MPA First Friday Forum: Population-Based Approaches to Managing Anxiety Disorders

Anxiety disorders are the most common mental health condition in the United States, affecting approximately one-third of the population.1 They frequently co-occur with depression, substance, and other anxiety-related conditions. Anxiety disorders are disproportionately associated with a variety of chronic disease risk factors, such as nicotine use, alcohol consumption, and sedentary behaviors, and chronic diseases, such as cardiovascular disease, diabetes, and asthma.2 The public health impact of untreated anxiety disorders is staggering. The adjusted estimated annual economic impact of anxiety disorders is $62 billion through disability, lost wages, and healthcare costs.3 Although highly effective treatments exist for anxiety, only a minority of patients with clinical anxiety receive some form of care. Unfortunately, even among those individuals being actively treated for their anxiety disorder, very few are receiving pharmacotherapy and/or psychotherapy that meet evidence-based practice guidelines.4

Cognitive behavioral therapy (CBT), especially exposure-based interventions, is the most effective treatment for anxiety disorders. 5 CBT is highly acceptable to patients, and typically outperforms evidence-based pharmacotherapy in the longer-term maintenance of treatment gains.6 Although access to CBT remains challenging, large-scale efforts are being made to change health care delivery systems to improve the dissemination of evidence-based treatments.

Improving Access to Psychological Therapies (IAPT) represents a significant "re-tooling" of the National Health Service in the United Kingdom. IAPT is the best example of a true population-based approach to managing anxiety.7 The development, implementation, and sustainability of IAPT has required considerable collaboration between empirical science and government agencies. The premise of this complex, population-based approach is relatively simple -- clinical improvement and recovery can result in enhanced social and economic participation. Properly treating anxiety disorders can reduce impairments, reliance on disability and welfare systems, and health care utilization. Reducing these costs and returning individuals to "taxable" employment holds promise in creating a favorable economic system to sustain and expand needed mental health services.8 Governmental investments have been strategically placed in the following areas: training a new workforce of mental health specialists using National Institute for Health and Clinical Excellence guidelines; creating multiple options of care (e.g., education, self-help, individual and group CBT); using screening to help direct patients to either low-step (i.e., generalist) or high-step (i.e., specialty) providers; offering treatment services across a wide variety of settings and locations; developing a unified database to track symptomatic and clinical outcomes; and utilizing employment advisors. Since its formal inception in 2008, significant improvements in clinical, functional, and economic domains have occurred. In fact, projections for 2017 suggest a favorable net financial benefit in excess of 4,500 million pounds.8

Can the United States assume an IAPT approach? At a national level, doubtful given the current landscape of political, health care, and insurance systems. However, given that primary care is the most common avenue through which patients obtain mental health services, opportunities exist in "re-tooling" primary care for accessing high-quality, evidence-based treatments for anxiety disorders. The Coordinated Anxiety Learning and Management (CALM) study was a large-scale, multi-site, randomized controlled trial that offered evidence-based CBT and pharmacotherapy for patients with generalized anxiety, panic, social anxiety, and posttraumatic stress disorders.9 Treatment was delivered within the primary care setting and care was coordinated by an anxiety clinical specialist. Patients were given the choice of CBT and/or pharmacotherapy, and all outcomes were tracked on a unified database. CBT was often delivered by the anxiety clinical specialist who also used a computerized program for education and demonstration of CBT skills. Randomized patients chose CBT either alone or in combination with pharmacotherapy approximately 90% of the time. Symptomatic response and remission rates generally supported anxious patients randomized to the CALM intervention relative to those patients involved in usual care.9,10

Lessons learned from IAPT and CALM have helped to guide the development of Mayo Clinic's Integrated Behavioral Health (IBH) program. IBH is a multi-specialty group of mental health providers who are physically co-located within the primary care setting. Patients are offered a variety of stepped-care options, including evidence-based CBT delivered by a team of social workers and psychologists. IBH therapists are trained in the use of exposure therapy and cognitive interventions, which are the most evidence-based treatment components for anxiety disorders. In order to maintain access for the larger primary care population, patients may participate in up to 10 individual therapy sessions. Symptomatic outcomes and CBT principles are tracked at every session using an online database. To date, more than 1,700 individual patients and over 3,000 individual therapy sessions have been tracked. Initial data analyses with 449 primary anxiety patients indicated that 64% of patients completed at least 2 CBT sessions (mean = 4.6 sessions). Over 60% of patients received exposure therapy (e.g., situational, imaginal, interoceptive), while approximately 85% received cognitive interventions (e.g., cognitive restructuring, mindfulness, acceptance). Global outcomes indicated significant pre to post changes on self-reported measures of anxiety and depression. Disorder-specific outcomes and psychotherapy principles used for patients with generalized anxiety disorder, panic disorder, obsessive compulsive disorder, and posttraumatic stress disorder were also summarized, again showing favorable responses on symptomatic outcomes. Similar to IAPT, the success and sustainability of our IBH program requires institutional commitment to assuming a population-based approach to screening, directing patients to the right step level of care, and tracking outcomes.  

The time is now for health care delivery systems to invest in the strategic dissemination of known, evidence-based treatments for anxiety disorders. IAPT and CALM have provided roadmaps of shared elements that can lead to the successful implementation and maintenance of population-based approaches for clinical anxiety. Not every patient needs or wants the same level of care, and in several cases, individual face-to-face sessions may not be necessary. However, the care offered and the care received must be evidence-based and delivered by trained providers in these approaches. Advances in technology can help expedite training providers in underserved areas in evidence-based treatments, allow for multi-site outcome tracking, and potentially offer patients effective online treatment options.    

Craig N. Sawchuk, Ph.D., L.P., is an Associate Professor and Vice-Chair of the Division of Integrated Behavioral Health with the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN. His main areas of clinical and research expertise involve adult anxiety disorders and dissemination of evidence-based treatments. Alongside his colleagues in the Division of Integrated Behavioral Health, he is applying population-based models to improve access to effective mental health treatments within the primary care setting.    


  1. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Walters, E.E. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. ArchGen Psychiatry, 2005;62:593-602.

  2. Sawchuk, C.N., Olatunji, B.O. Anxiety, health risk factors, and chronic disease. Am J Lifestyle Med, 2011; 5:531-541.

  3. Greenberg, P.E., Sisitski, T., Kessler, R.C., Finkelstein, S.N., Berndt, E.R., Davidson, J.R., et al.   The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry, 1999;60(7):427-435.

  4. Stein, M.B., Sherbourne, C.D., Craske, M.G., et al. Quality of care for primary care patients with  anxiety disorders. Am J Psychiatry, 2004;161-2230-2237.

  5. Hofmann, S.G., Smits, J.A. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry, 2008;69(4):621-632.

  6. Katzman, M.A., Bleau, P., Chokka, P., Kjemisted, K., van Ameringen, M., Anonty, M.M., et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress     and obsessive compulsive disorders. BMC Psychiatry, 2014;14:S1.
  7. Clark, D.M.. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry, 2011;23:318-327.

  8. Department of Health. IAPT three year report: the first million patients. 2012. Available for download at:

  9. Roy-Byrne, P.P., Craske, M.G., Sullivan, G., Rose, R.D., Edlund, M.J., Lang, A.J., et al.

  10. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial. JAMA, 2010;303:1921-1928. Craske, M.G., Stein, M.B., Sullivan, G., Sherbourne, C., Bystritsky, A,. Rose, R.D., et al. Disorder specific impact of CALM treatment for anxiety disorders in primary care. Arch Gen Psychiatry, 2011;68(4):378-388.
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Lisa Squire - Tuesday, June 07, 2016

I haven't noticed whether Event Recap is a usual feature. This is a great addition to the website/blast, since I can't always get to a 1st Friday. Thanks, Dr. Sawchuk, for this posting. Lisa S. Squire, Phd, LP

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