Anxiety In Primary Care Settings Research Articles

Psychometric properties of the Generalized Anxiety Disorder 7-item scale in youth: Screening in a primary care sample.

Anxiety disorders in youth are frequently underdiagnosed and untreated, partly due to a lack of screening in primary care. The Generalized Anxiety Disorder 7-item (GAD-7) scale is a brief self-report measure designed to screen for anxiety in primary care settings. However, little is known about the psychometrics of this scale with adolescents. Participants included 579 youth age 11 to 17 years who received screening for depression in a primary care setting through a web-based application, VitalSign6, over a 4-year period. Psychometric analyses were completed based on classical test theory (CTT) and item response theory (IRT). Using CTT and IRT methods, the GAD-7 has a unidimensional structure with good psychometric properties. In addition, the IRT analysis demonstrates that items 1 and 2 are strongly associated with the total score, and thus are good choices as a 2-item screening tool. Convergent validity was demonstrated, with high correlations between the GAD-7 and other measures of anxiety, and discriminant validity was also demonstrated, with low correlations to measures of other psychological states. This psychometric evaluation of the GAD-7 provides support for the utility of this measure with adolescents. The GAD-2 is a good estimate of GAD-7 total score.

Specific content for collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care

BackgroundIn primary care (PC) many patients suffer from multimorbidity involving depression and/or anxiety. Collaborative care (CC) has shown promising results for patients with depression, anxiety, and multimorbidity involving depression. However, specific content in CC for patients with multimorbidity involving depression and/or anxiety is unknown.Objective(i) To examine the effect of CC interventions in patients with multimorbidity involving depression and/or anxiety compared with usual care; (ii) to identify specific content of CC.MethodsWe conducted a systematic literature review of randomized controlled trial studies evaluating CC models for adults with multimorbidity involving depression and/or anxiety in PC settings. PubMed, CINAHL, Web of Science, and PsycInfo were searched in December 2019. We conducted a qualitative synthesis using an existing framework and developed a new framework to map the content for each studied intervention.ResultsWe identified 1,447 studies. Twelve publications were included. Eleven had medium-to-high quality of CC for patients with multimorbidity involving depression. Specific content of CC in these studies is: A stepped care model, involving medication and psychotherapy delivered by a nurse or psychologist Care Manager (CM) focusing on problem-solving techniques; follow-up including monitoring of symptoms and function, and relapse prevention strategies; scheduled CM supervision.ConclusionsSpecific content for CC for patients with multimorbidity involving depression is identified from current research. Research gaps were found regarding CC for patients with multimorbidity and anxiety, depression and anxiety, and depression and/or anxiety and more than 2 diseases.

762 Bedtime Procrastination but Not Total Sleep Time Mediates the Association Between Anxiety and Sleep Problems

Abstract Introduction There is a high rate of sleep disorders and anxiety in primary care settings and patients are most likely to report such issues to their primary care provider. This study assessed whether total sleep time and bedtime procrastination mediated the association between anxiety and sleep problems when covarying for age and attitudes about sleep. Methods 308 adult primary care patients seen at either a university integrated primary care clinic (n = 147; 47.7%) or federally qualified health center (n = 161; 52.3%) from August 2019 to March 2020 completed intake paperwork including questions assessing psychiatric symptoms and sleep. Results A structural equation model was used. To test for statistical mediation, we performed 500 bootstraps and examined bias-corrected estimates. The model evidenced good fit, X2 (16) = 22.53, p = .127, CFI = .98, TLI = .95, SRMR = .03, RMSEA = .04 [90% CI: .00, .07]. All manifest variables loaded significantly onto their latent factors (standardized loadings > .40, p values < .05). The model explained 14.7% of the variance in total sleep time (TST), 14.8% in sleep procrastination, and 54.0% in sleep problems. Anxiety was negatively associated with TST (β = -.36, p < .001) and positively associated with bedtime procrastination (β = .35, p < .001) and greater sleep problems (β = .63, p = .006). The association between anxiety and sleep problems was not statistically mediated by TST. There was a significant indirect effect of anxiety on sleep problems through bedtime procrastination. The total effect of anxiety on sleep problems was significant (β = .70, p = .003). We found a significant direct association between age and TST, and age and bedtime procrastination. However, there was no significant direct association between age and sleep problems (β = .00, p = .984). Sleep attitudes were unrelated to any of the primary study variables. None of the exogenous variable covariances were significant. The covariance between TST and bedtime procrastination was significant. Conclusion Sleep problems are pervasive and complex. This study highlights factors related to sleep problems and support anxiety and pre-bedtime behaviors as treatment targets. Support (if any) D40HP29826 (PI: Ana J. Bridges).

Clinical considerations in designing brief exposure interventions for primary care behavioral health settings.

Prevalence rates of anxiety disorders and symptoms in primary care (PC) settings are very high. Behavioral health consultants in primary care behavioral health (PCBH) settings enable increased access to evidence-based anxiety treatment. Despite strong extant support for exposure-based therapy for anxiety disorders, the use of exposure to treat anxiety in PC settings is low. Although barriers to exposure therapy (ET) may be exacerbated in PC settings, many anxiety presentations in PC warrant an exposure-based approach to treatment. Thus, exploration of feasibility and efficacy of ET in PC represents a critical area for advancing evidence-based treatment of anxiety symptoms. The current article addresses this gap through the presentation of two case examples of ET conducted in PCBH. Theoretical and practical information regarding the implementation of exposure using a brief (≤ 30 min), time-limited (4-6 visit) approached are presented. Results from the case examples demonstrate feasibility of conducting exposure in a brief format consistent with a PCBH approach. Additionally, patient outcomes presented suggest that ET conducted in PCBH reduces anxiety symptoms and may facilitate referral to specialty care settings. Exposure may offer promise in improving the quality of anxiety treatment in PC. Future work documenting both effectiveness and implementation outcomes of exposure in PC in clinical work and research trials is needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Adapting evidence-based, cognitive-behavioral interventions for anxiety for use with adults in integrated primary care settings.

Evidence-based treatments for adult patients with anxiety are greatly needed within primary care settings. Psychotherapy protocols, including those for cognitive-behavioral therapy (CBT), are often disorder-specific and were developed for specialty mental health settings, rendering them infeasible in primary care. Behavioral health consultants (BHCs) integrated into primary care settings are uniquely positioned to provide anxiety treatment. However, due to the dearth of empirically supported brief treatments for anxiety, BHCs are tasked with adapting existing treatments for use in primary care, which is quite challenging due to the abbreviated format and population-based approach to care. CBT protocols are highly effective in the treatment of anxiety and fit well with the self-management emphasis of integrated primary care. We review the rationale and procedure for 6 evidence-based CBT intervention techniques (psycho-education, mindfulness and acceptance-based behavioral techniques, relaxation training, exposure, cognitive restructuring, and behavioral activation) that can be adapted for use in the brief format typical of integrated primary care. We offer tips based on our clinical experience, highlight resources (e.g., handouts, websites, apps), and discuss 2 case examples to aid BHCs in their everyday practice. Our goal is to provide BHCs with practical knowledge that will facilitate the use of evidence-based interventions to improve the treatment of anxiety in primary care settings. (PsycINFO Database Record

Implementation of a collaborative care model for the treatment of depression and anxiety in a community health center: results from a qualitative case study.

BackgroundThe collaborative care model is a systematic approach to the treatment of depression and anxiety in primary care settings that involves the integration of care managers and consultant psychiatrists, with primary care physician oversight, to more proactively manage mental disorders as chronic diseases, rather than treating acute symptoms. While collaborative care has been shown to be more effective than usual primary care in improving depression outcomes in a number of studies, less is known about the factors that support the translation of this evidence-based intervention to real-world program implementation. The purpose of this case study was to examine the implementation of a collaborative care model in a community based primary care clinic that primarily serves a low-income, uninsured Latino population, in order to better understand the interdisciplinary relationships and the specific elements that might facilitate broader implementation.MethodsAn embedded single-case study design was chosen in order to thoroughly examine the components of one of several programs within a single organization. The main unit of analysis was semi-structured interviews that were conducted with seven clinical and administrative staff members. A grounded theory approach was used to analyze the interviews. Line-by-line initial coding resulted in over 150 initial codes, which were clustered together to rebuild the data into preliminary categories and then divided into four final categories, or main themes.ResultsFour unique themes about how the implementation of a collaborative care model worked in this setting emerged from the interviews: organizational change, communication, processes and outcomes of the program, and barriers to implementation. Each main theme had a number of subthemes that provided a detailed description of the implementation process and how it was unique in this setting.ConclusionThe results indicated that adequate training and preparation, acceptance and support from key personnel, communication barriers, tools for systematic follow-up and measurement, and organizational stability can significantly impact successful implementation. Further research is necessary to understand how organizational challenges may affect outcomes for patients.

Development of the CAT-ANX: A Computerized Adaptive Test for Anxiety

The authors developed a computerized adaptive test for anxiety that decreases patient and clinician burden and increases measurement precision. A total of 1,614 individuals with and without generalized anxiety disorder from a psychiatric clinic and community mental health center were recruited. The focus of the present study was the development of the Computerized Adaptive Testing-Anxiety Inventory (CAT-ANX). The Structured Clinical Interview for DSM-IV was used to obtain diagnostic classifications of generalized anxiety disorder and major depressive disorder. An average of 12 items per subject was required to achieve a 0.3 standard error in the anxiety severity estimate and maintain a correlation of 0.94 with the total 431-item test score. CAT-ANX scores were strongly related to the probability of a generalized anxiety disorder diagnosis. Using both the Computerized Adaptive Testing-Depression Inventory and the CAT-ANX, comorbid major depressive disorder and generalized anxiety disorder can be accurately predicted. Traditional measurement fixes the number of items but allows measurement uncertainty to vary. Computerized adaptive testing fixes measurement uncertainty and allows the number and content of items to vary, leading to a dramatic decrease in the number of items required for a fixed level of measurement uncertainty. Potential applications for inexpensive, efficient, and accurate screening of anxiety in primary care settings, clinical trials, psychiatric epidemiology, molecular genetics, children, and other cultures are discussed.

The primary health care version of ICD-11: the detection of common mental disorders in general medical settings

BackgroundThe primary health care version of the ICD-11 is currently being revised. AimTo test two brief sets of symptoms for depression and anxiety in primary care settings, and validate them against diagnoses of major depression and current generalised anxiety made by the CIDI. MethodThe study took place in general medical or primary care clinics in 14 different countries, using the Composite International Diagnostic Interview adapted for primary care (CIDI-PC) in 5,438 patients. The latent structure of common symptoms was explored, and two symptom scales were derived from item response theory (IRT), these were then investigated against research diagnoses. ResultsCorrelations between dimensions of anxious, depressive and somatic symptoms were found to be high. For major depression the 5 item depression scale has marked superiority over the usual 2 item scales used by both the ICD and DSM systems, and for anxiety there is some superiority. If the questions are used with patients that the clinician suspects may have a psychological disorder, the positive predictive value of the scale is between 78 and 90%. ConclusionThe two scales allow clinicians to make diagnostic assessments of depression and anxiety with a high positive predictive value, provided they use them only when they suspect that a psychological disorder is present.

Validation of the GAD-7 (Malay version) among women attending a primary care clinic in Malaysia

Anxiety is a common mental health disorder in primary care, with a higher prevalence among women compared to men. This is the first study to validate the Generalised Anxiety Disorder-7 questionnaire (GAD-7) as a case-finding instrument for anxiety in a primary care setting in Malaysia. The objective was to determine the diagnostic accuracy of the Malay version of the GAD-7 in detecting anxiety among women. This cross-sectional study was conducted in a government-funded primary care clinic in Malaysia. Consecutive women participants attending the clinic during data collection were given self-administered questionnaires including the GAD-7 (Malay version). Participants then were selected using systematic weighted random sampling for Composite International Diagnostic Interviews (CIDI). The GAD-7 was validated against the CIDI reference standard. The response rate was 87.5% for the questionnaire completion (895/1023), and 96.8% for diagnostic interviews (151/156). The prevalence of anxiety was 7.8%. The GAD-7 had a sensitivity of 76% (95% CI 61%-87%), a specificity of 94% (88%-97%), positive LR 13.7 (6.2-30.5) and negative LR 0.25 (0.14-0.45). The Malay version of the GAD-7 was found to be valid and reliable in case-finding for anxiety in this study. Due to its brevity, it is a suitable case-finding instrument for detecting anxiety in primary care settings in Malaysia.

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Treatment for anxiety disorders: Efficacy to effectiveness to implementation

Anxiety disorders are common, costly and debilitating, and yet often unrecognized or inadequately treated in real world, primary care settings. Our group has been researching ways of delivering evidence-based treatment for anxiety in primary care settings, with special interest to preserving the fidelity of the treatment while at the same time promoting its sustainability once the research is over. In this paper, we describe the programs we have developed and our directions for future research. Our first study evaluated the efficacy of CBT and expert pharmacotherapy recommendations for panic disorder in primary care, using a collaborative care model of service delivery (CCAP). Symptom, disability and mental health functioning measures were superior for the intervention group compared to treatment as usual both in the short term and the long term, although also more costly. In our ongoing CALM study, we have extended our population to include panic disorder, social anxiety disorder, generalized anxiety disorder and posttraumatic disorder, while at the same time utilizing clinicians with limited mental health care experience. In addition to pharmacotherapy management, we developed a computer-assisted CBT that guides both novice clinician and patient, thereby contributing to sustainability once the research is over. We have also incorporated a measurement based approach to treatment planning, using a web-based tracking system of patient status. To date, the computer-assisted CBT program has been shown to be acceptable to clinicians and patients. Clinicians rated the program highly, and patients engaged in the program. Future directions for our research include dissemination and implementation of the CALM program, testing potential alternations to the CALM program, and distance delivery of CALM.

Chronic depression and anxiety in primary care: approaches to liaison

Much attention has focused on prompt, accurate identification and treatment of depression and anxiety in primary care settings. Less is known about what to do when treatment is unsuccessful or the initial opportunity to intervene is missed. The long-term prognosis of depression and anxiety in primary care settings is not good: half of sufferers experience a relapsing remitting course and a quarter become chronic. There is also a relationship between chronicity and high service utilisation. The label “heartsink” has sometimes been applied to these patients, often pejoratively.