Anxiety Disorders in the Anxiety Disorders in the yyPrimary Care Setting:Primary Care Setting:

Educational Goals:Educational Goals:

1) How to best screen for anxiety disorders in 1) How to best screen for anxiety disorders in primary careprimary care2) R t h i di ti it i d2) R t h i di ti it i d2) Recent changes in diagnostic criteria and 2) Recent changes in diagnostic criteria and treatment regimenstreatment regimens3) Improving our systems for caring for 3) Improving our systems for caring for patients with anxiety disorderspatients with anxiety disorderspatients with anxiety disorderspatients with anxiety disorders

Case Presentation:Case Presentation:Case Presentation:Case Presentation:

68 years old very pleasant man with68 years old very pleasant man with68 years old very pleasant man with 68 years old very pleasant man with severe knee DJD along with HTN, CRI severe knee DJD along with HTN, CRI and atrial fibrillationand atrial fibrillationand atrial fibrillation.and atrial fibrillation.Missed three consecutive days in the OR Missed three consecutive days in the OR for TKA Notes he doesn’t sleep well infor TKA Notes he doesn’t sleep well infor TKA. Notes he doesn t sleep well in for TKA. Notes he doesn t sleep well in the hospital.the hospital.

“Anxiety Disorders in Primary Care: “Anxiety Disorders in Primary Care: Prevalence Impairment Comorbidity andPrevalence Impairment Comorbidity andPrevalence, Impairment, Comorbidity, and Prevalence, Impairment, Comorbidity, and

Detection”Detection”Kroenke, et al Annals Int MedKroenke, et al Annals Int Med--20072007,,

Approached 2982 consecutive patients at 15 US Approached 2982 consecutive patients at 15 US Primary Care sites 92% agreed and completedPrimary Care sites 92% agreed and completedPrimary Care sites, 92% agreed and completed Primary Care sites, 92% agreed and completed a 4a 4--page questionnaire.page questionnaire.1654/2149 who were approached agreed to a1654/2149 who were approached agreed to a1654/2149 who were approached agreed to a 1654/2149 who were approached agreed to a telephone interview and 965 completed a full telephone interview and 965 completed a full anxiety evaluation (including Medical Outcome anxiety evaluation (including Medical Outcome y ( gy ( gStudy FormStudy Form--20, DSM20, DSM--IV Structured Clinical IV Structured Clinical Interview and a 7Interview and a 7--item anxiety screening toolitem anxiety screening tool--G li d A i t Di dG li d A i t Di d 7 S l )7 S l )Generalized Anxiety DisorderGeneralized Anxiety Disorder--7 Scale).7 Scale).

Of the 965 patients:Of the 965 patients:Of the 965 patients:Of the 965 patients: 19.5% had at least 1 anxiety disorder19.5% had at least 1 anxiety disorder 8.6% PTSD8.6% PTSD%% 7.6% GAD7.6% GAD 6.8% Panic Disorder6.8% Panic Disorder 6.2% Social Anxiety Disorder6.2% Social Anxiety Disorder

41% with diagnosed anxiety disorders 41% with diagnosed anxiety disorders g yg yreported no current treatmentreported no current treatmentGADGAD--7 (and the simpler GAD7 (and the simpler GAD--2) 2) ( p( p ))performed well as screening tools for all 4 performed well as screening tools for all 4 disorders (ROCdisorders (ROC-- area 0.80area 0.80--0.91)0.91)

Anxiety disorders are often Anxiety disorders are often missed.missed.

Appro imatel 14Appro imatel 14 36% of patients ith an iet36% of patients ith an ietApproximately 14Approximately 14--36% of patients with anxiety 36% of patients with anxiety disorders are recognized in PC clinics.disorders are recognized in PC clinics.Approximately 25% receive an adequate trial ofApproximately 25% receive an adequate trial ofApproximately 25% receive an adequate trial of Approximately 25% receive an adequate trial of pharmacologic treatment.pharmacologic treatment.Less than 25% receive appropriate counseling/Less than 25% receive appropriate counseling/Less than 25% receive appropriate counseling/ Less than 25% receive appropriate counseling/ cognitive therapy.cognitive therapy.Nearly ½ patients screened in primary careNearly ½ patients screened in primary careNearly ½ patients screened in primary care Nearly ½ patients screened in primary care clinics with an anxiety disorder receive no clinics with an anxiety disorder receive no treatment.treatment.

““Lifetime Prevalence and AgeLifetime Prevalence and Age--ofof--Onset Onset Distributions of DSMDistributions of DSM IV Disorders in theIV Disorders in theDistributions of DSMDistributions of DSM--IV Disorders in the IV Disorders in the National Comorbidity Survey Replication” National Comorbidity Survey Replication”

Arch Gen PsychArch Gen Psych--20052005Arch Gen PsychArch Gen Psych 20052005

Surveyed 9282 English speaking US Surveyed 9282 English speaking US residentsresidents > 18 years old, using DSM> 18 years old, using DSM--IV criteriaIV criteria

Lifetime Prevalence:Lifetime Prevalence: Anxiety disordersAnxiety disorders-- 28.8%28.8%yy Mood disordersMood disorders-- 20.8%20.8% Substance use disordersSubstance use disorders-- 14.6%14.6% Substance use disordersSubstance use disorders 14.6%14.6% Any disorderAny disorder--46.4%46.4%

Lancet October 2011:Lancet October 2011:Lancet, October 2011:Lancet, October 2011:Second themed issue on global mental healthSecond themed issue on global mental healthggMental health problems affect 10Mental health problems affect 10--20% of 20% of children worldwide; mental ill health and poverty children worldwide; mental ill health and poverty i i i li i i linteract in a negative cycle.interact in a negative cycle.WHO reports that mental illness is the #2 cause WHO reports that mental illness is the #2 cause of total disability in economically developedof total disability in economically developedof total disability in economically developed of total disability in economically developed countries and it may pass cardiovascular countries and it may pass cardiovascular disease in upcoming years.disease in upcoming years.Up to “9 of 10 people with a mental health Up to “9 of 10 people with a mental health problem do not receive even basic care in some problem do not receive even basic care in some countries ”countries ”countries.countries.

DSMDSM--IV Criteria: Key Features of IV Criteria: Key Features of S ifi A i Di dS ifi A i Di dSpecific Anxiety DisordersSpecific Anxiety Disorders

DisorderDisorder Key featuresKey features

PD with or without agoraphobiaPD with or without agoraphobia Recurrent unexpected panic attacks without any obvious situational triggerRecurrent unexpected panic attacks without any obvious situational triggerPatient may actively avoid situation in which panic attacks are predicted to occurPatient may actively avoid situation in which panic attacks are predicted to occurIntolerance of physical symptoms of anxietyIntolerance of physical symptoms of anxiety

SAD and (or) social phobiaSAD and (or) social phobia Excessive or unrealistic fear of social or performance situationsExcessive or unrealistic fear of social or performance situationsSAD and (or) social phobiaSAD and (or) social phobia Excessive or unrealistic fear of social or performance situationsExcessive or unrealistic fear of social or performance situationsIntolerance of embarrassment or scrutiny by othersIntolerance of embarrassment or scrutiny by others

Specific phobiaSpecific phobia Excessive or unreasonable fear of a circumscribed object or situation, usually associated with Excessive or unreasonable fear of a circumscribed object or situation, usually associated with avoidance of the feared object (for example, an animal, blood, injections, heights, storms, driving, flying, avoidance of the feared object (for example, an animal, blood, injections, heights, storms, driving, flying, or enclosed places)or enclosed places)

OCDOCD Presence of obsessions; recurrent, unwanted, and intrusive thoughts, images, or urges that cause Presence of obsessions; recurrent, unwanted, and intrusive thoughts, images, or urges that cause marked anxiety (for example, thoughts about contamination, doubts about actions, distressing religious, marked anxiety (for example, thoughts about contamination, doubts about actions, distressing religious, aggressive, or sexual thoughts)aggressive, or sexual thoughts)

Compulsions; repetitive behaviors or mental acts that are performed to reduce the anxiety generated Compulsions; repetitive behaviors or mental acts that are performed to reduce the anxiety generated by the obsessions (for example, checking, washing, counting, or repeating)by the obsessions (for example, checking, washing, counting, or repeating)

GADGAD Uncontrollable and excessive worry occurring more days than not, about a number of everyday, Uncontrollable and excessive worry occurring more days than not, about a number of everyday, ordinary experiences or activities. Often accompanied by physical symptoms (for example, headaches ordinary experiences or activities. Often accompanied by physical symptoms (for example, headaches or upset stomach)or upset stomach)

Intolerance or uncertaintyIntolerance or uncertainty

PTSDPTSD Occurs after a traumatic event to which patient responds with intense fear, helplessness, or horror; Occurs after a traumatic event to which patient responds with intense fear, helplessness, or horror; patients relive the event in memory, avoid reminders of the event, and experience emotional numbing patients relive the event in memory, avoid reminders of the event, and experience emotional numbing and symptoms of increased arousaland symptoms of increased arousal

Intolerance of reexperiencing traumaIntolerance of reexperiencing trauma

DSMDSM--5: Due in May 20135: Due in May 2013DSMDSM 5: Due in May 20135: Due in May 2013Has a new diagnosis of mixed anxiety/depression; patient Has a new diagnosis of mixed anxiety/depression; patient g y p pg y p phas three or four of the symptoms of major depression has three or four of the symptoms of major depression (which must include depressed mood and/or anhedonia) (which must include depressed mood and/or anhedonia) and they are accompanied by anxious distress [two or and they are accompanied by anxious distress [two or y p y [y p y [more of these symptoms: irrational worry, preoccupation more of these symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen].tension, fear that something awful may happen]., g y pp ], g y pp ]

Trauma and Stressor Related Disorders: a new category Trauma and Stressor Related Disorders: a new category with PTSD separate from the Anxiety Disorderswith PTSD separate from the Anxiety Disorderswith PTSD separate from the Anxiety Disorderswith PTSD separate from the Anxiety Disorders

DSMDSM--55DSMDSM 55Priorities for change include:Priorities for change include:gg1)1) High rates of coHigh rates of co--occuring diagnoses identified occuring diagnoses identified

by DSMby DSM--IV criteriaIV criteria2)2) Hierarchial “pure” diagnostic categories don’tHierarchial “pure” diagnostic categories don’t2)2) Hierarchial pure diagnostic categories don t Hierarchial pure diagnostic categories don t

adequately describe an individuals clinical adequately describe an individuals clinical mental health presentationmental health presentation

3)3) The frequent use of NOS for patients who The frequent use of NOS for patients who don’t fit any specified designations/diagnosesdon’t fit any specified designations/diagnoses

4)4) DSMDSM--5 needs to be a “living document” open5 needs to be a “living document” open4)4) DSMDSM--5 needs to be a living document open 5 needs to be a living document open to ongoing revision to incorporate new findings to ongoing revision to incorporate new findings in the behavioral and neurosciences.in the behavioral and neurosciences.

Anxiety Disorders:Anxiety Disorders:Anxiety Disorders:Anxiety Disorders:DSMDSM--IVIV DSMDSM--55

Generalized anxiety Generalized anxiety disorderdisorderPanic disorderPanic disorder

Separation anxiety Separation anxiety disorderdisorderPanic disorderPanic disorder

AgoraphobiaAgoraphobiaSpecific phobiaSpecific phobiaSocial phobiaSocial phobia

AgoraphobiaAgoraphobiaSpecific phobiaSpecific phobiaSocial anxiety disorderSocial anxiety disorderSocial phobiaSocial phobia

ObsessiveObsessive--compulsive compulsive disorderdisorderPost traumatic stressPost traumatic stress

Social anxiety disorderSocial anxiety disorderGeneralized anxiety Generalized anxiety disorderdisorderSubstanceSubstance induced anxietyinduced anxietyPost traumatic stress Post traumatic stress

disorderdisorderAcute stress disorderAcute stress disorder

SubstanceSubstance--induced anxiety induced anxiety disorderdisorderUnspecified anxiety Unspecified anxiety disorderdisorderdisorderdisorder

Caveats when dealing with an anxious patient:Caveats when dealing with an anxious patient:Caveats when dealing with an anxious patient:Caveats when dealing with an anxious patient:

1)1) Include a history and physical examination, including a Include a history and physical examination, including a l i l ti t l t f di ll i l ti t l t f di lneurologic evaluation to evaluate for medical causes. neurologic evaluation to evaluate for medical causes.

Pursue adequate evaluation of other physical Pursue adequate evaluation of other physical symptoms or examination findings.symptoms or examination findings.

2)2) C id CBC ti h i t i TSH iC id CBC ti h i t i TSH i2)2) Consider CBC, routine chemistries, TSH, magnesium, Consider CBC, routine chemistries, TSH, magnesium, calcium, EKG and screening for substances.calcium, EKG and screening for substances.

3)3) “Collateral history” from a family member can be “Collateral history” from a family member can be helpfulhelpfulhelpful.helpful.

4)4) Consider all medications, withdrawal syndromes, Consider all medications, withdrawal syndromes, caffeine and other OTC’s.caffeine and other OTC’s.

5)5) A i ti t f th t d b di tiA i ti t f th t d b di ti5)5) Anxious patients are further stressed by diagnostic Anxious patients are further stressed by diagnostic uncertainty; try to be reassuring even when uncertain.uncertainty; try to be reassuring even when uncertain.

6)6) Rates of anxiety symptoms are commonly increased in Rates of anxiety symptoms are commonly increased in ti t ith COPD th PE P ki tti t ith COPD th PE P ki tpatients with COPD, asthma, PE, Parkinsons, postpatients with COPD, asthma, PE, Parkinsons, post--

CVACVA

Screening for anxiety disorders:Screening for anxiety disorders:Screening for anxiety disorders:Screening for anxiety disorders:Many screening tools/questionnaires available Many screening tools/questionnaires available y g qy g qwithout consensus for the primary care setting.without consensus for the primary care setting.Spitzer et al developed PRIMESpitzer et al developed PRIME--MD, a screening MD, a screening tool for 5 common mental health disorders in thetool for 5 common mental health disorders in thetool for 5 common mental health disorders in the tool for 5 common mental health disorders in the 1990s1990sRequired mean of 5.6 minutes of clinician time in Required mean of 5.6 minutes of clinician time in

ti t ith t l h lth di d 11 4ti t ith t l h lth di d 11 4patients with no mental health disorder, 11.4 patients with no mental health disorder, 11.4 minutes in patients with a diagnosisminutes in patients with a diagnosisHave developed many screening tools since: Have developed many screening tools since: a e de e oped a y sc ee g too s s cea e de e oped a y sc ee g too s s cePHQPHQ--4 (Anxiety and Depression) and 4 (Anxiety and Depression) and Provisional Diagnostic Instrument 4Provisional Diagnostic Instrument 4

M ti t ith i t di d hM ti t ith i t di d hMany patients with anxiety disorders have Many patients with anxiety disorders have more than one mental health disorder: 1/3 more than one mental health disorder: 1/3 t 2/3 i it 2/3 i ito 2/3 in many seriesto 2/3 in many series“OASIS: Overall anxiety severity and “OASIS: Overall anxiety severity and impairment scale”impairment scale”-- recent studies suggest recent studies suggest it can be used across anxiety disorders it can be used across anxiety disorders with multiple anxiety disorders and with with multiple anxiety disorders and with subsub--threshold anxiety.threshold anxiety.MINI: MiniMINI: Mini--International Neuropsychiatric International Neuropsychiatric InterviewInterview

1 O th l t 2 k h ft h b b th d b f th f ll i1 O th l t 2 k h ft h b b th d b f th f ll i N t t llN t t ll S lS l M thM th N lN l

Brief Patient Health Questionnaire This questionnaire is an important part of providing you with the best health care possible. Your answers will help in the understanding problems that you may have.Name__________ Age______ Sex__________ Date__________

1.Over the last 2 weeks, how often have you been bothered by any of the following 1.Over the last 2 weeks, how often have you been bothered by any of the following problems?problems?

Not at allNot at all Several Several DaysDays

More than More than half the dayshalf the days

Nearly Nearly every dayevery day

a. Little interest or pleasure in doing thingsa. Little interest or pleasure in doing things

b. Feeling down, depressed, or hopelessb. Feeling down, depressed, or hopeless

c Trouble falling or staying asleep or sleeping too muchc Trouble falling or staying asleep or sleeping too muchc. Trouble falling or staying asleep, or sleeping too muchc. Trouble falling or staying asleep, or sleeping too much

d. Feeling tired or having little energyd. Feeling tired or having little energy

e. Poor appetite or overeatinge. Poor appetite or overeating

f. Feeling bad about yourselff. Feeling bad about yourself-- or that you are a failure or have let yourself or your family downor that you are a failure or have let yourself or your family down

g. Trouble concentrating on things, such as reading the newspaper or watching televisiong. Trouble concentrating on things, such as reading the newspaper or watching television

h. Moving or speaking so slowly that other people could have noticed? Or the oppositeh. Moving or speaking so slowly that other people could have noticed? Or the opposite--being so fidgety or restless that you have been moving around a lot more than usualbeing so fidgety or restless that you have been moving around a lot more than usual

i. Thoughts that you would be better off dead or hurting yourself in some wayi. Thoughts that you would be better off dead or hurting yourself in some way

2 Q ti b t i t2 Q ti b t i t NONO YESYES2. Questions about anxiety2. Questions about anxiety NONO YESYES

a. In the last 4 weeks, have you had an anxiety attacka. In the last 4 weeks, have you had an anxiety attack-- suddenly feeling fear or panic?suddenly feeling fear or panic?

IF you checked “NO”, go to question #3IF you checked “NO”, go to question #3

b. Has this ever happened before?b. Has this ever happened before?

c. Do some of these attacks come suddenly out of the bluec. Do some of these attacks come suddenly out of the blue-- that is, in situations where you that is, in situations where you don’t expect to be nervous or uncomfortable?don’t expect to be nervous or uncomfortable?

d. Do these attacks bother you a lot or are you worried about having another attack?d. Do these attacks bother you a lot or are you worried about having another attack?

e. During your last bad anxiety attack, did you have symptoms like shortness of breath, e. During your last bad anxiety attack, did you have symptoms like shortness of breath, sweating your heart racing or pounding dizziness or faintness tingling or numbness orsweating your heart racing or pounding dizziness or faintness tingling or numbness orsweating, your heart racing or pounding, dizziness or faintness, tingling or numbness, or sweating, your heart racing or pounding, dizziness or faintness, tingling or numbness, or nausea or upset stomach?nausea or upset stomach?

3. If you checked off any problems on this questionnaire so far, how difficult have these 3. If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other problems made it for you to do your work, take care of things at home, or get along with other people?people?

The Generalized Anxiety Disorder (GAD)The Generalized Anxiety Disorder (GAD)--7 scale.7 scale.The Generalized Anxiety Disorder (GAD)The Generalized Anxiety Disorder (GAD) 7 scale.7 scale.

Over the last 2 weeks, how often have you been Over the last 2 weeks, how often have you been bothered by the following problems?bothered by the following problems?

Not at allNot at all Several Several daysdays

More than More than half the half the daysdays

Nearly Nearly every every dayday

Feeling nervous, anxious, or on edgeFeeling nervous, anxious, or on edge 00 11 22 33

Not being able to stop or control worryingNot being able to stop or control worrying 00 11 22 33

Worrying too much about different thingsWorrying too much about different things 00 11 22 33

Having trouble relaxingHaving trouble relaxing 00 11 22 33

Being so restless that it is hard to sit stillBeing so restless that it is hard to sit still 00 11 22 33

Becoming easily annoyed or irritableBecoming easily annoyed or irritable 00 11 22 33

Feeling afraid as if something awful might happenFeeling afraid as if something awful might happen 00 11 22 33

Total Score= Add Columns ____ + ____ + ____ + ____

Generalized Anxiety Disorder:Generalized Anxiety Disorder:Generalized Anxiety Disorder:Generalized Anxiety Disorder:

58 year old WM new in clinic after58 year old WM new in clinic after58 year old WM new in clinic after 58 year old WM new in clinic after presenting to the ER with painless, presenting to the ER with painless, macroscopic hematuria for 1 ½ yearsmacroscopic hematuria for 1 ½ yearsmacroscopic hematuria for 1 ½ years. macroscopic hematuria for 1 ½ years. Now so frequent and severe that he felt Now so frequent and severe that he felt compelled to present to the ER; U/Scompelled to present to the ER; U/Scompelled to present to the ER; U/S compelled to present to the ER; U/S revealed a 4 cm bladder tumor. Very revealed a 4 cm bladder tumor. Very anxious appearing man on a long list ofanxious appearing man on a long list ofanxious appearing man on a long list of anxious appearing man on a long list of herbal medications; declines further herbal medications; declines further imaging or Urology consultation on his firstimaging or Urology consultation on his firstimaging or Urology consultation on his first imaging or Urology consultation on his first visit. visit.

Generalized Anxiety DisorderGeneralized Anxiety DisorderGeneralized Anxiety DisorderGeneralized Anxiety Disorder

Uncontrollable and excessive worryUncontrollable and excessive worryUncontrollable and excessive worry, Uncontrollable and excessive worry, occurring more days than not, about a occurring more days than not, about a number of everyday ordinary experiencesnumber of everyday ordinary experiencesnumber of everyday, ordinary experiences number of everyday, ordinary experiences or activities. Often accompanied by or activities. Often accompanied by physical symptoms ( eg headaches orphysical symptoms ( eg headaches orphysical symptoms ( eg headaches or physical symptoms ( eg headaches or upset stomach).upset stomach).Intolerance of uncertaintyIntolerance of uncertaintyIntolerance of uncertainty.Intolerance of uncertainty.

Generalized Anxiety DisorderGeneralized Anxiety DisorderGeneralized Anxiety DisorderGeneralized Anxiety DisorderExcessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (for example, domains like family, health, finances, and school/work difficulties)(for example, domains like family, health, finances, and school/work difficulties)The excessive anxiety and worry occur on more days than not for three months or moreThe excessive anxiety and worry occur on more days than not for three months or morey y yy y yThe anxiety and worry are associated with one or more of the following symptoms:The anxiety and worry are associated with one or more of the following symptoms: Restlessness or feeling keyed up or on edgeRestlessness or feeling keyed up or on edge Being easily fatiguedBeing easily fatigued Difficulty concentrating or mind going blankDifficulty concentrating or mind going blank IrritabilityIrritability Muscle tensionMuscle tension Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

The anxiety and worry are associated with one (or more) of the following behaviors:The anxiety and worry are associated with one (or more) of the following behaviors: Marked avoidance of situations in which a negative outcome could occurMarked avoidance of situations in which a negative outcome could occur Marked time and effort preparing for situations in which a negative outcome could occurMarked time and effort preparing for situations in which a negative outcome could occur

M k d ti ti i b h i d i iM k d ti ti i b h i d i i ki d t iki d t i Marked procrastination in behavior or decisionMarked procrastination in behavior or decision--making due to worriesmaking due to worries Repeatedly seeking reassurance due to worriesRepeatedly seeking reassurance due to worries

The focus of the anxiety and worry are not restricted to symptoms of another disorder, such as Panic The focus of the anxiety and worry are not restricted to symptoms of another disorder, such as Panic Disorder (e.g., anxiety about having a panic attack), Social Anxiety Disorder (e.g., being embarrassed in Disorder (e.g., anxiety about having a panic attack), Social Anxiety Disorder (e.g., being embarrassed in public) Obsessivepublic) Obsessive--Compulsive Disorder (e g anxiety about being contaminated) Separation AnxietyCompulsive Disorder (e g anxiety about being contaminated) Separation Anxietypublic), Obsessivepublic), Obsessive Compulsive Disorder (e.g., anxiety about being contaminated), Separation Anxiety Compulsive Disorder (e.g., anxiety about being contaminated), Separation Anxiety Disorder (e.g., anxiety about being away from home or close relatives), Anorexia Nervosa (e.g., fear of Disorder (e.g., anxiety about being away from home or close relatives), Anorexia Nervosa (e.g., fear of gaining weight), Somatization Disorder (e.g., anxiety about multiple physical complaints), Body Dysmorphic gaining weight), Somatization Disorder (e.g., anxiety about multiple physical complaints), Body Dysmorphic Disorder (e.g., worry about perceived appearance flaws), Illness Anxiety Disorder (e.g., belief about having Disorder (e.g., worry about perceived appearance flaws), Illness Anxiety Disorder (e.g., belief about having a serious illness), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.a serious illness), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,

ti l th i t t f f ti iti l th i t t f f ti ioccupational, or other important areas of functioning.occupational, or other important areas of functioning.The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or an Autism Spectrum Disorder.Mood Disorder, a Psychotic Disorder, or an Autism Spectrum Disorder.

Overview of therapy for anxiety Overview of therapy for anxiety di ddi ddisordersdisorders

DiagnosisDiagnosis CBTCBT Medication Medication TherapyTherapy

Medication Medication TherapyTherapy

?benzodiazepines?benzodiazepines OtherOther

11stst LineLine 22ndnd LineLine

1) Panic disorder1) Panic disorder Combination with Combination with medications or alone medications or alone (patient preference (patient preference and availability)and availability)

SSRISSRI(side(side--effects, cost, effects, cost, drug interactions can drug interactions can guide choice)guide choice)

SNRISNRI(venlafaxine ER)(venlafaxine ER)

For severe SXS, For severe SXS, immediate effect if immediate effect if no substance abuse no substance abuse (active).(active).

Use CBT and Use CBT and medications if medications if comorbidities or comorbidities or persistent symptomspersistent symptomsg )g )

Duration at least 1 Duration at least 1 year after decrease year after decrease symptoms.symptoms.

Prefer short term.Prefer short term.

2) Social Anxiety 2) Social Anxiety disorderdisorder

Individual CBT Individual CBT maybe more helpful maybe more helpful

SSRISSRI-- equal in equal in efficacy to CBT, efficacy to CBT,

SNRISNRI-- ? also 1? also 1stst lineline As aboveAs above Dual tx with CBT Dual tx with CBT and medications not and medications not

than group, now than group, now including cognitive including cognitive restructuring, restructuring, exposure practices exposure practices and possibly internetand possibly internet

faster but may not faster but may not last as longlast as long

proven to be more proven to be more effectiveeffective

3) G li d3) G li d NNT 4 itiNNT 4 iti SSRI SNRISSRI SNRI TCATCA A bA b 2020 40% l40% l3) Generalized 3) Generalized Anxiety disorderAnxiety disorder

NNT= 4 vs waiting NNT= 4 vs waiting list controls or usual list controls or usual therapytherapy

SSRI, SNRISSRI, SNRILong term duration Long term duration may be necessarymay be necessary

TCATCA As aboveAs above 2020--40% relapse 40% relapse within 6within 6--12 months 12 months of medication of medication discontinuationdiscontinuation

4) Post4) Post--traumatic traumatic TraumaTrauma-- focused focused SSRI or SNRISSRI or SNRI Prazosin to Prazosin to As aboveAs above Often necessary to Often necessary to stress disorderstress disorder CBTCBT Start at low dose Start at low dose

and titrate up, and titrate up, patiently if possiblepatiently if possible

decrease decrease nightmares, ? nightmares, ? atypical atypical antipsychoticsantipsychotics

switch or combine switch or combine therapiestherapies

Generalized Anxiety Disorder: Generalized Anxiety Disorder: treatment responsetreatment response

Prognosis varies with severity of symptoms, Prognosis varies with severity of symptoms, g y y p ,g y y p ,presence of comorbidities (especially presence of comorbidities (especially depression, substance abuse or other anxiety depression, substance abuse or other anxiety disorders) and social factorsdisorders) and social factorsdisorders), and social factors.disorders), and social factors.Response rates vary with how definedResponse rates vary with how defined-- often in often in the 45the 45--80% range; remission rates 2080% range; remission rates 20--30% less30% lessthe 45the 45 80% range; remission rates 2080% range; remission rates 20 30% less.30% less.Start low dose, monitor closely for adverse Start low dose, monitor closely for adverse effects and benefit and titrate dose.effects and benefit and titrate dose.Cognitive Behavioral Therapy is firstCognitive Behavioral Therapy is first--line therapy line therapy if available, generally equal to medications and if available, generally equal to medications and longer lastinglonger lastinglonger lasting.longer lasting.

Five reasons to better integrate mental Five reasons to better integrate mental h lth i t th i ttih lth i t th i ttihealthcare into the primary care setting:healthcare into the primary care setting:

1)1) Patients prefer it.Patients prefer it.2)2) Mental health problems are missed or Mental health problems are missed or

misattributed to physical illnesses particularlymisattributed to physical illnesses particularlymisattributed to physical illnesses, particularly misattributed to physical illnesses, particularly in elderly patients.in elderly patients.

3)3) Patients are more likely to receive care for MH Patients are more likely to receive care for MH )) yyproblems when it’s identified and able to be problems when it’s identified and able to be treated in a PC setting.treated in a PC setting.

4)4) Receiving MH care in the primary care contextReceiving MH care in the primary care context4)4) Receiving MH care in the primary care context Receiving MH care in the primary care context enables better integration of care.enables better integration of care.

5)5) Treating MH issues in PC setting can help Treating MH issues in PC setting can help d ti ti t l ill d MHd ti ti t l ill d MHdestigmatize mental illness and MH care.destigmatize mental illness and MH care.

Everything you know for sure changes Everything you know for sure changes e er fi e ears “Stress and the cit ”e er fi e ears “Stress and the cit ”every five years: “Stress and the city”every five years: “Stress and the city”

––Nature, June 23Nature, June 23rdrd 2011.2011.

In 1950, 30% of the world’s population lived in In 1950, 30% of the world’s population lived in urban settings. In 2040, 70% of the world’s urban settings. In 2040, 70% of the world’s population will live in urban settings.population will live in urban settings.p p gp p gLiving in the city is associated with a 2 times Living in the city is associated with a 2 times increase in the rate of schizophrenia and increase in the rate of schizophrenia and markedly increased risks of anxiety andmarkedly increased risks of anxiety andmarkedly increased risks of anxiety and markedly increased risks of anxiety and depression.depression.Used functional MRI to measure brain function Used functional MRI to measure brain function d i i l t t td i i l t t tduring a social stress test.during a social stress test.Amydala and cingulate cortex activation was Amydala and cingulate cortex activation was different in those who grew up in large citiesdifferent in those who grew up in large cities--different in those who grew up in large citiesdifferent in those who grew up in large citiesand it was “doseand it was “dose--dependent”.dependent”.

“Abnormalities in the neural circuitry (within the“Abnormalities in the neural circuitry (within theAbnormalities in the neural circuitry (within the Abnormalities in the neural circuitry (within the amygdala, medial prefrontal cortex, insular amygdala, medial prefrontal cortex, insular cortex and hippocampus) underlie fear, memory cortex and hippocampus) underlie fear, memory and emotions ”and emotions ”and emotions…and emotions…National Institute of Mental Health (NIMH) National Institute of Mental Health (NIMH) proposed recently that mental health disorders proposed recently that mental health disorders should be viewed as disorders of brain circuitry should be viewed as disorders of brain circuitry (Graham; AmJ Psych in 8/2011) in the hope that (Graham; AmJ Psych in 8/2011) in the hope that this conception will help lead to advances in this conception will help lead to advances in p pp pearly detection of vulnerability to the disorders early detection of vulnerability to the disorders and in predicting treatment response.and in predicting treatment response.“ anxiety disorders would be conceptualized“ anxiety disorders would be conceptualized…anxiety disorders would be conceptualized …anxiety disorders would be conceptualized not as distinct diagnostic categories but as not as distinct diagnostic categories but as disorders of fear circuitry or of fear extinction or disorders of fear circuitry or of fear extinction or inhibition ”inhibition ”inhibition.inhibition.

“Functional Neuroimaging of Anxiety: A Meta“Functional Neuroimaging of Anxiety: A Meta--analysis of Emotional Processing in PTSD, Social analysis of Emotional Processing in PTSD, Social

Anxiety Disorder, and specific Phobia”Anxiety Disorder, and specific Phobia”Am J Pychiatry 2007Am J Pychiatry 2007

Functional MRI and PET scanning show greaterFunctional MRI and PET scanning show greaterFunctional MRI and PET scanning show greater Functional MRI and PET scanning show greater activation in the amygdala and insula in patients activation in the amygdala and insula in patients with any of the 3 disorderswith any of the 3 disorders--linked to negative linked to negative a y o e 3 d so de sa y o e 3 d so de s ed o ega eed o ega eemotional responses.emotional responses.Hyperactivation was more similar in SAD and Hyperactivation was more similar in SAD and ypypspecific phobias than PTSD; PTSD also had specific phobias than PTSD; PTSD also had decreased activity in the cingulate cortexdecreased activity in the cingulate cortex

Katon and RoyKaton and Roy--Byrne, editorial Byrne, editorial A l f I M d 200A l f I M d 200Annals of Int Med: 2007Annals of Int Med: 2007

Research on primary careResearch on primary care based care ofbased care ofResearch on primary careResearch on primary care--based care of based care of depression suggests that changing the depression suggests that changing the systemsystem--ofof--care was the most significantcare was the most significantsystemsystem ofof care was the most significant care was the most significant change.change.Must link good screening programs toMust link good screening programs toMust link good screening programs to Must link good screening programs to evidenceevidence--based treatment programs.based treatment programs.“quality of care and outcomes improve“quality of care and outcomes improvequality of care and outcomes improve quality of care and outcomes improve when screening is coupled with multimodal when screening is coupled with multimodal intervention programs, such as intervention programs, such as p gp gcollaborative care.”collaborative care.”

Collaborative Care Models for depression: Collaborative Care Models for depression: A hi f I t l M di i th i 11/06A hi f I t l M di i th i 11/06Archives of Internal Medicine theme issue; 11/06Archives of Internal Medicine theme issue; 11/06

Systematic review and metaSystematic review and meta--analysis of 37 RCT’s analysis of 37 RCT’s l ti ll b ti d l l il ti ll b ti d l l ievaluating collaborative care models vs usual primary evaluating collaborative care models vs usual primary

care showed improved medication compliance and care showed improved medication compliance and improved depression outcomes at 6, 12, 18 months and improved depression outcomes at 6, 12, 18 months and probably at 2 and 5 yearsprobably at 2 and 5 yearsprobably at 2 and 5 years.probably at 2 and 5 years.Primary benefits of collaborative care models included Primary benefits of collaborative care models included improved antidepressant medication compliance, care improved antidepressant medication compliance, care managers with more MH training and regular caseloadmanagers with more MH training and regular caseloadmanagers with more MH training, and regular caseload managers with more MH training, and regular caseload supervision.supervision.Additional costs noted in first 12 months may be Additional costs noted in first 12 months may be recouped in years 2 and 3recouped in years 2 and 3recouped in years 2 and 3.recouped in years 2 and 3.USPSTF recommends screening adults for depression USPSTF recommends screening adults for depression (B recommendation) when staff(B recommendation) when staff--assisted depression assisted depression care supports are in place; recommends againstcare supports are in place; recommends againstcare supports are in place; recommends against care supports are in place; recommends against routinely screening when staffroutinely screening when staff--assisted supports are not assisted supports are not in place.in place.

“Disorder“Disorder--Specific Impact of Coordinated Specific Impact of Coordinated Anxiety Learning and Management TreatmentAnxiety Learning and Management TreatmentAnxiety Learning and Management Treatment Anxiety Learning and Management Treatment

for Anxiety Disorders in Primary Care”for Anxiety Disorders in Primary Care”Craske et al, Arch Gen Psychiatry April 2011Craske et al, Arch Gen Psychiatry April 2011

Compared usual care for anxiety disorders in Compared usual care for anxiety disorders in primary care setting with a flexible treatmentprimary care setting with a flexible treatment--deli er model (Coordinated An iet Learningdeli er model (Coordinated An iet Learningdelivery model (Coordinated Anxiety Learning delivery model (Coordinated Anxiety Learning and Management [CALM])and Management [CALM])RCT at 17 US primary care clinicsRCT at 17 US primary care clinicsp yp yAllowed choice of CBT, medication or both and Allowed choice of CBT, medication or both and included computer assisted program to optimize included computer assisted program to optimize delivery of therapy and webdelivery of therapy and web--based outcomebased outcomedelivery of therapy and webdelivery of therapy and web--based outcome based outcome monitoringmonitoringApproximately 37% chose CBT only, 7% Approximately 37% chose CBT only, 7%

di ti l d 56% b thdi ti l d 56% b thmedications only, and 56% bothmedications only, and 56% both

“Attempted to provide evidence“Attempted to provide evidence--based care based care including CBT and/or pharmacologic treatment including CBT and/or pharmacologic treatment g p gg p gin health care systems that didn’t reliably have in health care systems that didn’t reliably have this availablethis availableCollaborative care model to treat the 4 mostCollaborative care model to treat the 4 mostCollaborative care model to treat the 4 most Collaborative care model to treat the 4 most common anxiety disorders: hired an Anxiety common anxiety disorders: hired an Anxiety Clinical Specialist at each site to help direct, Clinical Specialist at each site to help direct, monitor and coordinate care along with PC andmonitor and coordinate care along with PC andmonitor and coordinate care, along with PC and monitor and coordinate care, along with PC and psychiatrypsychiatryCreated a computer based CBT program that Created a computer based CBT program that p p gp p gincluded modules that provided skills to treat all included modules that provided skills to treat all four anxiety disorders and individual modules to four anxiety disorders and individual modules to address unique aspects of each disorderaddress unique aspects of each disorderq pq pDescribe in separate publication (General Describe in separate publication (General Hospital Psychiatry 33 (2011) 336Hospital Psychiatry 33 (2011) 336--342) how 342) how they trained their primary care clinic staffs tothey trained their primary care clinic staffs tothey trained their primary care clinic staffs to they trained their primary care clinic staffs to provide CALMprovide CALM--ITV CareITV Care

1004 patients referred from PC clinic by the 1004 patients referred from PC clinic by the p yp yproviders (120 internists, 28 FP’s) ages 18providers (120 internists, 28 FP’s) ages 18--75 75 who met DSMwho met DSM--IV criteria for 1 or more anxiety IV criteria for 1 or more anxiety di ddi ddisordersdisordersUsed MINI (Mini International Neuropsychiatric Used MINI (Mini International Neuropsychiatric I t i ) t k DSMI t i ) t k DSM IV di i OASISIV di i OASISInterview) to make DSMInterview) to make DSM--IV diagnosis; OASIS IV diagnosis; OASIS score of at least 8 on a 0score of at least 8 on a 0--20 scale20 scaleCoCo occurring major depression was permitted;occurring major depression was permitted;CoCo--occurring major depression was permitted; occurring major depression was permitted; stratified randomization based on location and stratified randomization based on location and depression comorbiditydepression comorbiditydepression comorbiditydepression comorbidityIn patients with multiple anxiety disorders they In patients with multiple anxiety disorders they chose which one was “most troubling.”chose which one was “most troubling.”chose which one was most troubling.chose which one was most troubling.

CALMCALM-- outcomes:outcomes:CALMCALM outcomes:outcomes:Response and remission rates based on BSIResponse and remission rates based on BSI--12 12 pp(Brief Symptom Inventory) versus Usual Care(Brief Symptom Inventory) versus Usual Care6 months:6 months: Response rates 58% vs 37%Response rates 58% vs 37% Remission rates 43% vs 28% (NNT 7)Remission rates 43% vs 28% (NNT 7)

12 months:12 months:12 months:12 months: Response rates 64% vs 45%Response rates 64% vs 45% Remission rates 52% vs 33% (NNT 5Remission rates 52% vs 33% (NNT 5--6)6)e ss o a es 5 % s 33% ( 5e ss o a es 5 % s 33% ( 5 6)6)

Similar improvements in response and remission Similar improvements in response and remission rates at 18 months notedrates at 18 months noted

“Cost“Cost--effectiveness of a primary effectiveness of a primary care model for anxiety disorders”care model for anxiety disorders”

Konig, et al British Journal of Psychiatry 2009.Konig, et al British Journal of Psychiatry 2009.

Cluster randomized controlled trial: 23 practices received Cluster randomized controlled trial: 23 practices received intervention which included enhanced training on intervention which included enhanced training on diagnosis and treatment of anxiety disorders for the GP’s diagnosis and treatment of anxiety disorders for the GP’s g yg yand access to a psychiatric liaison service.and access to a psychiatric liaison service.In Germany (Leipzig) patients have direct access to In Germany (Leipzig) patients have direct access to office based psychiatrists and psychoterapists but still a office based psychiatrists and psychoterapists but still a p y p y pp y p y plarge proportion of patients with anxiety are managed large proportion of patients with anxiety are managed solely in PC.solely in PC.Assessed overall cost of care and quality: ? guideline Assessed overall cost of care and quality: ? guideline l l h th h th t f t til l h th h th t f t tilevel pharmacotherapy or psychotherapy, cost of testing level pharmacotherapy or psychotherapy, cost of testing and care including ER visits, Beck Depression and and care including ER visits, Beck Depression and Anxiety inventories at 6Anxiety inventories at 6--9 months.9 months.N b fit i t i i tN b fit i t i i tNo benefit was seen: no improvement in anxiety scores, No benefit was seen: no improvement in anxiety scores, costs and the liaison service was not frequently utilized.costs and the liaison service was not frequently utilized.

“Integrating Mental Health and Primary Care “Integrating Mental Health and Primary Care Services in the Department of VeteransServices in the Department of VeteransServices in the Department of Veterans Services in the Department of Veterans

Affairs Health Care Systems”Affairs Health Care Systems”J Clin Psychol Med Settings, 2008J Clin Psychol Med Settings, 2008

Integration of mental health care in the primary care Integration of mental health care in the primary care setting is a high priority for the VHA.setting is a high priority for the VHA.2005: VA Mental Health Strategic Plan began 2005: VA Mental Health Strategic Plan began implementation to “fundamentally transform how mental implementation to “fundamentally transform how mental health care is delivered” including both cohealth care is delivered” including both co--located located collaborative care and care management.collaborative care and care management.Attempting to evaluate which components of these Attempting to evaluate which components of these changes are associated with better outcomes; unable to changes are associated with better outcomes; unable to g ;g ;do RCT’s for system changes:do RCT’s for system changes:2011 review of Behavioral Health Interventions in New 2011 review of Behavioral Health Interventions in New York state VA PC clinics dealt primarily with depressionYork state VA PC clinics dealt primarily with depressionYork state VA PC clinics dealt primarily with depression York state VA PC clinics dealt primarily with depression and anxiety issues (50% +); trying to use brief and anxiety issues (50% +); trying to use brief interventions (not full CBT) for these issues.interventions (not full CBT) for these issues.

“Transdiagnostic Internet treatment for anxiety “Transdiagnostic Internet treatment for anxiety disorders: a randomized controlled trial ”disorders: a randomized controlled trial ”disorders: a randomized controlled trial.disorders: a randomized controlled trial.

Behavior Research and Therapy, 2010Behavior Research and Therapy, 2010A “transdiagnostic” or unified program that targets theA “transdiagnostic” or unified program that targets theA transdiagnostic or unified program that targets the A transdiagnostic or unified program that targets the common elements and symptoms of multiple anxiety common elements and symptoms of multiple anxiety disorders: GAD, panic disorder or SADdisorders: GAD, panic disorder or SADInternetInternet--based clinician guided CBT program thebased clinician guided CBT program theInternetInternet based, clinician guided CBT program, the based, clinician guided CBT program, the Anxiety Program; 6 lessons over 8 weeks with Anxiety Program; 6 lessons over 8 weeks with homework assignments, weekly telephone or ehomework assignments, weekly telephone or e--mail mail contact from a clinical psychologist and automatic econtact from a clinical psychologist and automatic e--mailsmails-- also access to a moderated online discussion also access to a moderated online discussion forum.forum.Requires approximately 5Requires approximately 5--6 minutes/week of clinician 6 minutes/week of clinician tititimetimeSignificant improvement on multiple anxiety scales Significant improvement on multiple anxiety scales (GAD(GAD--7) that was sustained at 3 months7) that was sustained at 3 monthsMore than 70% had multiple diagnoses, 46% had More than 70% had multiple diagnoses, 46% had depression alsodepression also

“Cost“Cost--effectiveness of Interneteffectiveness of Internet--based cognitive behavior therapy based cognitive behavior therapy vs cognitive behavioral group therapy for social anxiety disorder:vs cognitive behavioral group therapy for social anxiety disorder:vs cognitive behavioral group therapy for social anxiety disorder: vs cognitive behavioral group therapy for social anxiety disorder:

Results from a randomized controlled trial”Results from a randomized controlled trial”October 2011 Behavior Research and Therapy.October 2011 Behavior Research and Therapy.

Initial publication in March 2011 online Initial publication in March 2011 online only; PLoS (Public Library of Science)only; PLoS (Public Library of Science)only; PLoS (Public Library of Science)only; PLoS (Public Library of Science)N=126 pts with SAD; equal numbers in N=126 pts with SAD; equal numbers in each. MH disorders, 20each. MH disorders, 20--30% on meds30% on medseach. MH disorders, 20each. MH disorders, 20 30% on meds 30% on meds during study, mean age 35 with SAD x 21 during study, mean age 35 with SAD x 21 yearsyearsyy55% responders with ICBT, 34% with 55% responders with ICBT, 34% with CBGTCBGTCost effective, less therapist timeCost effective, less therapist time

“Using the Internet to provide CBT”“Using the Internet to provide CBT”Andersson 2009Andersson 2009

Seems wrongSeems wrongSeems wrongSeems wrongInternet based therapy as good or better Internet based therapy as good or better than facethan face toto face therapies for Panicface therapies for Panicthan facethan face--toto--face therapies for Panic face therapies for Panic disorder, SAD, PTSD, depressiondisorder, SAD, PTSD, depression-- and and maintainedmaintainedmaintainedmaintainedGuidance is neededGuidance is neededNow being tried for full spectrum ofNow being tried for full spectrum ofNow being tried for full spectrum of Now being tried for full spectrum of disorders from tinnitus to pain syndromes disorders from tinnitus to pain syndromes and moreand moreand moreand more

“Effectiveness of cognitive behavioral “Effectiveness of cognitive behavioral therapy in primary health care: a review”therapy in primary health care: a review”therapy in primary health care: a reviewtherapy in primary health care: a review

Hoifodt, et al Family Practice, October 2011.Hoifodt, et al Family Practice, October 2011.

Reviewed 17 studies on the effectiveness of CBTReviewed 17 studies on the effectiveness of CBTReviewed 17 studies on the effectiveness of CBT Reviewed 17 studies on the effectiveness of CBT delivered in the primary care setting rather than delivered in the primary care setting rather than specialized MH services.specialized MH services.Eight studies of supported internetEight studies of supported internet or computeror computer basedbasedEight studies of supported internet Eight studies of supported internet --or computeror computer-- based based CBT (six of which were RCT’s) suggest this treatment is CBT (six of which were RCT’s) suggest this treatment is effective for mild to moderate depression and anxiety.effective for mild to moderate depression and anxiety.Relapse rates are high for patients on pharmacotherapyRelapse rates are high for patients on pharmacotherapyRelapse rates are high for patients on pharmacotherapy Relapse rates are high for patients on pharmacotherapy for depressive and anxiety disorders when the for depressive and anxiety disorders when the medications are withdrawn; CBT seems to be as medications are withdrawn; CBT seems to be as effective in preventing relapses in the long term as effective in preventing relapses in the long term as p g p gp g p gkeeping patients on medications.keeping patients on medications.Author’s conclusion: “…CBTAuthor’s conclusion: “…CBT--based self help with based self help with clinicianclinician--support delivered in everyday primary care support delivered in everyday primary care pp y y p ypp y y p ysettings represents an effective treatment for depression settings represents an effective treatment for depression and anxiety disorders.”and anxiety disorders.”

“They’re anti-anxiety pills- but I’m afraid to take them.”

Conclusions:Conclusions:Conclusions:Conclusions:

1)1) Consider screening all patients forConsider screening all patients for1)1) Consider screening all patients for Consider screening all patients for anxiety and/or depression; GADanxiety and/or depression; GAD--7 or 7 or PHQPHQ--44

2)2) Cognitive Behavioral Therapy is now first Cognitive Behavioral Therapy is now first line for most anxiety disorders or line for most anxiety disorders or yySSRI/SNRI’sSSRI/SNRI’s

3)3) New systems of care, including directed New systems of care, including directed )) y gy gCBT (potentially online) and collaborative CBT (potentially online) and collaborative case management appear very case management appear very

i ii ipromisingpromising