Kelly J MacLaren, Jakubovski Ewgeni, Bloch Michael H
Yale OCD Research Clinic and Department of Psychiatry, Yale University, New Haven.
J Clin Psychiatry. 2015 Mar;76(3):267-78. doi: 10.4088/JCP.13m08922.
Most patients with anxiety disorders receive treatment in primary care settings. Limited moderator data are available to inform clinicians of likely prognostic outcomes for individual patients. We identify baseline characteristics associated with outcome in adults seeking treatment for anxiety disorders.
We conducted an exploratory moderator analysis from the Coordinated Anxiety Learning and Management (CALM) trial. In the CALM trial, 1,004 adults who met DSM-IV criteria for generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and/or posttraumatic stress disorder (PTSD) were randomized to usual care (UC) or a collaborative care intervention (ITV) of cognitive-behavioral therapy and/or pharmacotherapy between June 2006 and April 2008. Logistic regression was used to examine baseline characteristics associated with remission and response overall and by treatment condition. Receiver operating curve (ROC) analyses identified subgroups associated with similar likelihood of response and remission of global anxiety symptoms. Remission was defined as score < 6 on the 12-item Brief Symptom Inventory (BSI-12) anxiety and somatization subscales. Response was defined as at least 50% reduction on BSI-12, or meeting remission criteria.
Randomization to ITV over UC was often the strongest predictor of outcome. Several baseline patient characteristics were associated with poor treatment outcome including comorbid depression, increased severity of underlying anxiety disorder(s) (P < .001), low socioeconomic status (perceived [P < .001] and actual [P < .05]), and limited social support (P < .001). Patient characteristics associated with particular benefit from ITV were being female (P < .05), increased depression (P < .01)/GAD severity (P < .05), and low socioeconomic status (P < .05). ROC analysis demonstrated prognostic subgroups with large differences in response likelihood.
Further research should focus on the effectiveness of implementing the ITV intervention of CALM in community treatment centers where patients typically are of low socioeconomic status and may particularly benefit from ITV.
ClinicalTrials.gov identifier: NCT00347269.
大多数焦虑症患者在初级保健机构接受治疗。目前可用于指导临床医生了解个体患者可能预后结果的调节因素数据有限。我们确定了寻求焦虑症治疗的成年人中与治疗结果相关的基线特征。
我们对协同焦虑学习与管理（CALM）试验进行了探索性调节因素分析。在CALM试验中，1004名符合DSM-IV广泛性焦虑障碍（GAD）、惊恐障碍、社交焦虑障碍和/或创伤后应激障碍（PTSD）标准的成年人在2006年6月至2008年4月期间被随机分配到常规护理（UC）或认知行为疗法和/或药物治疗的协作护理干预（ITV）组。采用逻辑回归分析来检查总体上以及按治疗条件与缓解和反应相关的基线特征。受试者工作特征曲线（ROC）分析确定了与全球焦虑症状缓解和反应可能性相似的亚组。缓解定义为12项简明症状量表（BSI-12）焦虑和躯体化分量表得分<6。反应定义为BSI-12至少降低50%，或符合缓解标准。
随机分配到ITV组而非UC组通常是治疗结果的最强预测因素。几个基线患者特征与不良治疗结果相关，包括共病抑郁、潜在焦虑症严重程度增加（P<.001）、社会经济地位低（感知的[P<.001]和实际的[P<.05]）以及社会支持有限（P<.001）。从ITV中特别受益的患者特征为女性（P<.05）、抑郁增加（P<.01）/GAD严重程度增加（P<.05）以及社会经济地位低（P<.05）。ROC分析显示了反应可能性差异很大的预后亚组。
进一步的研究应聚焦于在社区治疗中心实施CALM的ITV干预的有效性，这些中心的患者通常社会经济地位较低，可能特别受益于ITV。
ClinicalTrials.gov标识符：NCT00347269。
