Raphael D. Rose

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00347269.

Neuroticism as a common dimension in the internalizing disorders

BACKGROUND Several theories have posited a common internalizing factor to help account for the relationship between mood and anxiety disorders. These disorders are often co-morbid and strongly covary. Other theories and data suggest that personality traits may account, at least in part, for co-morbidity between depression and anxiety. The present study examined the relationship between neuroticism and an internalizing dimension common to mood and anxiety disorders. METHOD A sample of ethnically diverse adolescents (n=621) completed self-report and peer-report measures of neuroticism. Participants also completed the Structured Clinical Interview for DSM-IV (SCID). RESULTS Structural equation modeling showed that a single internalizing factor was common to lifetime diagnosis of mood and anxiety disorders, and this internalizing factor was strongly correlated with neuroticism. Neuroticism had a stronger correlation with an internalizing factor (r=0.98) than with a substance use factor (r=0.29). Therefore, neuroticism showed both convergent and discriminant validity. CONCLUSIONS These results provide further evidence that neuroticism is a necessary factor in structural theories of mood and anxiety disorders. In this study, the correlation between internalizing psychopathology and neuroticism approached 1.0, suggesting that neuroticism may be the core of internalizing psychopathology. Future studies are needed to examine this possibility in other populations, and to replicate our findings.

Disorder-Specific Impact of Coordinated Anxiety Learning and Management Treatment for Anxiety Disorders in Primary Care

CONTEXT Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered. OBJECTIVE To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD). DESIGN A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments. SETTING Seventeen US primary care clinics. PATIENTS Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up. INTERVENTIONS CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC. MAIN OUTCOME MEASURES Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores. RESULTS CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders. CONCLUSIONS CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

The Northwestern-UCLA Youth Emotion Project: Associations of cognitive vulnerabilities, neuroticism and gender with past diagnoses of emotional disorders in adolescents

Neuroticism has been hypothesized to be a non-specific risk factor for both anxiety and unipolar mood disorders whereas some cognitive and personality-cognitive vulnerabilities have been hypothesized to be more specific to depression. Using a retrospective design with a sample of 575 high school juniors, we tested three competing models of the associations among these variables. Both neuroticism and the cognitive and personality-cognitive vulnerabilities had significant zero-order associations with rates of past diagnoses of both anxiety and unipolar mood disorders. Neuroticism had significant unique associations with past anxiety disorders and comorbid anxiety and unipolar mood disorders whereas the other vulnerabilities did not. In addition, gender interacted with neuroticism but not with the other vulnerabilities in associating with past diagnoses of mood disorders, showing that neuroticism is more highly associated with past unipolar mood diagnoses in males than in females. Finally, the cognitive and personality-cognitive vulnerabilities overlapped with substantial portions of the variance that neuroticism shared with diagnoses. These results suggest that, at least for retrospective associations with past anxiety and unipolar mood disorders, the cognitive and other personality-cognitive vulnerabilities are non-specific facets of neuroticism.

The role of neuroticism and extraversion in the stress–anxiety and stress–depression relationships

Abstract Though there is a considerable amount of research supporting the association between stressful life events and major depression, there is a paucity of research concerning a range of other life stress constructs, non-depressive disorders, the role of stable personality traits, and gender differences. This study addresses these deficits by: (a) focusing on the association between interpersonal and non-interpersonal chronic life stress (CLS) and both depressive and anxiety disorders; (b) examining the roles of neuroticism and low extraversion in these associations; and (c) assessing gender differences. Participants were 603 adolescents from a study examining risk factors for emotional disorders. Depression and social phobia were associated with interpersonal CLS (IP-CLS), with neuroticism partially accounting for these associations. Low extraversion partially accounted for the association between social phobia and IP-CLS. Depression was also associated with non-interpersonal CLS (NI-CLS), but only in females. This study provides preliminary evidence for the importance of personality variables in explaining shared associations between stress and depression. Additionally, the stress–social phobia relationship is highlighted with no evidence supporting an association between other anxiety disorders and CLS.

Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement.

OBJECTIVE The present study explored treatment dose and patient engagement as predictors of treatment outcome in cognitive behavioral therapy (CBT) for anxiety disorders. METHOD Measures of high versus low treatment dose and high versus low patient engagement in CBT were compared as predictors of 12- and 18-month outcomes for patients being treated for anxiety disorders with CBT (with or without concurrent pharmacotherapy) in primary care settings as part of a randomized controlled effectiveness trial of the Coordinated Anxiety Learning and Management (CALM) intervention. Measures of dose (attendance, exposure completion) and engagement in CBT (homework adherence, commitment) were collected throughout treatment, and blinded follow-up phone assessments of outcome measures (12-item Brief Symptom Inventory, Patient Health Questionnaire 8, Sheehan Disability Scale) were completed at 12 and 18 months. Propensity score weighting controlled for baseline differences in demographics and symptom severity between patients with high and low dose and engagement. These analyses included the 439 patients who selected CBT as treatment modality. RESULTS Completing exposures, having high attendance, and being more adherent to completing homework predicted better outcomes across all measures at 12 and 18 months, and high CBT commitment predicted better outcomes on all measures at 18 months. CONCLUSIONS This study found that higher treatment dose and patient engagement in CBT for anxiety disorders were stable and robust predictors of greater reductions in anxiety symptoms, depression symptoms, and functional disability.

Functioning and disability levels in primary care out-patients with one or more anxiety disorders.

BACKGROUND Anxiety disorders are the most prevalent mental health disorders and are associated with substantial disability and reduced well-being. It is unknown whether the relative impact of different anxiety disorders is due to the anxiety disorder itself or to the co-occurrence with other anxiety disorders. This study compared the functional impact of combinations of anxiety disorders in primary care out-patients. METHOD A total of 1004 patients with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) or post-traumatic stress disorder (PTSD) provided data on their mental and physical functioning, and disability. Multivariate regressions compared functional levels for patients with different numbers and combinations of disorders. RESULTS Of the patients, 42% had one anxiety disorder only, 38% two, 16% three and 3% all four. There were few relative differences in functioning among patients with only one anxiety disorder, although those with SAD were most restricted in their work, social and home activities and those with GAD were the least impaired. Functioning levels tended to deteriorate as co-morbidity increased. CONCLUSIONS Of the four anxiety disorders examined, GAD appears to be the least disabling, although they all have more in common than in distinction when it comes to functional impairment. A focus on unique effects of specific anxiety disorders is inadequate, as it fails to address the more pervasive impairment associated with multiple anxiety disorders, which is the modal presentation in primary care.

Are anxiety and depression just as stable as personality during late adolescence? Results from a three-year longitudinal latent variable study.

Although considerable evidence shows that affective symptoms and personality traits demonstrate moderate to high relative stabilities during adolescence and early adulthood, there has been little work done to examine differential stability among these constructs or to study the manner in which the stability of these constructs is expressed. The present study used a three-year longitudinal design in an adolescent/young adult sample to examine the stability of depression symptoms, social phobia symptoms, specific phobia symptoms, neuroticism, and extraversion. When considering one-, two-, and three-year durations, anxiety and personality stabilities were generally similar and typically greater than the stability of depression. Comparison of various representations of a latent variable trait-state-occasion (TSO) model revealed that whereas the full TSO model was the best representation for depression, a trait stability model was the most parsimonious of the best-fitting models for the anxiety and personality constructs. Over three years, the percentages of variance explained by the trait component for the anxiety and personality constructs (73-84%) were significantly greater than that explained by the trait component for depression (46%). These findings indicate that symptoms of depression are more episodic in nature, whereas symptoms of anxiety are more similar to personality variables in their expression of stability.

Use of Complementary and Alternative Medicine in a Large Sample of Anxiety Patients

OBJECTIVE To examine a large sample of patients with anxiety and the association between types of complementary and alternative treatments that were used, demographic variables, diagnostic categories, and treatment outcomes. METHOD Cross-sectional and longitudinal survey during the Coordinated Anxiety Learning and Management (CALM) study that assessed this intervention against the Usual Care in a sample of patients with anxiety recruited from primary care. Interviewer-administered questionnaires via a centralized telephone survey by blinded assessment raters. The interviews were done at baseline, 6, 12, and 18 months of the study. A total of 1004 adults ages 18-75 who met DSM-IV criteria for Generalized Anxiety Disorder (GAD), Panic Disorder, Social Anxiety Disorder, or Post-Traumatic Stress Disorder. We assessed medication/herbal use, the use of any alternative therapies, and combined Complementary and Alternative Medicine (CAM) use. RESULTS We found an extensive (43%) use of a variety of CAM treatments that is consistent with previous study results in populations with anxiety. Only a few significant demographic or interventional characteristics of CAM users were found. Users most often had a diagnosis of GAD, were older, more educated, and had two or more chronic medical conditions. CAM users who had a 50% or more drop in anxiety scores over 18 months were less likely to report continued use of alternative therapies. CONCLUSIONS The study confirms the importance of awareness of CAM use in this population for possible interference with traditional first-line treatments of these disorders, but also for finding the best integrative use for patients who require multiple treatment modalities.

Abbreviated PTSD Checklist (PCL) as a Guide to Clinical Response

OBJECTIVE The objective of this study was to evaluate two abbreviated versions of the PTSD Checklist (PCL), a self-report measure of posttraumatic stress disorder (PTSD) symptoms, as an index of change related to treatment. METHOD Data for this study were from 181 primary care patients diagnosed with PTSD who enrolled in a large randomized trial. These individuals received a collaborative care intervention (cognitive behavioral therapy (CBT) and/or medication) or usual care and were followed 6 and 12 months later to assess their symptoms and functioning. The sensitivity of the PCL versions (i.e., full, two-item, six-item), correlations between the PCL versions and other measures, and use of each as indicators of reliable and clinically significant change were evaluated. RESULTS All versions had high sensitivity (.92-.99). Correlations among the three versions were high, but the six-item version corresponded more closely to the full version. Both shortened versions were adequate indicators of reliable and clinically significant change. CONCLUSION Whereas prior research has shown the two-item or six-item versions of the PCL to be good PTSD screening instruments for primary care settings, the six-item version appears to be the better alternative for tracking treatment-related change.