Elsevier

General Hospital Psychiatry

Volume 29, Issue 5, September–October 2007, Pages 379-387
General Hospital Psychiatry

Psychiatry and Primary Care
Design of the Coordinated Anxiety Learning and Management (CALM) study: innovations in collaborative care for anxiety disorders

https://doi.org/10.1016/j.genhosppsych.2007.04.005Get rights and content

Abstract

Background

Despite a marked increase in the number of persons seeking help for anxiety disorders, the care provided may not be evidence based, especially when delivered by nonspecialists. Since anxiety disorders are most often treated in primary care, quality improvement interventions, such as the Coordinated Anxiety Learning and Management (CALM) intervention, are needed in primary care.

Research Design

This study is a randomized controlled trial of a collaborative care effectiveness intervention for anxiety disorders.

Subjects

Approximately 1040 adult primary care patients with at least one of four anxiety disorders (generalized anxiety disorder, panic disorder, posttraumatic stress disorder or social anxiety disorder) will be recruited from four national sites.

Intervention

Anxiety clinical specialists (ACSs) deliver education and behavioral activation to intervention patients and monitor their symptoms. Intervention patients choose cognitive–behavioral therapy, antianxiety medications or both in “stepped-care” treatment, which varies according to clinical needs. Control patients receive usual care from their primary care clinician. The innovations of CALM include the following: flexibility to treat any one of the four anxiety disorders, co-occurring depression, alcohol abuse or both; use of on-site clinicians to conduct initial assessments; and computer-assisted psychotherapy delivery.

Evaluation

Anxiety symptoms, functioning, satisfaction with care and health care utilization are assessed at 6-month intervals for 18 months.

Conclusion

CALM was designed for clinical effectiveness and easy dissemination in a variety of primary care settings.

Introduction

About 11% of the US population will suffer from an anxiety disorder each year, and almost 29% will experience an anxiety disorder at some point in their lives [1]. Despite a marked increase in the proportion of individuals seeking help for anxiety disorders in the last 10 years [2], their care may not be evidence based, especially when provided by nonspecialists [3]. Since persons with anxiety disorders are most often treated in primary care settings, quality improvement interventions within those settings are needed.

One approach to improving mental health care in primary care settings is the “collaborative care” model [4], [5], [6], [7], which is closely patterned on the “chronic disease model” [8]. Various forms of the collaborative care model have been tested, but some features are common to all [9], [10], [11], [12]. Patients typically remain under the care of their primary care provider, who is assisted by a care manager, usually a master's-level clinician (e.g., nurse, social worker), working in consultation with a psychiatrist. In addition to expert consultation and care managers, collaborative care interventions contain other components that are useful in chronic disease management, including techniques to help patients manage their condition (patient education, psychotherapy, motivational enhancement and approaches to identifying and reducing treatment barriers) and ongoing clinical monitoring of outcomes. Collaborative care interventions are “bundles” of practices that contribute to overall care delivery. These interventions have recently become more flexible by allowing patients a choice of treatments [13].

Most studies on collaborative care have been designed to assist primary care physicians in treating depression [11], [12], [13], [14]. Our previous work Collaborative Care for Anxiety and Panic is one example of a collaborative care intervention for panic disorder (PD) [15]. Similar work has tested collaborative care models for the treatment of PD [16] and of both PD and generalized anxiety disorder (GAD) in primary care [17]. Collaborative care models are beginning to be used to improve the treatment of substance use disorders in primary care [18] and for the management of depression within specialty medical clinics, such as HIV clinics (J.S. Pyne, personal communication).

Many collaborative care models have been shown to be both clinically effective and cost-effective, yet these models are not yet widely used and are rarely sustained beyond the period of external research funding [4], [5], [6], [7], [9], [19], [20], although this now may be changing [21]. Because of the many barriers to funding for and the implementation of collaborative care, making these interventions as “user-friendly” as possible is key to their successful dissemination [22].

This paper describes the design and rationale of the Coordinated Anxiety Learning and Management (CALM) study, the largest randomized trial of collaborative care for anxiety disorders to date. CALM contains a number of innovations, including the following: (a) treating any one of four anxiety disorders [PD, GAD, posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD)] in a single intervention; (b) accommodating multiple comorbidities, including depression, alcohol abuse and chronic medical conditions; (c) emphasizing cognitive–behavioral therapy (CBT) and providing innovative CBT training and delivery; and (d) using clinicians rather than research personnel to perform assessments. In addition, CALM incorporates newer more flexible features initially used in the Improving Mood: Promoting Access to Collaborative Treatment for Late-Life Depression (IMPACT) study [9], including patient choice, “stepped care” (rather than a rigid treatment protocol) and real-time clinical monitoring through a structured Web site that is accessible to all key study personnel.

Based, in part, on feedback from primary care providers who wanted an optimally “user-friendly” collaborative care model, the CALM intervention was developed to maximize ease of dissemination [23] in a variety of primary care settings lacking on site mental health expertise.

Section snippets

Study sample

Patients are recruited and treated at four sites: Seattle, Los Angeles, San Diego and Little Rock. Centralized data collection (telephone baseline and follow-up assessments) by the RAND Survey Research Group offers both efficiency and uniformity, as data are collected across all sites by the same set of interviewers who are blind to the patients' status. Each of the four treatment sites will recruit 260 subjects from a variety of primary care clinics. The institutional Review Boards at all five

Conclusions

The CALM study will test an innovative collaborative care model for anxiety disorders. The intervention has been implemented in 12 clinics in four sites in the United States. With a population of 1040 subjects, it will be the largest randomized trial to date of persons with anxiety disorders. The CALM intervention represents a step forward in collaborative care models because it is expected to be effective for multiple mental health disorders and to accommodate a range of comorbid conditions.

Acknowledgments

This work was supported by National Institute of Mental Health grants (U01 MH070018 to RAND, U01 MH058915 to University of California Los Angeles, U01 MH057835 to University of California San Diego, U01 MH057858 to University of Washington, U01MH070022 to University of Arkansas for Medical Sciences, MH065324 to Dr. Roy-Byrne and MH64122 to Dr. Stein) and by a VA Health Services Research and Development Service Career Award to Dr. Edlund (RCD 03-036).

The authors thank Carrie Edlund, M.S., and

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