Nearly one in five Americans suffers from an anxiety disorder in any given year, according to the National Comorbidity Survey Replication Study reported in 2005. And the majority of them are seeking care in general medical, rather than specialty behavioral health, settings.
“Often, these persons do not understand what's wrong, and when they go to their family doctor, these treatable illnesses are frequently missed,” says Bradley N. Gaynes, MD, MPH, professor in the department of psychiatry at the University of North Carolina. The consequences of this reality are dire.
“Untreated anxiety disorders result in disability and generate increased costs because the physical manifestations of anxiety often prompt expensive diagnostic procedures,” says Dr. Peter Roy-Byrne, professor and vice-chairman in the department of psychiatry at the University of Washington at Harborview Medical Center.
But the consequences also offer an opportunity for clinicians and organizations in the behavioral health camp wishing to enhance their practice profile by collaborating with their colleagues in primary care. For many complicated reasons, the linkages between these two camps have been slow to come by.
Recent advances in the ability to detect and manage anxiety disorders in the primary care setting should strengthen and promote linkages between the two camps.
Recognizing anxiety disorders in primary care: the M-3 Screener
Gaynes is the lead author of a recent study validating a new screening tool called My Mood Monitor (M-3), a one-page, web-based checklist that can be completed in a few minutes and indicates whether a patient has an anxiety disorder or other behavioral conditions.1
Their study included 647 patients from his university's Family Practice Medicine Clinic. Each subject filled out the 27-question M-3 checklist and then participated in a follow-up interview with a clinician who had no access to the results of the M-3.
“The M-3 was effective in screening for any mood or anxiety disorder 83 percent of the time and for a specific disorder in 76 percent of cases,” said Gaynes. “Its diagnostic accuracy equals that of presently-used single-disorder screens but with the additional benefit of being combined into a one-page tool.” The M-3 also screens for suicide risk and substance abuse, urging users who might be at risk for these and other conditions to seek follow-up care.
What distinguishes the M-3 from other screening tools is that it includes multiple psychiatric disorders, rather than focusing on a single disease such as depression or anxiety. It is also readily accessible at a Web site (http://www.mymoodmonitor.com), where an individual can anonymously answer 27 questions that identify his/her risk for depression, anxiety, PTSD, and bipolar disorder. After answers are recorded, the individual can then generate a “total score” in each of several categories that gauges the severity of their condition at the current time. A score of 33 or more (on a 0 to 100 scale) in any category indicates an increased probability that the individual is being affected by the condition. The tool then suggests appropriate follow-up care.
While the M-3 is a screening scale developed in a primary care setting, I have used it in my psychiatric practice with new and long-term patients. I find it to be a quick and accurate way to focus on critical symptoms and behaviors. My patients go to the Web site, complete the tool (without violating their HIPAA rights) and send results to me that quickly inform my clinical diagnostic impression. The ratings can be kept on file using Microsoft's HealthVault to help in assessing the risk-benefit ratio of each patient's treatment over time.
According to Michael Byer, co-author of the M-3 checklist, “There are opportunities for primary care clinics and practices to receive reimbursement funds for administering mental health/health risk assessment screens via CPT Code 99420.”
Treating anxiety in primary care: the “CALM” model
Once a psychiatric problem has been identified in a primary care setting, how does it get treated? Roy-Byrne and his colleagues have just published a study describing a flexible treatment delivery model called Coordinated Anxiety Learning and Management (CALM).2
Their study, funded by NIMH, compared the effectiveness of CALM to “care as usual” (UC) at 17 clinics in four U.S. cities. Together, the clinics provided more than 780,000 visits to over 35,000 patients annually, along with a diverse clinician, patient and insurance mix.
The CALM Model addresses the four most common anxiety disorders, even when they co-occur with depression. Following diagnosis, each patient in the CALM approach selects pharmacotherapy, cognitive behavioral therapy (CBT), or both. The study was conducted as follows:
Physicians identified subjects eligible for the study. This group, which included 120 internists and 28 primary care physicians, received a half-day of training from a local psychiatrist who offered:
A three-step medication-management algorithm;
As-needed follow-up consultation by telephone or e-mail; and
Face-to-face assessments for complex or treatment-refractory patients.
The treatment algorithm included first-line use of selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants (see table), dose optimization, and adverse effect monitoring. For treatment-refractory patients, second- and third-level medications included combinations of two antidepressants or an antidepressant and benzodiazepine.