CALM is a model of collaborative care for anxiety disorders in primary care settings involving medication management, clinician-supervised computerized cognitive behavioral therapy (CBT; CALM Tools for Living), and web-based patient tracking.
CALM targets multiple anxiety disorders, including panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and social anxiety disorder using a model of stepped care that allows patients to choose to receive medication management, CALM Tools for Living, or both. Patients can change the intensity of care by increasing the mode of care they are receiving (CBT or medication), adding an additional mode, or switching to a different mode of care. Patients with co-occurring disorders choose the most salient disorder to target. CALM Tools for Living includes eight 60-minute modules delivered over 6-8 sessions by a minimally trained clinician. Modules address self-monitoring, psychoeducation, developing a fear hierarchy, breathing, cognitive restructuring, in-person and imagined exposure, and relapse prevention. Psychoeducation, cognitive restructuring, and exposure modules include content tailored to the target disorder. Clinicians help patients to navigate CALM Tools for Living, understand material, and practice skills. CALM Tools for Living prompts clinicians to engage in specific activities with patients (e.g. skill demonstration and practice). Clinicians can track patient information and outcomes and exchange information with psychiatrists and primary care providers through dashboard features.
Cognitive Behavioral Therapy (CBT)
Young Adults (18-30)
Primary Care Practices
Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings
Craske MG, Rose RD, Lang A, et al. Depression and Anxiety. 2009. 26: 235-242. doi: 10.1002/da.20542
Summary: This study describes initial ACS-reported acceptability and participant-reported efficacy results from an ongoing randomized controlled trial. Participants included 261 patients who received at least 1 CALM Tools for Living session from 13 urban primary care clinics. ACSs (n=13) rated intervention ease of use and acceptability (5 questions, 7-point Likert scale). Participants completed assessments of anxiety, depression, outcome expectations, and self-efficacy at each intervention session. Researchers also used participant ratings of module understanding (0-100) and quiz scores from each module to evaluate feasibility and acceptability. ACS ratings of intervention ease of use and acceptability were all above 5, suggesting CALM Tools for Living was easy to deliver and acceptable. Average patient-rated understanding was above 80 for all modules and average patient quiz scores were above 90% for all modules. Participant anxiety and depression scores significantly decreased between first and last CALM sessions. Outcome expectations and self-efficacy increased significantly between first and last CALM sessions. Only participants not taking benzodiazepines reported improvements in self-efficacy. Clinician suggestions for improvement included simplifying language, reducing text and content redundancy, and allowing for greater flexibility.
Take Away: CALM demonstrated preliminary evidence of being acceptable to clinicians and improving patient anxiety and depression.
Delivery of evidence-based treatment for multiple anxiety disorders in primary care: A randomized controlled trial
Roy-Byrne P, Craske MG, Sullivan G, et al. Journal of the American Medical Association. 2010. 303(19): 1921-1928. doi: 10.1001/jama.2010.608
Summary: Researchers recruited 1,004 primary care patients diagnosed with at least 1 anxiety disorder from 17 urban primary care clinics using staff referral or clinic-based advertisements. Most participants had at least 2 anxiety disorders and comorbid depression. Anxiety Clinical Specialists (ACSs; n=14) screened participants and delivered CALM. ACSs were not required to have prior experience with anxiety management or CBT and included social workers, registered nurses, and master- and doctoral-level psychologists. Participants were randomized to receive primary care as usual or CALM collaborative care for 10-12 weeks. Participants receiving CALM chose to receive medication management (9%), CALM Tools for Living (34%), or both (57%). Participants completed assessments of anxiety symptoms, depression symptoms, disability, physical health, mental health, healthy days, satisfaction with mental and overall healthcare at 6, 12, and 18 months. CALM participants reported significantly lower anxiety symptoms at all time points relative to participants who received usual care. A significantly greater proportion of CALM participants demonstrated treatment response (i.e., at least 50% reduction in symptoms) and remission (i.e., less than 6 on Brief Symptom Inventory-12) from targeted anxiety disorders than control participants. Relative to control participants, CALM participants also reported significantly better scores on all other outcomes except physical health at all time points, as well as greater satisfaction with overall health.
Take Away: CALM may be effective at reducing symptoms of anxiety and depression in primary care patients with anxiety disorders.
Randomized clinical trial evaluating the preliminary effectiveness of an integrated anxiety disorder treatment in substance use disorder specialty clinics
Wolitzky-Taylor K, Krull J, Rawson R, Roy-Byrne P, Ries R, Craske M. Journal of Consulting or Clinical Psychology. 2018. 86(1): 81-88. doi: 10.1037/ccp0000276
Summary: Researchers conducted a pilot study of an adaptation of CALM for treatment of comorbid anxiety in patients in substance use treatment programs (CALM for Addiction Recovery Centers; CALM ARC) to evaluate preliminary efficacy. CALM ARC involved a 7-session computerized CBT program for groups delivered by SUD counselors. Participants were randomized to receive CALM ARC as an augment to treatment as usual (TAU) or TAU alone. Participants completed assessments of past 30-day alcohol and drug use and anxiety symptoms at baseline, post-treatment, and 6-month follow-up. A CBT-trained psychologist rated counselor fidelity to CALM ARC protocol for 22.3% of sessions. Counselors achieved 99.3% fidelity. Most participants (69.2%) completed at least 5 sessions; 15.4% of participants completed 7 sessions. CALM ARC participants completed about 50% of assigned homework. CALM ARC participants experienced significant reductions in anxiety symptoms and alcohol use between pre- and post-treatment, and effects were maintained at follow-up. Changes in anxiety symptoms and alcohol use were significantly greater for CALM ARC participants than TAU participants. There were no significant changes in drug use in CALM ARC participants, while those receiving TAU alone reported significant increases in drug use over time.
Take Away: CALM ARC was successfully delivered by substance use counselors and may improve anxiety symptoms and mitigate substance use in patients with comorbid anxiety and substance use disorders.
A quality improvement project aimed at adapting primary care to ensure the delivery of evidence-based psychotherapy for adult anxiety
Williams MD, Sawchuk CN, Shippee ND, et al. BMJ Quality Improvement Report. 2018. 7: e000066. doi: 10.1136/ bmjoq-2017-000066
Summary: This article describes a quality improvement project for implementation of CALM in Mayo primary care clinics, comparing treatment response from 57 patients to the original CALM trial (Roy-Byrne P, Craske MG, Sullivan G, et al., 2010). CALM was offered to adult patients diagnosed with one of the four CALM target anxiety disorders or anxiety disorder, not otherwise specified. Researchers gathered a multi-disciplinary steering group including members from administration, nursing, primary care, social work, psychology, and psychiatry and a quality improvement facilitator to undertake a series of 25 Plan-Do-Study-Act (PDSA) cycles to adapt the CALM model to primary care practices. PDSA cycles addressed the process of referring patients to appropriate behavioral health providers, brief therapy protocols for patients with sub-threshold anxiety, staff documentation of intervention process and outcomes, and algorithmic approaches to pharmacotherapy for anxiety. The primary clinical outcome was treatment response, defined as a 50% or greater reduction in generalized anxiety disorder. Rate of treatment response was 51% in the quality improvement project, compared to 57% in the original trial. Among participants who completed CALM (28.1%), rate of treatment response 93.8%, compared to 34.2% of non-completers. CALM completion was significantly related to treatment response.
Take Away: Implementation of CALM in primary care resulted in similar treatment response rates to the original CALM trial.