在初级保健中提供基于证据的多种焦虑障碍治疗：一项随机对照试验。

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

机构信息

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations, Seattle, Washington 98104, USA.

出版信息

JAMA. 2010 May 19;303(19):1921-8. doi: 10.1001/jama.2010.608.

DOI:10.1001/jama.2010.608

PMID:20483968

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC2928714/

Abstract

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.

摘要

背景

提高精神卫生保健质量需要将临床干预措施从受控研究环境转移到实际实践环境中。尽管在抑郁症方面已经取得了这些进展，但在焦虑症方面却很少开展工作。

目的

确定针对多种初级保健焦虑症（惊恐障碍、广泛性焦虑障碍、社交焦虑障碍和创伤后应激障碍）的灵活治疗提供模式是否优于常规护理（UC）。

设计、地点和患者：在 4 个美国城市的 17 个初级保健诊所中，进行了一项协调焦虑学习和管理（CALM）的随机对照有效性试验，将其与 UC 进行了比较。2006 年 6 月至 2008 年 4 月期间，共纳入了 1004 名患有焦虑症（伴或不伴重度抑郁症）、年龄在 18 至 75 岁、能说英语或西班牙语的患者，随后对他们进行了 3 至 12 个月的治疗。在 2009 年 10 月完成了基线后 6、12 和 18 个月的盲法随访评估。

干预措施

CALM 允许选择认知行为疗法（CBT）、药物治疗或两者兼用；包括实时基于网络的结果监测，以优化治疗决策；以及一个计算机辅助程序，以优化非专业照护管理者提供的 CBT，并协助初级保健临床医生促进依从性和优化药物治疗。

主要观察指标

12 项Brief Symptom Inventory（BSI-12）焦虑和躯体症状评分。次要结局包括反应者（与治疗前 BSI-12 评分相比，≥50%的减少）和缓解者（BSI-12 总分<6）的比例。

结果

与 UC 相比，CALM 在总体焦虑症状方面有显著改善（BSI-12 组的平均差异分别为-2.49[95%置信区间（CI）：-3.59 至-1.40]、-2.63[95%CI：-3.73 至-1.54]和-1.63[95%CI：-2.73 至-0.53]，分别在 6、12 和 18 个月时）。在 12 个月时，反应率和缓解率（CALM 与 UC）分别为 63.66%（95%CI：58.95%-68.37%）与 44.68%（95%CI：39.76%-49.59%），以及 51.49%（95%CI：46.60%-56.38%）与 33.28%（95%CI：28.62%-37.93%），反应的治疗需要数为 5.27（95%CI：4.18-7.13），缓解的治疗需要数为 5.50（95%CI：4.32-7.55）。