Anxiety interventions delivered in primary care behavioral health routine clinical practice.

Abstract

Introduction: Although anxiety is highly prevalent in primary care and a top reason for referral to primary care behavioral health (PCBH) services, there are limited data on which anxiety interventions are used in routine PCBH practice. The objective of this study was to identify interventions delivered when treating anxiety in PCBH practice. Method: We conducted an online survey of PCBH providers regarding their clinical practice with patients who present for treatment of anxiety symptoms. The final sample comprised 209 PCBH providers recruited from e-mail listservs of national professional organizations (59.3% psychologists, 23.4% social workers, 12.4% counselors, 4.8% other). Providers reported on use (yes/no) of 17 interventions in their most recent session with their most recent adult patient presenting with a primary concern of non-trauma-related anxiety. Results: On average, patients were reported to be 42.2 (14.73) years old, White (73.7%), and male (56.5%) with anxiety symptoms of moderate severity (65.6%). Most reportedly had comorbid sleep difficulties (63.6%), depressive symptoms (58.4%), and/or stress/adjustment (56.0%). Providers reported delivering an average of 5.77 (2.05, range: 1-15) interventions, with psychoeducation (94.7%), relaxation training (64.1%), and supportive therapy (60.8%) being most common. Several highly efficacious evidence-based interventions for anxiety, including cognitive therapy (45.0%) and exposure (21.1%), were less common. Discussion: While PCBH providers delivered numerous brief interventions for anxiety, cognitive therapy and exposure were underutilized. Furthermore, PCBH patients with anxiety symptoms were complex, with significant severity and comorbidity. These results suggest implications for research, clinical training, intervention design, and future implementation efforts.

Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial.

“…They emphasized the need for flexibility to tailor treatment to individual patients’ needs and preferences, as not all modules would be relevant to everyone. BHPs reported high familiarity and comfort with skills in MAST-V except for exposure and mindfulness meditation, consistent with prior research on PCBH usual care (Shepardson, Minnick, & Funderburk, 2020). We thus added a background section to review the goals and rationale for all modules, which clarifies the scope to reduce confusion or misperceptions.…”

“…With little to no guidance for brief behavioral anxiety treatment in PCBH, BHPs are left to idiosyncratically adapt specialty care protocols, frequently drawing from cognitive-behavioral therapy (CBT; Funderburk et al, 2011). BHPs reported using an average of 5.8 interventions for anxiety within a single PCBH appointment, with psychoeducation (95%), relaxation training (64%), and supportive therapy (61%) being most common, while cognitive restructuring (45%) and exposure (21%) were used less often (Shepardson, Minnick, & Funderburk, 2020). These findings raise questions about the appropriateness and potency of intervention that patients are receiving.…”

“…Similar transdiagnostic processes affecting attention, reasoning, thought, and behavior lead to the development and maintenance of these anxiety presentations (Mansell et al, 2009), so the same general approach to treatment is relevant for them all. MAST also accommodates common comorbid symptoms of insomnia, depression, and stress, which are reported by over half of PCBH patients being seen for a presenting complaint of anxiety (Shepardson, Minnick, & Funderburk, 2020).…”

“…After reviewing the literature on primary care-based anxiety interventions (Shepardson et al, 2018), we identified intervention techniques that are not only effective in reducing anxiety, but also compatible with PCBH practice. In addition, we incorporated research on Veterans’ anxiety treatment preferences (Shepardson & Funderburk, 2016), BHP usual care practices in behavioral anxiety treatment (Shepardson, Minnick, & Funderburk, 2020), and barriers and facilitators to using empirically supported behavioral anxiety interventions in PCBH practice (Shepardson, Fletcher, et al, 2020). The first author drafted detailed outlines for the therapist manual and patient handouts then obtained feedback from the second author, an expert in PCBH, and third author, an expert in PCBH and CBT for anxiety, both of whom have expertise in intervention development.…”

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

“…However, exposure therapy (ET), arguably the most effective intervention for anxiety (Deacon & Abramowitz, 2004; Foa & McLean, 2016; Olatunji, Cisler, & Deacon, 2010), has received little attention in the PC-based anxiety treatment literature. Indeed, a survey of PCBH providers regarding intervention techniques used in the most recent visit with a patient referred for anxiety found that only 21% delivered ET (Shepardson, Minnick, & Funderburk, 2020). Furthermore, research in the context of evidenced based treatment for anxiety in primary care specifically highlights the importance of decreasing avoidance as such behavior may persist beyond symptom improvement and necessitate a behavioral approach (Roy-Byrne et al, 2009).…”