Currently accepted at: JMIR Mental Health
Date Submitted: Aug 20, 2018
Open Peer Review Period: Aug 20, 2018 - Aug 31, 2018
Date Accepted: Nov 30, 2018
(closed for review but you can still tweet)
A Propensity Matched Controlled Trial of a Guided Digital Cognitive Behavioral Program for Anxiety in Primary Care
Untreated anxiety disorders are common and costly, particularly in medical settings where they can often drive excessive health care utilization.1,2 When anxiety is identified, treatment generally occurs in primary care with very few patients referred to specialized mental health care2 and even fewer receive evidence-based care.3,4 Most clinically significant anxiety in primary care is treated by psychotropic medications, even though cognitive behavioral therapy (CBT) is recommended as first line treatment.2,4 Despite the valuable CBT dissemination and implementation work and substantiated models of integrating cognitive behavioral (CB) approaches into primary care, scalability remains a problem.5,6 Digital CB programs are emerging as one solution.7 Digital CBT is effective in treating anxiety8 including within non-U.S. primary care settings 9, 10; however, its viability and effectiveness for addressing anxiety in a U.S. primary care setting is not known.
This study examines the feasibility, acceptability, and effectiveness of a coach-facilitated digital cognitive behavioral program in anxious adults in primary care.
Using a two arm propensity matched control design, patients screening positive for anxiety (GAD-7 > 5)were offered the digital cognitive behavioral program (active group n = 158) or enhanced primary care as usual (CAU n = 158). Primary outcomes included anxiety, quality of life (QoL), and ambulatory medical utilization over 6 months. Intent-to-treat (ITT) and modified intent-to-treat (mITT) analyses were completed.
70% of patients downloaded the cognitive behavioral mobile app program and 63% of these were considered engaged, defined as completion of 3 or more techniques. Although the active group (ITT) did not significantly outperform enhanced CAU in regards to anxiety reduction (p = .99; effect size d = .001) or improved QoL (p = .07; d = .20), in the engaged subgroup (mITT), there was a significant improvement in physical health-related QoL (p = .01; d = .41). Program usage was associated with a higher anxiety response rate and lower rates of deterioration. The active group (ITT) was associated with a significantly lower likelihood of high utilization of outpatient medical care compared to enhanced CAU (p < .0001; OR = .09).
A coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable. Although the primary outcomes did not improve more than enhanced care as usual, health care utilization declined and some secondary outcomes improved in patients who engaged in the program. For primary care patients prescribed a digital cognitive behavioral program for anxiety experienced improvements in anxiety and significantly reduced medical utilization even among those who have chronic medical conditions and behavioral health comorbidities. Clinical Trial: ClinicalTrials.gov ID: NCT03186872
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