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Background: Broadly disseminating and implementing evidence-based psychotherapies with high fidelity, particularly cognitive behavioral therapy (CBT), has proved challenging for many health-care systems, including the Department of Veterans Affairs, especially in primary care settings such as small or remote clinics. A computer-based tool (based on the coordinated anxiety learning and management (CALM) program) was designed to support primary care-based mental health providers in delivering CBT. The objectives of this study are to modify the CALM tool to meet the needs of mental health clinicians in veterans affairs (VA) community-based outpatient clinics (CBOCs) and rural "veterans", use external facilitation to implement CBT and determine the effect of the CALM tool versus a manualized version of CALM to improve fidelity to the CBT treatment model, and conduct a needs assessment to understand how best to support future implementation of the CALM tool in routine care.Methods/design: Focus groups will inform the redesign of the CALM tool. Mental health providers at regional VA CBOCs; CBT experts; VA experts in implementation of evidence-based mental health practices; and veterans with generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, "with or without" depression will be recruited. A hybrid type III design will be used to examine the effect of receiving CBT training plus either the CALM tool or a manual version of CALM on treatment fidelity. External facilitation will be used as the overarching strategy to implement both CBT delivery methods. Data will also be collected on symptoms of the targeted disorders. To help prepare for the future implementation of the CALM tool in VA CBOCs, we will perform an implementation need assessment with mental health providers participating in the clinical trial and their CBOC directors.Discussion: This project will help inform strategies for delivering CBT with high fidelity in VA CBOCs to veterans with anxiety disorders and PTSD with or without depression. If successful, results of this study could be used to inform a national rollout of the CALM tool in VA CBOCs including providing recommendations for optimizing the adoption and sustained use of the computerized CALM tool among mental health providers in this setting.Trial Registration: ClinicalTrials.gov, NCT02488551. [ABSTRACT FROM AUTHOR]

The article discusses a randomized controlled trial which examined the efficacy of flexible treatment-delivery model in treating primary care anxiety disorders. The trial included 1,004 patients with anxiety disorders, aged 18 to 75 years, who were treated with Coordinated Anxiety Learning and Management (CALM) or usual care (UC) in primary care clinics in four U.S. cities between June 2006 and April 2008. Study researchers concluded that CALM resulted in greater improvement in patients with anxiety disorders, depression and functional disability, compared with UC.

In a recent study of treatment for panic disorder in primary care, the Composite International Diagnostic Interview (CIDI-Auto) was used to provide psychiatric diagnoses. However, during and after data collection, it was discovered that the CIDI appeared to place, or fail to place, a substantial number of people into diagnostic categories in ways that conflicted with the investigators' clinical experience. The wording of questions in the panic module, coupled with a lack of structured follow-up probes, resulted in apparent false negatives for panic disorder. Moreover, patients who would otherwise meet criteria for panic disorder or social phobia did not receive a diagnosis based on rules that may be discordant with clinical practice and, at times, the design of the DSM-IV. For this study, changes were made to the interview, including additional probes for the panic disorder module and modification of the decision rules used to assign or rule out diagnoses of panic disorder and social phobia. The changes resulted in greater inclusion of patients in the panic disorder and social phobia diagnostic categories and we argue that these changes to the DIDI-Auto increase the clinical validity of this instrument. We did not examine the false positive rate for the unmodified or modified CIDI, but this is an important issue that needs to be evaluated in future research. [ABSTRACT FROM AUTHOR]

Background: The coronavirus (COVID-19) pandemic presents an unprecedented crisis with potential negative mental health impacts.Methods: This study used data collected via Youper, a mental health app, from February through July 2020. Youper users (N = 157,213) in the United States self-reported positive and negative emotions and anxiety and depression symptoms during the pandemic. We examined emotions and symptoms before (pre), during (acute), and after (sustained) COVID-related stay-at-home orders.Results: For changes in frequency of reported acute emotions, from the pre to acute periods, anxiety increased while tiredness, calmness, happiness, and optimism decreased. From the acute to sustained periods, sadness, depression, and gratitude increased. Anxiety, stress, and tiredness decreased. Between the pre and sustained periods, sadness and depression increased, as did happiness and calmness. Anxiety and stress decreased. Among symptom measures, anxiety increased initially, from the pre to the acute periods, but later returned to baseline.Limitations: The study sample was primarily comprised of young people and women. The app does not collect racial or ethnicity data. These factors may limit generalizability. Sample size was also not consistent for all data collected.Conclusions: The present study suggests that although there were initial negative impacts on emotions and mental health symptoms in the first few weeks, many Americans demonstrated resilience over the following months. The impact of the pandemic on mental health may not be as severe as predicted, although future work is necessary to understand longitudinal effects as the pandemic continues. [ABSTRACT FROM AUTHOR]

Adolescence is a developmental period characterized by remarkable volatility and comorbidity in internalizing disorders. Delineating internalizing symptom change in a manner that accounts for symptoms' shared versus distinctive features is imperative to an understanding of their development. An additional question concerns how vulnerabilities for internalizing disorders relate to development of internalizing symptoms. Cross-sectional and prospective associations between neuroticism and internalizing psychopathology are well-established, yet conclusive evidence on neuroticism's relation to the progression of symptom dimensions relevant to internalizing disorders remains absent. In this investigation, we used latent growth curve modeling to characterize the trajectories of tri-level model internalizing dimensions (General Distress, Anhedonia-Apprehension, Fears, Anxious Arousal, Fears of Specific Stimuli, Social Fears, Narrow Depression, Interoceptive/Agoraphobic Fears) and examined whether a general neuroticism factor predicted their growth. We used anxiety and depressive symptom data spanning 6 years, collected from 606 high school juniors mostly vulnerable for internalizing disorders. We observed a pattern of results that varied by symptom dimension. Only Anhedonia-Apprehension showed a distinct increasing trend, on average. Neuroticism predicted an adverse symptom course for the dimension of General Distress. Our results reinforce the notion that neuroticism confers substantial risk for internalizing symptom maintenance and extend past findings by demonstrating that neuroticism forecasts a poor symptom course for General Distress but not narrower dimensions of internalizing. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Purpose: To explore the feasibility and utility of using a workshop, and supervision-consultation plus external facilitation to disseminate and implement cognitive-behavioral therapy in Veterans Affairs (VA) community-based outpatient clinics (CBOCs)., Methods: This study occurred in the context of a randomized controlled trial aimed at comparing 2 methods for implementing Coordinated Anxiety Learning Management (CALM) in VA CBOCs. A 3-phase (workshop, supervision-consultation, external facilitation) model was used to support 32 VA CBOC mental health providers in learning and adopting CALM in their clinical practice. Qualitative data describe training activities and the feasibility and utility of each training phase in addressing challenges to adopting CALM., Findings: All 3 phases of the model were feasible to use with our sample of CBOC mental health providers. Providers reported challenges learning CALM during the workshop and concerns about not having enough training post-workshop to use CALM in practice. Providers primarily utilized supervision-consultation to tailor CALM to their practice, including learning how to prioritize a target disorder, "switch" the focus of treatment to a different disorder when comorbidities were present, and modify CALM sessions to fit shorter treatment visits. Providers primarily utilized external facilitation to further tailor CALM to their practice through implementation (eg, concrete help) and support-oriented help. Key lessons for implementing CALM in CBOCs are presented and discussed., Conclusions: Findings provide initial evidence for the feasibility and utility of using each component of a facilitation-enhanced training model to promote CBOC VA providers' implementation of a computer and manual version of CALM in their practice., (© 2019 National Rural Health Association.)

Sharing specific autobiographical events is likely to influence the support people give us; a person who shares little detail of their lives may be unlikely to attract social support and this may in turn contribute towards anxious and depressive symptoms. Participants ( N  = 142) reported memories evoked by negative and positive cue words and these memories were coded for whether or not they referred to a specific event lasting less than 24 h. At this time (T1) and one year later (T2), participants also completed the UCLA Life Stress Interview (LSI), which includes a measure of social support, and measures of depression and anxiety comprising a general distress latent construct. The tendency to recall fewer specific memories was associated with lower social support given by friends and romantic partners and this was in turn associated with elevated general distress at T2, even when accounting for T1 social support and general distress. Our findings contribute to the literature regarding the social function of memory and suggest another route via which reduced specificity contributes to emotional disorders.

Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, high-quality guidelines can facilitate shared decision making and identify gaps in knowledge.

Large racial disparities in the use of mental health care persist. Differences in treatment preferences could partially explain the differences in care between minority and nonminority populations. We compared beliefs about mental illness and treatment preferences between adult African-Americans, Hispanics, Asian Americans, Native Americans, and White Americans with diagnosed anxiety disorders. Measures of beliefs about mental illness and treatment were drawn from the National Comorbidity Survey Replication and from our previous work. There were no significant differences in beliefs between the African-Americans and the White Americans. The beliefs of the Hispanics and the Native Americans were most distinctive, but the differences were small in magnitude. Across race/ethnicity, the associations between beliefs and service use were generally weak and statistically insignificant. The differences in illness beliefs and treatment preferences do not fully explain the large, persistent racial disparities in mental health care. Other crucial barriers to quality care exist in our health care system and our society as a whole.

Objective: The authors examined the effects of a collaborative care intervention for anxiety disorders in primary care on lower-income participants relative to those with higher incomes. They hypothesized that lower-income individuals would show less improvement or improve at a lower rate, given that they would experience greater economic stress over the treatment course. An alternative hypothesis was that lower-income participants would improve at a higher rate because the intervention facilitates access to evidence-based treatment, which typically is less available to persons with lower incomes., Method: Baseline demographic and clinical characteristics of patients with lower (N=287) and higher (N=717) income were compared using t tests and chi-square tests for continuous and categorical variables, respectively. For the longitudinal analysis of intervention effects by income group, the outcome measures were jointly modeled at baseline and at 6, 12, and 18 months by study site, income, time, intervention, time and intervention, income and time, income and intervention, and time, intervention, and income., Results: Although lower-income participants were more ill and had greater disability at baseline than those with higher incomes, the two income groups were similar in clinical response. The lower-income participants experienced a comparable degree of clinical improvement, despite receiving fewer treatment sessions, less relapse prevention, and less continuous care., Conclusions: These findings contribute to the ongoing discussion as to whether or not, and to what extent, quality improvement interventions work equally well across income groups or require tailoring for specific vulnerable populations.

Objective: The objective of this study was to evaluate two abbreviated versions of the PTSD Checklist (PCL), a self-report measure of posttraumatic stress disorder (PTSD) symptoms, as an index of change related to treatment., Method: Data for this study were from 181 primary care patients diagnosed with PTSD who enrolled in a large randomized trial. These individuals received a collaborative care intervention (cognitive behavioral therapy (CBT) and/or medication) or usual care and were followed 6 and 12 months later to assess their symptoms and functioning. The sensitivity of the PCL versions (i.e., full, two-item, six-item), correlations between the PCL versions and other measures, and use of each as indicators of reliable and clinically significant change were evaluated., Results: All versions had high sensitivity (.92-.99). Correlations among the three versions were high, but the six-item version corresponded more closely to the full version. Both shortened versions were adequate indicators of reliable and clinically significant change., Conclusion: Whereas prior research has shown the two-item or six-item versions of the PCL to be good PTSD screening instruments for primary care settings, the six-item version appears to be the better alternative for tracking treatment-related change., (Published by Elsevier Inc.)

Objective: Primary care providers are increasingly taking on the role of ad hoc mental health provider. However, before patients in primary care can be treated, they must be identified. This study set out to validate a very brief screening instrument for identifying primary care patients with anxiety and depression., Method: Eight hundred one primary care patients completed a questionnaire screening for (1) panic disorder, posttraumatic stress disorder (PTSD) and social phobia, or (2) panic disorder, generalized anxiety disorder (GAD) and major depression. Screening was followed by a diagnostic interview. The properties of the questionnaires were examined to identify a small set of items that effectively and efficiently screened for panic disorder, PTSD, social phobia, GAD and depression., Results: Five items were selected across the two versions of the questionnaire, comprising the Anxiety and Depression Detector (the ADD). The sensitivities for the items ranged from 0.62 to 1.00, and the specificity values ranged from 0.56 to 0.83. When a "yes" answer to any of the screening questions was used to predict the presence of any diagnosis, sensitivity values were 0.92 to 0.96 and specificity values were 0.57 to 0.82. Sensitivity and specificity values varied little by gender, age or ethnicity., Conclusions: The five items of the ADD appear to comprise a useful screening device for anxiety and depressive disorders in primary care settings.

Objective: This study presents the psychometric properties of a brief measure to assess beliefs about psychotropic medications and psychotherapy among patients with anxiety disorders., Method: Data were collected on a large sample of primary care patients with a range of anxiety disorders, as part of the Collaborative Care for Anxiety and Panic study. Factor analyses using principal axis factoring with Varimax rotations were used to determine the factor structure of the beliefs scale. Internal consistency, concurrent validity and predictive validity of the resulting subscales were examined., Results: Two subscales emerged, one reflecting beliefs about psychotropic medications and the other assessing beliefs about psychotherapy. Both showed strong internal consistency and concurrent validity. The beliefs about psychotropic medication demonstrated strong predictive validity., Conclusions: This measure may be a useful tool for assessing treatment beliefs among patients with anxiety disorders toward the provision of more quality treatment for this population. Its brevity may make it particularly useful in primary health care settings.

Recently the National Institutes of Health has been emphasizing research that takes findings generated by clinical research and translates them into treatments for patients who are seen in day-to-day nonresearch settings. This translational process requires a series of steps in which elements of both efficacy and effectiveness research are combined into successively more complex designs. However, there has been little discussion of exactly how to develop and operationalize these designs. This article describes an approach to the development of these hybrid designs. Their operationalization is illustrated by using the design of an ongoing effectiveness treatment study of panic disorder in primary care. Experts in both efficacy and effectiveness research collaborated to address the methodologic and data collection issues that need to be considered in designing a first-generation effectiveness study. Elements of the overall study design, setting or service delivery context, inclusion and exclusion criteria, recruitment and screening, assessment tools, and intervention modification are discussed to illustrate the thinking behind and rationale for decisions about these different design components. Although the series of decisions for this study were partly influenced by considerations specific to the diagnosis of panic disorder and the context of the primary care setting, the general stepwise approach to designing treatment interventions using an effectiveness model is relevant for the development of similar designs for other mental disorders and other settings.