Adapting Evidence-Based Interventions for Anxiety for Use in Integrated Primary Care Settings

1. Session G4a Saturday, October 18, 2014 Adapting Evidence-Based Interventions for Anxiety for Use in Integrated Primary Care Settings Robyn L. Shepardson, PhD Postdoctoral Research Fellow VA Center for Integrated Healthcare Jennifer S. Funderburk, PhD Clinical Research Psychologist VA Center for Integrated Healthcare Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. The views expressed in this presentation are those of the authors and do not reflect the official policy of the Department of Veterans Affairs, Department of Defense, or other departments of the U.S. government

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the rationale for selecting particular anxiety interventions • Describe the main techniques involved in a variety of brief interventions for anxiety • Identify several practice tools to support use of brief anxiety interventions • Discuss the implications of the current evidence base on clinical practice and future research

4. Overview • Background on anxiety in primary care • Anxiety and the Triple Aim • Empirically supported treatments for anxiety • Adapting ESTs for primary care • Implications for clinical practice and future research

5. What is Your Role? • Behavioral health consultant • Primary care provider • Nurse • Administrator • Other

6. Think of a Case… • 32 y/o female referred for anxiety • No major medical issues • Works 50 hours/week as nurse • Taking care of father with early Alzheimer’s • Single mom with 2 kids • 13 y/o son struggling in school • Feels overwhelmed • Always “on the go,” can’t relax • Feeling lightheaded a lot • Trouble falling asleep • Panic attacks 1-2x/week • Calling son’s school almost daily

7. Anxiety is Prevalent in Primary Care • 15-19% any anxiety disorder • Based on SCID diagnoses by MHPs • 19.5% any of big 4 ADs • 8.6% PTSD, 7.6% GAD, 6.2% SAD, 6.8% PD • 34% had >1 anxiety disorder • Subthreshold anxiety also common (Ansseau et al., 2004; Cwikel, Zilber, Feinson, & Lerner, 2008; Niesenson, Pepper, Schwenk, & Coyne, 1998) (Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007) (Cwikel et al., 2008; Rucci et al., 2003; Wittchenet al., 2002)

8. Anxiety is Burdensome • Impairment • Decreased quality of life • Worse psychosocial functioning • High burden of disability • Over and above comorbid MDD • Even subthreshold symptoms are impairing • Economic costs • High medical utilization • Cost of treatment, medication, workplace costs (Beard, Weisberg, & Keller, 2010; Olatuni, Cisler, & Tolin, 2007; Sherbourne et al., 2010; Stein et al., 2005) • (Batelaan et al., 2007; Fehm, Beesdo, Jacobi, & Fiedler, 2008; Kessler et al., 2005 AGP; Mendlowicz & Stein, 2000) (Deacon, Lickel, & Abramowitz, 2008; Greenberg et al., 1999)

9. Anxiety is Burdensome • Chronic course • Delay between onset & help-seeking is ~10 years • High comorbidity • Other anxiety disorders: >60% • MDD: ~45% current, >70% lifetime • Anx + Dep worse off • Medical illnesses: e.g., IBS, CVD, pain, asthma • Suicidality • AD are risk factor for ideation and attempts • PC patients with AD: 13% active SI, 18% lifetime suicide attempt (Wang et al., 2005) (Hirshfeld, 2001; Rivas-Vasquez et al., 2004; Rodriguez et al., 2004; Roy-Byrne et al., 2008) (Bomyea et al., 2013; Cougle, Keough, Riccardi, & Sachs-Ericsson, 2009; Nepon, Belik, Bolton, & Sareen, 2010; Sareen et al., 2005)

10. Anxiety and the Triple Aim • Patients • Decrease anxiety symptoms • Improve functioning and coping skills • Population • Triage ensures care at appropriate level • Free up PCP time/resources • Health Care System • Reduce medical utilization • Reduce medication costs

11. Anxiety Treatment in Primary Care How do you treat patients presenting with anxiety symptoms?

12. Evidence-Based Treatment • We aspire to evidence-based practice • Goal: “to promote effective psychological practice and enhance public health by applying empirically supported principles” of assessment and intervention • Patient preferences are important! (APA Presidential Task Force on Evidence-Based Practice, 2006) (Tompkins, Swift, & Callahan, 2013)

13. Empirically Supported Treatments for Anxiety • Strong empirical support but usually disorder specific • CBT for panic disorder • CBT for GAD • CBT for social phobia • What about high comorbidity among anxiety disorders? • What about anxiety NOS? • What about subthreshold anxiety symptoms? • (McHugh, Smits, & Otto, 2009) • (Mitte, 2005) • (Heimberg, 2002)

14. Empirically Supported Treatments for Anxiety • Developed for traditional specialty mental health settings • Intensity/Dosage: 12-20 sessions • Frequency: weekly • Duration: 50-90 minutes • Not compatible with IPC • Goal: 1-6 sessions lasting 15-30 minutes • In practice: usually only 1-2 sessions • (Rowan & Runyan, 2005; Strosahl& Robinson, 2008) • (Wray, Szymanski, Kearney, & McCarthy, 2012; Funderburk et al., 2011; • Bryan, Morrow, & Appolonio, 2009)

15. Brief EST for Anxiety? • Little work done on brief treatment for anxiety • Literature review: PC-based psychological treatments for anxiety • Only 28 studies • 16 were disorder specific (GAD and/or PD) • Only 10 were 6 sessions or less • Only 4 of those were 30 minutes or less per session • CALM computerized treatment

16. Brief EST for Anxiety? • Anxiety disorders share common etiology, symptoms, maintaining processes, etc. and are highly comorbid • Perceived future threat, avoidance, physiological arousal • Similar treatment approach across disorders • Goal: increase awareness and learn coping skills (Norton & Philipp, 2008)

17. 5 Useful (and Brief) Interventions for IPC • Adapted from existing evidence-based interventions • Psycho-education • Relaxation training • Cognitive restructuring • Behavioral activation • Exposure

18. Psycho-education • Providing basic information about anxiety • Can range from passive (e.g., a pamphlet) to active (e.g., multiple sessions led by therapist) • Advantages • Increase patients’ knowledge about their condition and correct their misperceptions • Less expensive than other approaches • Easy to administer • More accessible than therapy/meds • First step in stepped care • Provides rationale for other interventions (Donker, Griffiths, Cuijpers, & Christensen, 2009)

19. Psycho-education • Topics to cover • Common symptoms • Anxiety spiral • Relationship between thoughts, feelings, & behavior • Prevalence (normalize) • Adaptive nature of anxiety & fear • Goals of treatment (figure from Asmundson, Taylor, Bovell & Collimore, 2006)

20. Psycho-education (figure from Roy-Byrne et al., 2009)

21. Psycho-education • Resources • For you: CIH patient education handouts • http://www.mirecc.va.gov/cih-visn2/clinical_resources.asp • For patients: Anxiety Disorders Association of American • www.adaa.org/understanding-anxiety

22. Relaxation Training • EST for anxiety (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008) • Teach patient to attend to and control their physiological arousal • Variety of techniques • Diaphragmatic breathing • Progressive muscle relaxation • Applied relaxation • Autogenic training • Transcendental meditation • Many protocols call for 8-12 sessions (Conrad & Roth, 2007)

23. Relaxation Training • Adapted to fit in primary care format • Educate on the physiological relaxation response • Reinforce anything patient already does that cultivates this • Teach one simple skill via a 3-5 minute demo • Have patient rate tension level before & after • Explain relaxation as a skill (like piano) • Plan regular practice • Problem solve barriers • If skeptical, normalize, note others’ success with it, and suggest they try as an experiment

24. Relaxation Training • Provide a menu of options • Deep breathing • Mindfulness meditation • PMR • Guided imagery

25. Relaxation Training • Encourage regular at-home practice • Self-directed • Guided by audio or video • Resources (see handout) • CIH handouts • Mobile apps • Websites

26. Cognitive Restructuring • Learn to identify and evaluate the accuracy of negative thoughts and develop alternative thoughts • Targets cognitive distortions • Overestimating / jumping to conclusions • Catastrophizing • Thought records, downward arrow exercises, behavioral experiments to test hypotheses

27. Cognitive Restructuring • Adapting for primary care • Highlight contribution of negative thought patterns and cognitive distortions to anxiety spiral • Educate that thoughts are hypotheses, not facts • Encourage to challenge thoughts • Consider alternative explanations • Evaluate the evidence for and against

28. Cognitive Restructuring Thought: That must be the dog again. The poor thing can hardly see where he is going when it is light out, much less in the dark. Feeling: Sad, calm Situation: You wake up in the middle of the night due to a crashing noise coming from downstairs Thought: That must be the stupid dog again. I don’t know how much longer I can put up with him waking us up every night. Feeling: Angry, annoyed Feeling: Scared, anxious Thought: That was too loud to be from the dog. It must be someone breaking in our house.

29. Case Example • 65 y/o male referred for stress • Has uncontrolled diabetes, back pain, hypertension • Works part-time as cashier • $ stress, behind on mortgage • Daughter has cancer, pt helps watch granddaughter • Feels tense and irritable • Frequent heart palpitations • GI problems • Smoking more than usual • Won’t discuss $ with wife

30. Cognitive Restructuring • Exercise to help the patient consider alternative thoughts What if … ? When we say to ourselves “what if … ?” we are often identifying a potential danger: “what if something terrible happens?” “what if it all goes wrong?” Each time we do this there are many equally plausible neutral and even positive possibilities that we are failing to see. If we only see the bad possibilities and not the good ones then we have an unbalanced view of the situation. Try to come up with 3 neutral or “glass half full” ways of seeing each “glass half empty” worry. (worksheet from http://psychology.tools/what-if.html)

31. Cognitive Restructuring • Explain idea of cognitive distortions • See if patient can identify any thinking errors they tend to make

32. Cognitive Restructuring • Exercise to help the patient consider alternative explanations • Pie Chart • Identify the distorted belief • Rate the strength of the belief • Have the patient make a list of all the possible factors involved • Using the list, divide the pie chart up into percentages starting at the bottom of the list • Re-rate the belief from #1 (worksheet from http://psychology.tools/pie-chart.html)

33. Behavioral Activation • EST for depression • Targets avoidance/disengagement • Activity monitoring* • Assessment of goals and values • Activity scheduling* • Skills training • BA helpful for anxiety? • Comorbid depression common • Decrease avoidance and re-engage in life (Dimidjian et al., 2011; Kanter et al., 2010)

34. Behavioral Activation • Easily adapted to brief format for primary care • Identify pleasurable, valued activities • Verbal questioning (e.g., hobbies you (used to) enjoy, what kinds of things would you be doing if you were not feeling so down) • Self-report questionnaire (e.g, Pleasant Events Schedule) • Set BA goals • Collaborative process with patient • Incremental approach (start small) • SMART goals • Ideally tied to values

35. Case Example • 32 y/o female referred for anxiety • No major medical issues • Works 50 hours/week as nurse • Taking care of father with early Alzheimer’s • Single mom with 2 kids • 13 y/o son struggling in school • Feels sad and overwhelmed • Always “on the go,” can’t relax • Feeling lightheaded a lot • Trouble falling asleep • Panic attacks 1-2x/week • Calling son’s school almost daily

36. Behavioral Activation • Values assessment to inform goals (worksheet from http://psychology.tools/values.html)

37. Exposure • Repeated exposure to internal or external fear cues to disconfirm anxious thoughts and lessen emotional reactivity • Help patient learn that anxiety can decrease without resorting to avoidance or escape • Particular type of exposure tailored to specific symptoms, e.g., • Interoceptive exposure to bodily sensations for panic • Exposure to feared object/situation for phobia • Can be done using imagery or in vivo • Start at bottom of anxiety hierarchy and work up

38. Exposure • May be challenging in PC due to time constraints • Have patient create anxiety hierarchy • Start with an exposure in-session • Imaginary or in vivo depending on details • Plan gradual exposures for homework • Attend to cognitive distortions that arise

39. Which Approach Should I Use? • Consider several patient factors: • Most bothersome symptoms • Preferences / interest • Education level / literacy • Concrete vs. abstract thinking • Psychological mindedness • What has helped them in the past • Others? • Also: your training and comfort level with different interventions

40. Other Approaches • Problem-solving therapy • Solution-focused therapy • ACT • Self-help materials • Lifestyle changes • Exercise & yoga • Improve sleep • Improve diet (e.g., reduce caffeine) • Reducing smoking & drinking • CAM • Other ideas?

41. Discussion & Implications • Clinical • Not many interventions that fit within a brief format • Have to adapt existing evidence-based interventions to fit • Keep in mind, different goals and population in PC & SMH • More focus on self-management in PC • Less severe cases in PC compared to SMH • Research • Need to identify what BHPs are doing in the real world • Need to develop and evaluate brief interventions • Triple Aim outcomes: patient satisfaction and functioning, population health, healthcare costs • Then disseminate widely

42. Questions? • Please take a handout

43. Bibliography / Reference Arch, J. J., & Craske, M. G. (2009). First-line treatment: A critical appraisal of cognitive behavioral therapy developments and alternatives. Psychiatric Clinics of North America, 32, 525-547. Bystritsky, A., Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2013). Current diagnosis and treatment of anxiety disorders. Pharmacy and Therapeutics, 38, 30-57. Campbell, J., & Larzelere, M. (2014). Behavioral interventions for office-based care: Stress and anxiety disorders. FP Essentials, 418, 28-40. Combs, H., & Markman, J. (2014). Anxiety disorders in primary care. Medical Clinics of North America, 98, 1007-1023. Roy-Byrne, P., Veitengruber, J. P., Bystritsky, A., Edlund, M. J., Sullivan, G., Craske, M. G., … Stein, M. B. (2009). Brief intervention for anxiety in primary care patients. Journal of the American Board of Family Medicine, 22, 175-186.

44. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period was included throughout this presentation.

45. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!

46. Measurement-based Care • Ongoing assessment of anxiety symptoms to track progress • Have patient complete self-report measures in waiting room or at start of each session • Brief measures in public domain • Generalized Anxiety Disorder-7 (GAD-7) • Overall Anxiety Severity and Impairment Scale (OASIS) • Also give depression measure to track mood and suicidal ideation • Patient Health Questionnaire-9 (PHQ-9)