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

https://doi.org/10.1016/j.janxdis.2020.102345Get rights and content

Highlights

  • CBT for anxiety disorder can be effectively implemented in primary care.

  • Self-reported anxiety and depression symptoms improved over the course of treatment.

  • Disorder specific evidence-based treatments can be employed in clinical practice.

Abstract

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.

Introduction

Anxiety disorders are one of the most commonly occurring mental health conditions, with lifetime prevalence estimates ranging from 2-12% across the diagnostic categories (Kessler, Ruscio, Shear, & Wittchen, 2009). Individuals with anxiety disorders experience impairments across multiple domains, including elevated short- and long-term disability rates (Hendriks et al., 2014, 2016) and reduced quality of life (Olatunji, Cisler, & Tolin, 2007). In addition, anxiety disorders pose a significant economic burden to society. In the United States, healthcare-related expenses for anxiety disorders have been estimated at $33.7 billion (Shirneshan et al., 2013). In spite of this, clinical anxiety continues to be consistently undertreated, with few receiving an adequate course of treatment, even in high income countries (Alonso et al., 2018).

Primary care has long been described as the “de facto” mental health system in the United States (Reiger, Goldberg, & Taube, 1978), a characterization that holds true for anxiety disorders. Clinically anxious individuals commonly present in primary care, with prevalence rates as high as 20% (Combs & Markman, 2014; Love & Love, 2019). The demand for mental health services is not solely due to high prevalence rates of anxiety disorders in primary care, but also based on the treatment seeking patterns observed in this population. Large-scale epidemiological studies have shown that the vast majority of anxious individuals seek treatment in this setting rather than within specialty mental health clinics (Alonso et al., 2018; Wang et al., 2005). Consequently, primary care frequently serves as the main access point for anxiety disorder treatment.

The traditional structure of primary care is not well suited to meet the growing needs of these patients. Primary care providers, even those who seek extra skills and training, are affected by significant scheduling constraints, nominal mental health support, and limited time to maintain their knowledge of evidence-based practices thereby hindering their ability to provide high quality care. Accordingly, individuals with anxiety disorders have historically received inadequate treatment within primary care (Stein et al., 2004, 2011; Wang et al., 2005; Weisberg, Dyck, Culpepper, & Keller, 2007; Weisberg, Beard, Moitra, Dyck, & Keller, 2014). Integrating mental health providers into the primary care environment is an important avenue to increase the accessibility of evidence-based treatments (Baird et al., 2014).

Section snippets

Anxiety Treatment in Primary Care

Cognitive behavioral therapy (CBT) is well suited for the primary care setting due to its short-term structure and skills-based approach. CBT has been shown to be an efficacious treatment for anxiety disorders in primary care (Zhang et al., 2019). The most notable randomized controlled trial (RCT) conducted in primary care was the Coordinated Anxiety Learning and Management (CALM) trial, a multi-site study of over 1,000 individuals diagnosed with anxiety disorders. Participants were recruited

Participants

Eligible participants included 1,726 adult patients referred to IBH by their Mayo Clinic primary care provider between June 2014 and January 2019. Limited inclusion and exclusion criteria were applied in an effort for the study sample to accurately represent the usual treatment-seeking patient population. All participants included in analyses completed institutional informed consent for research purposes. Of those eligible patients treated in IBH during the study’s surveillance period, 137

Demographic Information and Clinical Characteristics

Demographic information and clinical characteristics are reported in Table A1. Participants were predominantly female, White, partnered, and insured. While participants were on average middle aged, a wide age range of participants received services (range = 18-96). The majority of participants obtained services at one of the five primary care clinics located in Rochester, Minnesota, with a subset of participants being seen at other, smaller primary care clinics located in southeast Minnesota,

Discussion

The primary finding from this study is that CBT delivered to individuals with anxiety disorders in primary care resulted in significant improvements in self-reported anxiety and depression symptoms. Among participants with clinically significant anxiety symptoms who engaged in psychotherapy, the effect size was large for anxiety symptoms and medium for depression symptoms. These findings are similar in magnitude to previous primary care-based studies (Craske et al., 2011; Roy-Byrne et al., 2010

Declaration of Competing Interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

The authors wish to thank Tracy Pietrzak for her technical assistance with designing and maintaining the psychotherapy tracking database and Maureen Drews for her assistance obtaining the relevant data.

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