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Observations

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Nonexpert treatment shown to be more effective than primary care in soothing widespread anxiety

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anxiety treatment flexible cognitive behavior therapy computer-assistedNEW YORK—One-size-fits-all treatments are particularly rare in the mental health world, where each patient's ailments can seem unique.


But a team of researchers seems to have found a therapeutic model to treat anxiety disorders as wide-ranging as post-traumatic stress disorder (PTSD), social phobia and panic disorder. Lead study author Dr. Peter Roy-Byrne, of the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine, presented the findings May 18 at a press briefing in New York convened by JAMA The Journal of the American Medical Association.


When taken together, anxiety disorders affect about 18 percent of the population (which is more than twice the rate of depression). Some three fourths of people with mental disorders are managed in primary care (which Roy-Byrne called "the de facto mental health system"), but getting those patients—especially those with anxiety disorders—to see mental health specialists is much harder than getting them to see a radiologist, Roy-Byrne noted.


He and his team devised a flexible, collaborative care system that lightened loads for both doctors and psychiatrists (or psychologists) while making it easier for patients to get the help they needed. By enlisting the skills of nurses or masters-level clinicians with some training in anxiety management and an online patient progress tracking system, the treatment plan could adapt to patients without sending them to an expensive psychiatrist or psychologist, which has been shown to be especially difficult in anxiety patients (and could also allow specialists more time to address patients who most need their care). And a controlled trial, published May 19 in JAMA, showed promising results.


The researchers randomized 1,004 patients with at least one anxiety disorder (with and without major depression) to either their treatment model (which offered a choice of drug-based therapy as prescribed by overseeing doctors, computer-assisted cognitive behavioral therapy or a combination of both) or standard care (any treatment by their primary physician, recommended counselor or medication).


Patients receiving medication in the experimental group were advised about type and dosage as well as given additional guidance about healthy lifestyle habits, such as sleep hygiene and behavioral tips. Those getting cognitive behavioral therapy met with a nurse or masters-level clinician to work through a computer-guided program, which provided questions, examples and videos to guide the sessions as well as tailor and reinforce concepts. Primary care physicians and psychiatrists or psychologists oversaw the progress of patients and administrators via an online tracking system that charted attendance, performance and wellbeing so that they could follow-up or intervene if necessary.


The trial itself was open to patients' changing needs, so if patients entered the trial on ineffective levels of medication but didn't want to switch, the docs allowed them to stay on their preferred regimen. And if an experimental-group patient was not improving on a current path (of cognitive behavior therapy or pharmacological treatment), doctors could immediately see that and recommend alternative courses of action.


After a series of blinded follow-ups with patients (at six, 12 and 18 months after the start of the trial), the researchers found that with just six to eight sessions, patients in the treatment group were "averaging really negligible symptoms," he said. Fifty-one percent of people in the flexible, monitored treatment group were in remission at 18 months, compared to 36 percent of the usual care group.


The results "showed how we could use technology" to treat a broad range of anxiety disorders, Roy-Byrne noted on Tuesday. And because the treatment model was effective for a broad range of disorders, it could help the many people who have more than one ailment, "which is the rule rather than the exception," he added.


By using clinician-administered, evidence-based strategy, he said, "you can get a lot of people better fast." And the social implications of the model were not lost on Roy-Byrne. He noted that the days of the well-to-do and well-insured seeking in-depth psychiatric help for every minor mental health issue might be numbered. "How can you more responsibly distribute the expertise?" he asked. With an evidence-based treatment protocol, he concluded, the psychiatric and psychological big guns could be reserved for those who really needed them.


Image courtesy of iStockphoto/AlexRaths

The views expressed are those of the author and are not necessarily those of Scientific American.

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