Abstract
BackgroundCognitive behavioral therapy (CBT) is the gold standard treatment for adult anxiety disorders but is often not readily available in a scalable manner in many clinical settings.ObjectiveThis study examines the feasibility, acceptability, and effectiveness of a coach-facilitated digital cognitive behavioral program for anxious adults in primary care.MethodsIn an open trial, patients who screened positive for anxiety (General Anxiety Disorder-7 [GAD7] score ≥5) were offered the digital cognitive behavioral program (active group, n=593). Primary outcomes included anxiety, quality of life (QoL), and ambulatory medical use over 6 months. Intent-to-treat (ITT) and modified intent-to-treat (mITT) analyses were completed. Subsequently, we compared the outcomes of participants with those of a matched control group receiving primary care as usual (CAU; n=316).ResultsMore than half of the patients downloaded the cognitive behavioral mobile app program and about 60% of these were considered engaged, which was defined as completion of ≥3 techniques. The active group demonstrated medium size effects on reducing anxiety symptoms (effect size d=0.44; P<.001) and improving mental health QoL (d=0.49; P<.001) and showed significantly improved physical health QoL (d=0.39; P=.002) and a decreased likelihood of high utilization of outpatient medical care (odds ratio=0.49; P<.001). The active group did not significantly outperform the CAU group in anxiety reduction or QoL improvement (d=0.20; P=.07). However, intent-to-treat analysis showed that the active group had a significantly lower likelihood of high utilization of outpatient medical care than the enhanced CAU group (P<.0001; odds ratio=0.09).ConclusionsA coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable. Primary care patients prescribed a digital cognitive behavioral program for anxiety experienced significant improvements in anxiety symptoms, QoL, and reduced medical utilization. This effect was observed even among patients with chronic medical conditions and behavioral health comorbidities. Although the primary outcomes in the active group did not improve significantly more than the CAU group, health care utilization declined, and some secondary outcomes improved in participants who engaged in the program compared to the CAU group.Trial RegistrationClinicalTrials.gov NCT03186872; https://clinicaltrials.gov/ct2/show/NCT03186872
Highlights
Untreated anxiety disorders are common and their management is expensive, in medical settings where they can often drive excessive health care utilization [1,2]
A coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable
The primary outcomes in the active group did not improve significantly more than the care as usual (CAU) group, health care utilization declined, and some secondary outcomes improved in participants who engaged in the program compared to the CAU group
Summary
Untreated anxiety disorders are common and their management is expensive, in medical settings where they can often drive excessive health care utilization [1,2]. Treatment is generally administered in primary care; very few patients are referred to specialized mental health care [2] and even fewer receive adequate pharmacotherapy using medications with known efficacy for anxiety disorders or empirically supported cognitive behavioral therapy (CBT) [3,4]. Most cases of clinically significant anxiety in primary care are treated using psychotropic medications, even though CBT is recommended as the first-line treatment [2,4]. Digital CBT is effective in treating anxiety [8,9] even in non-US primary care settings [10,11]; its viability and effectiveness for addressing anxiety in a US primary care setting are not known. Cognitive behavioral therapy (CBT) is the gold standard treatment for adult anxiety disorders but is often not readily available in a scalable manner in many clinical settings
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