEG activity was analyzed as a function of global power shifts in Alpha and Beta activity, and with sLORETA current source density estimates of cingulate cortex regions of interest. Results demonstrated that both a quiet rest control condition and the VR meditation significantly reduced subjective reports of anxiety and increased Alpha power. However, the VR intervention uniquely resulted in shifting proportional power from higher Beta frequencies into lower Beta frequencies, and significantly reduced broadband Beta activity in the anterior cingulate cortex. These effects are consistent with a physiological reduction of anxiety. This pilot study provides preliminary evidence supporting the therapeutic potential of VR for anxiety management and stress reduction programs.

Applying the Principles for Digital Development: Case Study of a Smartphone App to Support Collaborative Care for Rural Patients With Posttraumatic Stress Disorder or Bipolar Disorder

BACKGROUND

Despite a proliferation of patient-facing mobile apps for mental disorders, there is little literature guiding efforts to incorporate mobile tools into clinical care delivery and integrate patient-generated data into care processes for patients with complex psychiatric disorders.

OBJECTIVE

The aim of this study was to seek to gain an understanding of how to incorporate a patient-provider mobile health (mHealth) platform to support the delivery of integrated primary care-based mental health services (Collaborative Care) to rural patients with posttraumatic stress disorder and/or bipolar disorder.

METHODS

Using the Principles for Digital Development as a framework, we describe our experience designing, developing, and deploying a mobile system to support Collaborative Care. The system consists of a patient-facing smartphone app that integrates with a Web-based clinical patient registry used by behavioral health care managers and consulting psychiatrists. Throughout development, we engaged representatives from the system's two user types: (1) providers, who use the Web-based registry and (2) patients, who directly use the mobile app. We extracted mobile metadata to describe the early adoption and use of the system by care managers and patients and report preliminary results from an in-app patient feedback survey that includes a System Usability Scale (SUS).

RESULTS

Each of the nine Principles for Digital Development is illustrated with examples. The first 10 patients to use the smartphone app have completed symptom measures on average every 14 days over an average period of 20 weeks. The mean SUS score at week 8 among four patients who completed this measure was 91.9 (range 72.5-100). We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions.

CONCLUSIONS

Adhering to the Principles for Digital Development, we created and deployed an mHealth system to support Collaborative Care for patients with complex psychiatric conditions in rural health centers. Preliminary data among the initial users support high system usability and show promise for sustained use. On the basis of our experience, we propose five additional principles to extend this framework and inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions: design for public health impact, add value for all users, test the product and the process, acknowledge disruption, and anticipate variability.

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.

A quality improvement project aimed at adapting primary care to ensure the delivery of evidence-based psychotherapy for adult anxiety

Primary care patients frequently present with anxiety with prevalence ratios up to 30%. Brief cognitive–behavioural therapy (CBT) has been shown in meta-analytic studies to have a strong effect size in the treatment of anxiety. However, in surveys of anxious primary care patients, nearly 80% indicated that they had not received CBT. In 2010, a model of CBT (Coordinated Anxiety Learning and Management (CALM)) adapted to primary care for adult anxiety was published based on results of a randomised controlled trial. This project aimed to integrate an adaptation of CALM into one primary care practice, using results from the published research as a benchmark with the secondary intent to spread a successful model to other practices. A quality improvement approach was used to translate the CALM model of CBT for anxiety into one primary care clinic. Plan-Do-Study-Act steps are highlighted as important steps towards our goal of comparing our outcomes with benchmarks from original research. Patients with anxiety as measured by a score of 10 or higher on the Generalized Anxiety Disorder 7 item scale (GAD-7) were offered CBT as delivered by licensed social workers with support by a PhD psychologist. Outcomes were tracked and entered into an electronic registry, which became a critical tool upon which to adapt and improve our delivery of psychotherapy to our patient population. Challenges and adaptations to the model are discussed. Our 6-month response rates on the GAD-7 were 51%, which was comparable with that of the original research (57%). Quality improvement methods were critical in discovering which adaptations were needed before spread. Among these, embedding a process of measurement and data entry and ongoing feedback to patients and therapists using this data are critical step towards sustaining and improving the delivery of CBT in primary care.

Evidence-Based Psychotherapy in Primary Care

The functional and financial effects of untreated psychiatric disorders within primary care have led to the development of novel service delivery models to improve access to high-quality, evidence-based mental health treatments. Cognitive-behavioral therapy (CBT) is an efficacious and effective psychotherapeutic approach for treating a broad range of mental health conditions. CBT is a practical, skill-building approach that emphasizes self-efficacy and self-management of symptoms while working toward defined and measurable treatment goals. Although significant barriers to the full dissemination of CBT remain, collaborative care and integrated behavioral health programs embedded within primary care clinics can enhance treatment outcomes by using CBT. Identifying core CBT principles used in the treatment of anxiety (e.g., exposure), depression (e.g., behavioral activation), and insomnia (e.g., stimulus control) is an important step toward improving the quality of care for these conditions. High-impact, low-intensity CBT programs hold promise in improving access to this evidence-based treatment across a broader population.

Advancing Personalized Medicine: Application of a Novel Statistical Method to Identify Treatment Moderators in the Coordinated Anxiety Learning and Management Study

There has been increasing recognition of the value of personalized medicine where the most effective treatment is selected based on individual characteristics. This study used a new method to identify a composite moderator of response to evidence-based anxiety treatment (CALM) compared to Usual Care. Eight hundred seventy-six patients diagnosed with one or multiple anxiety disorders were assigned to CALM or Usual Care. Using the method proposed by Kraemer (2013), 35 possible moderators were examined for individual effect sizes then entered into a forward-stepwise regression model predicting differential treatment response. K-fold cross validation was used to identify the number of variables to include in the final moderator. Ten variables were selected for a final composite moderator. The composite moderator effect size (r = .20) was twice as large as the strongest individual moderator effect size (r = .10). Although on average patients benefitted more from CALM, 19% of patients had equal or greater treatment response in Usual Care. The effect size for the CALM intervention increased from d = .34 to d = .54 when accounting for the moderator. Findings support the utility of composite moderators. Results were used to develop a program that allows mental health professionals to prescribe treatment for anxiety based on baseline characteristics (http://anxiety.psych.ucla.edu/treatmatch.html).

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.

Morbid Anxiety: Identification and Treatment

Due to their prevalence, chronicity, and poorly understood pathophysiology, anxiety disorders remain an important public health problem. Despite clear diagnostic guidelines and the availability of excellent evidence-based treatments, most anxiety patients remain underrecognized and inadequately treated. This clinical synthesis highlights changes to anxiety disorder diagnosis that became effective with DSM-5. The article also provides some clinical perspective on clarifying differential diagnostic problems and building an alliance with the anxious patient. The quality and strength of the evidence base for current anxiolytic medications options (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, benzodiazepines, and other agents), antianxiety psychotherapies (cognitive-behavioral therapy and brief dynamic therapies), and combination treatments are discussed. A brief update on newer treatment strategies, such as cognitive enhancement, complementary therapies, and neuromodulation, is included. Future directions for anxiety nosology and treatment are summarized, including the National Institute of Mental Health Research Domain Criteria initiative and the promising role of personalized medicine.

Anxiety

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions-including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal-is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Improving outcomes for patients with medication-resistant anxiety: effects of collaborative care with cognitive behavioral therapy

BACKGROUND

Many patients with anxiety disorders remain symptomatic after receiving evidence-based treatment, yet research on treatment-resistant anxiety is limited. We evaluated effects of cognitive behavioral therapy (CBT) on outcomes of patients with medication-resistant anxiety disorders using data from the Coordinated Anxiety Learning and Management (CALM) trial.

METHODS

Primary care patients who met study entry criteria (including DSM-IV diagnosis of generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or social anxiety disorder) despite ongoing pharmacotherapy of appropriate type, dose, and duration were classified as medication resistant (n = 227). Logistic regression was used to estimate effects of CALM's CBT program (CALM-CBT; chosen by 104 of 117 medication-resistant patients randomized to CALM) versus usual care (UC; n = 110) on response [≥ 50% reduction of 12-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptom score] and remission (BSI-12 < 6) at 6, 12, and 18 months. Within-group analyses examined outcomes by treatment choice (CBT vs. CBT plus medication management) and CBT dose.

RESULTS

Approximately 58% of medication-resistant CALM-CBT patients responded and 46% remitted during the study. Relative to UC, CALM-CBT was associated with greater response at 6 months (AOR = 3.78, 95% CI 2.02-7.07) and 12 months (AOR = 2.49, 95% CI 1.36-4.58) and remission at 6, 12, and 18 months (AORs = 2.44 to 3.18). Patients in CBT plus medication management fared no better than those in CBT only. Some evidence suggested higher CBT dose produced better outcomes.

CONCLUSIONS

CBT can improve outcomes for patients whose anxiety symptoms are resistant to standard pharmacotherapy.