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Cited by 134Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMental Health Treatment and AccessPsychotherapy Techniques and Applications

Disorder-Specific Impact of Coordinated Anxiety Learning and Management Treatment for Anxiety Disorders in Primary Care

Open access
Craske, Michelle G., Stein, Murray B., Sullivan, Greer, Sherbourne, Cathy, Bystritsky, Alexander, Rose, Raphael D., Lang, Ariel J., Welch, Stacy +3 more·2011·Archives of General Psychiatry
DOI 10.1001/archgenpsychiatry.2011.25PMC PMC3074172
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Abstract

CONTEXT: Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered. OBJECTIVE: To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD). DESIGN: A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments. SETTING: Seventeen US primary care clinics. PATIENTS: Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up. INTERVENTIONS: CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC. MAIN OUTCOME MEASURES: Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores. RESULTS: CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders. CONCLUSIONS: CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

AI snapshot

Written from the paper’s full text.

TL;DR

In a 17-clinic primary care randomized controlled trial, CALM (computer-guided CBT and/or pharmacotherapy recommendations) was more effective than usual care for principal generalized anxiety disorder, panic disorder, and social anxiety disorder at selected follow-ups, but not for principal PTSD. Among comorbid anxiety disorders, only social anxiety disorder showed statistically significant CALM superiority.

Key findings

  • For principal GAD, CALM was superior to usual care at 6 months (−1.61; 95% CI = −2.42 to −0.79), 12 months (−2.34; 95% CI = −3.22 to −1.45), and 18 months (−2.37; 95% CI = −3.24 to −1.50).
  • For principal PD, CALM was superior at 6 months (−2.00; 95% CI = −3.55 to −0.44) and 12 months (−2.71; 95% CI = −4.29 to −1.14); for principal SAD, at 6 months (−7.05; 95% CI = −12.11 to −2.00).
  • For comorbid SAD, CALM was superior at 6 months (−4.26; 95% CI = −7.96 to −0.56), 12 months (−8.12; 95% CI = −11.84 to −4.40), and 18 months (−6.23; 95% CI = −9.90 to −2.55). Other comorbid disorders favored CALM but were not statistically significant.
  • Principal PTSD showed no significant differences at any follow-up, although effect sizes were similar in magnitude to other disorders: −0.29 at 6 months, −0.43 at 12 months, and −0.48 at 18 months.

Methods

  • Randomized controlled effectiveness trial comparing CALM intervention with usual care in 17 primary care clinics in 4 US cities; 1004 patients with principal DSM-IV GAD (n=549), PD (n=262), SAD (n=132), or PTSD (n=61), mean age 43.7 years (SD=13.7), 70.9% female.
  • CALM consisted of computer-guided CBT and/or pharmacotherapy recommendations delivered with collaborative care; assessments occurred at baseline, 6, 12, and 18 months using disorder-specific scales: GADSS, PDSS-SR, SPIN, and PCL-C.
  • Outcomes were modeled with repeated-measures analysis over four assessments, using restricted maximum likelihood under missing-at-random assumptions; analyses were intent-to-treat, with Hochberg correction for multiple comparisons.

Limitations

  • The paper states that independent diagnostic assessments were not made at each follow-up; disorder-specific symptom scales may have been differentially sensitive to change, complicating cross-disorder comparisons; and the design does not permit dismantling which CALM components produced effects.
  • The paper notes that usual care was active—27–34% reported receiving CBT with at least 3 elements and 36–42% reported appropriate anti-anxiety medication at an appropriate dose for at least 2 months—which likely attenuated between-group effect sizes.
  • Evident from the text: principal PTSD had a relatively small sample (n=61), and comorbid analyses used smaller cell sizes (GAD n=207; PD n=213; SAD n=273; PTSD n=120), limiting statistical power for some comparisons.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1001/archgenpsychiatry.2011.25

Cites

51 of 51 references verified0 citation errors · 0 not checkable

Statistics

3 tests recomputed · 0 with the reported and recomputed p on opposite sides of .05

Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In the CALM trial, the intervention was better than usual care for principal panic disorder at the 6-month follow-up, with an estimated difference of −2.00 (95% CI −3.55 to −0.44).

    “CALM was superior to Usual Care for principal GAD at 6-month (−1.61; 95% CI = −2.42 to −.79), 12-month (−2.34; 95% CI = −3.22 to −1.45) and 18-month (−2.37; 95% CI = −3.24 to −1.50), PD at 6-month (−2.00; 95% CI = −3.55 to −0.44) and 12-month (−2.71; 95% CI = −4.29 to −1.14), and SAD at 6-month (−7.05; 95% CI = −12.11 to −2.00) outcomes.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.
  • Findingown data

    In the CALM trial, the intervention was better than usual care for comorbid social anxiety disorder at the 6-month follow-up, with an estimated difference of −4.26 (95% CI −7.96 to −0.56).

    “CALM was superior to Usual Care for comorbid SAD at 6-month (−4.26; 95% CI = −7.96 to −0.56), 12-month (−8.12, 95% CI = −11.84 to −4.40) and 18- month (−6.23, 95% CI = −9.90 to −2.55) outcomes.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.
  • Findingown data

    In the CALM trial, the intervention was better than usual care for principal social anxiety disorder at the 6-month follow-up, with an estimated difference of −7.05 (95% CI −12.11 to −2.00).

    “CALM was superior to Usual Care for principal GAD at 6-month (−1.61; 95% CI = −2.42 to −.79), 12-month (−2.34; 95% CI = −3.22 to −1.45) and 18-month (−2.37; 95% CI = −3.24 to −1.50), PD at 6-month (−2.00; 95% CI = −3.55 to −0.44) and 12-month (−2.71; 95% CI = −4.29 to −1.14), and SAD at 6-month (−7.05; 95% CI = −12.11 to −2.00) outcomes.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.
  • Findingown data

    In the CALM trial, the intervention was better than usual care for principal panic disorder at the 12-month follow-up, with an estimated difference of −2.71 (95% CI −4.29 to −1.14).

    “CALM was superior to Usual Care for principal GAD at 6-month (−1.61; 95% CI = −2.42 to −.79), 12-month (−2.34; 95% CI = −3.22 to −1.45) and 18-month (−2.37; 95% CI = −3.24 to −1.50), PD at 6-month (−2.00; 95% CI = −3.55 to −0.44) and 12-month (−2.71; 95% CI = −4.29 to −1.14), and SAD at 6-month (−7.05; 95% CI = −12.11 to −2.00) outcomes.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.
  • Findingown data

    In the CALM trial, the intervention was better than usual care for principal generalized anxiety disorder at the 6-month follow-up, with an estimated difference of −1.61 (95% CI −2.42 to −0.79).

    “CALM was superior to Usual Care for principal GAD at 6-month (−1.61; 95% CI = −2.42 to −.79), 12-month (−2.34; 95% CI = −3.22 to −1.45) and 18-month (−2.37; 95% CI = −3.24 to −1.50), PD at 6-month (−2.00; 95% CI = −3.55 to −0.44) and 12-month (−2.71; 95% CI = −4.29 to −1.14), and SAD at 6-month (−7.05; 95% CI = −12.11 to −2.00) outcomes.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.
  • May combine two claims. 30
  • Classified as probably not a substantial claim. 13

  • May combine two claims.

    Findingown data

    For comorbid anxiety disorders other than social anxiety disorder, the effect sizes favored CALM but the differences were not statistically significant.

    “Effect sizes favored CALM, but were not statistically significant for other comorbid disorders.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.

  • May combine two claims.

    Findingown data

    For comorbid PTSD, scores did not differ significantly between ITV and UC at any follow-up, although effect sizes favored ITV.

    “and PTSD (ESs = −.18 to −.33).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For PTSD, PCLC scores were not significantly different between ITV and UC at any follow-up, although effect sizes were similar to other disorders.

    “For PTSD, PCLC scores were not significantly different between ITV and UC at any follow-up assessment, although ESs were of similar magnitude to those of the other disorders: −.29 (6 months), −.43 (12 months) and −.48 (18 months).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Effect sizes did not differ significantly across the four groups at any follow-up, except GAD > PD at 18 months.

    “Effect sizes did not differ significantly across the four groups at any of the follow-up assessments, with one exception; the effect size for GAD was significantly larger than for PD at the 18 month assessment, p < .01.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For comorbid GAD, scores did not differ significantly between ITV and UC at any follow-up, although effect sizes favored ITV.

    “Although ESs always favored ITV, scores on the disorder specific measures did not differ significantly between ITV and UC at any follow-up assessment for GAD (ESs=−.18 to −.24)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For comorbid PD, scores did not differ significantly between ITV and UC at any follow-up, although effect sizes favored ITV.

    “PD (ESs = −.21 to −.33)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    GAD was the most common principal anxiety disorder (55%), followed by PD (26%), SAD (13%), and PTSD (6%).

    “GAD was the most common principal anxiety disorder (55%), followed by PD (26%), then SAD (13%) and PTSD (6%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    The sample was ethnically diverse, medically ill, and highly comorbid in terms of anxiety disorders and major depressive disorder.

    “The sample was ethnically diverse, medically ill, and highly comorbid in terms of anxiety disorders and major depressive disorder.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Computer-assisted programs had been used for CBT training and self-directed CBT, but not for ongoing assistance to mental health providers delivering CBT.

    “Computer-assisted programs have been used in training in CBT,9,10 and in self-directed CBT,11 but they have not before been used for ongoing assistance of the mental health provider in the delivery of CBT.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [9] Carroll KM Rounsaville BJ A vision of the next generation of behavioral therapies research in the addictions Addiction 2007 102 6 850 862 17523974 PMC2148498

      Not checked in the free run.

    • cites [10] Gega L Norman IJ Marks IM Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: Randomized controlled trial with pre-registration nursing students Int J Nurs Stud 2007 44 3 397 405 16631177

      Not checked in the free run.

    • cites [11] Spek V Cuijpers P Nyklicek I Riper H Keyzer J Pop V Internet-based congnitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis Psychol Med 2007 37 3 319 328 17112400

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    CALM, which includes computer-guided CBT and/or pharmacotherapy recommendations, is more effective than usual care for principal anxiety disorders and, to a smaller degree, for comorbid anxiety disorders in primary care.

    “CALM (CBT and psychotropic recommendations) is more effective than Usual Care for principal anxiety disorders, and to a lesser extent, comorbid anxiety disorders that present in primary care.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The repeated-measures analyses assume that missing outcome data are missing at random.

  • May combine two claims.

    Study design and conductown data

    The average number of CBT visits and medication visits, and the percentage who completed all visits by 3 and 6 months, were similar across the four groups.

    “The average number of CBT visits (6.7–8.2) and medication visits (2.1–2.9), and the percentage who completed all visits by 3 months (35–52%) and by 6 months (85–92%), were similar across the four groups.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Attrition weights were used in cross-sectional analyses to account for participants who missed follow-up assessments.

    “For cross-sectional analyses (such as percentage of responders at the 3 follow-up times), we used attrition weights to correctly account for those Ps that missed one or more follow-up assessments.38”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] Brick JM Kalton G Handling Missing Data in Survey Research Stat Methods Med Res 1996 5 3 215 238 8931194

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Study retention was high, with non-response rates ranging from 9.8-14.9% at 6 months, 17.4-22.5% at 12 months, and 15.9-24.0% at 18 months across the four principal anxiety disorders.

    “Study retention was high. Specifically, non-response rates (“no contact” and “cumulative refusals”) ranged from 9.8–14.9 across all four principal anxiety disorders at 6 months, 17.4–22.5 at 12 months and 15.9–24.0 at 18 months.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    P values were two-tailed and adjusted within outcome measures using Hochberg's method for multiple comparisons.

    “All P values were 2-tailed and are adjusted within outcome measures using Hochberg’s39 correction method to account for multiple comparisons.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] Hochberg Y A sharper Bonferroni procedure for multiple tests of significance Biometnika 1988 75 4 800 802

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The MINI diagnostic interview was administered by the Anxiety Clinical Specialist after formal training and diagnostic reliability testing.

    “based on the Mini International Neuropsychiatric Interview (MINI)25 administered by the ACS after formal training and diagnostic reliability testing”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] Sheehan DV Lecrubier Y Sheehan KH Amorim P Janavs J Weiller E Hergueta T Baker R Dunbar GC The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10 J Clin Psychiatry 1998 59 22 33 9881538

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    There was some imbalance (p<.10) in education, ethnicity, number of comorbid anxiety disorders, and GAD for PD only, which were used as covariates.

    “There was some imbalance (at p<.10) in education, ethnicity, number of comorbid anxiety disorders and GAD for PD only, which were used as covariates in the analyses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The block size used in randomization was concealed from all clinical site study members.

    “Block size was masked to all clinical site study members.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Randomization in the trial used stratified permuted blocks by clinic and comorbid major depression, assigned by an automated RAND program.

    “After baseline assessment, Ps were randomized, using stratified (by clinic and presence of co-morbid major depression) permuted block randomization, to ITV or UC by an automated program at RAND.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Average ACS adherence to the CALM CBT protocol was 5.0 (+/− 1.3) on a 7-point scale, with no differences across the four principal anxiety disorder groups.

    “Average ACS adherence to the CALM CBT protocol was 5.0 (+/− 1.3) (on a 7-point scale) with no differences across the four principal anxiety disorder groups, F(3,258)=.62, ns.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The assessment battery was administered by a centralized RAND telephone survey team that was blinded to group assignment.

    “The assessment battery was administered at baseline, 6, 12, and 18 months via a centralized phone survey by the RAND survey research group, blinded to group assignment.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The intent-to-treat analysis included all participants who had a baseline assessment.

    “This is an efficient way for conducting an intent-to-treat analysis since it includes all Ps with a baseline assessment: 94 Ps (9.4%) completed baseline only; 63 (6%) completed baseline and one follow-up; 112 (11.1%) completed baseline and two follow-ups; and 735 (73%) completed baseline and all three follow-up”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Follow-up assessments at 6, 12, and 18 months were conducted blind to treatment assignment.

    “Blind assessments occurred at 6, 12, and 18 months after baseline.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    CBT sessions were digitally recorded, and a random sample was rated for adherence and competency by two independent PhD-level raters who first established inter-rater reliability.

    “For the CALM CBT program, digital recordings of each ACS session at each site (n=259) were randomly selected for adherence/competency monitoring using a set of 1–7 point Likert-scales (higher scores represents better performance), completed by 2 PhD level independent raters who initially demonstrated inter-rater reliability.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Stein MB Roy-Byrne PP Craske MG Bystritsky A Sullivan G Pyne JM Wayne K Sherbourne C Functional Impact and Health Utility of Anxiety Disorders in Primary Care Outpatients Medical Care 2005 43 12 1164 1170 16299426

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Earlier research indicates that adequate CBT for a principal anxiety disorder also improves comorbid disorders.

    “Since previous research has indicated that adequate CBT treatment of a principal anxiety disorder simultaneously improves rates of comorbid disorders,17,18,19,20,21,22 we hypothesized that the CALM intervention would benefit comorbid disorders as well.”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [17] Borkovec TD Abel JL Newman H Effects of psychotherapy on comorbid conditions in generalized anxiety disorder J Consult Clin Psychol 1995 63 3 479 483 7608362

      Not checked in the free run.

    • cites [18] Brown TA Barlow DH Long-term outcome in cognitive-behavioral treatment of panic disorder: Clinical predictors and alternative strategies for assessment J Consult Clin Psychol 1995 63 5 754 765 7593868

      Not checked in the free run.

    • cites [19] Craske MG Farchione TJ Allen LB Barrios V Stoyanova M Rose R Cognitive behavioral therapy for panic disorder and comorbidity: More of the same or less of more? Behav Res Ther 2007 45 6 1095 1109 17069753

      Not checked in the free run.

    • cites [20] Stanley MA Beck JG Glasco JD Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive-behavioral and supportive approaches Behav Ther 1996 27 4 565 581

      Not checked in the free run.

    • cites [21] Tsao JCI Lewin MR Craske MG The effects of cognitive-behavior therapy for panic disorder on comorbid conditions J Anxiety Disord 1998 12 4 357 371 9699119

      Not checked in the free run.

    • cites [22] Tsao JCI Mystkowski JL Zucker BG Craske MG Effects of cognitive-behavioral therapy for panic disorder on comorbid conditions: Replication and extenstion Behav Ther 2002 33 4 493 509

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    The effect sizes for differences between ITV and UC were low to moderate, but they are in the range of effect sizes for differences between CBT and other active treatments for anxiety disorders (d=.43).

    “The effect sizes for differences between ITV and UC were low to moderate. However, they are in the range of effect sizes for differences between CBT and other active treatments (such as psychodynamic, interpersonal and supportive therapies) for anxiety disorders (d=.43) 41.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [41] Tolin DF Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review Clinical Psych Review 2010 (in press) 20547435

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    The disorder-specific symptom scales may have been differentially sensitive to change, rendering comparisons across disorders problematic.

    “The disorder-specific symptom scales may have been differentially sensitive to change, thus rendering comparisons across disorders problematic.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The intervention was superior to usual care for comorbid anxiety symptoms, although only comorbid SAD statistically benefited.

    “Also, effect sizes indicated that our intervention was superior to usual care for comorbid anxiety symptoms, although the only comorbid anxiety to statistically benefit from our intervention over and above usual care was SAD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The comparison was made more stringent because many UC patients received active CBT or medication treatment; specifically, 27-34% of UC reported receiving CBT with at least 3 elements, and 36-42% reported appropriate anti-anxiety medication.

    “27–34% of the UC reported receiving CBT with at least 3 elements, and 36–42% reported any appropriate anti-anxiety medication at an appropriate dose for at least 2 months.14”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Roy-Byrne P Craske MG Sullivan G Rose RD Edlund MJ Lang AJ Bystritsky A Welch SS Chavira DA Golinelli D Campbell-Sills L Sherbourne CD Stein MB Delivery of Evidence-Based Treatment for Multiple Anxiety Disoders in Primary Care JAMA 2010 303 19 1921 1928 20483968 PMC2928714

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The results with GAD were the strongest both statistically and in terms of effect sizes, which is particularly important since GAD is among the most commonly presenting anxiety disorders in primary care.

    “The results with GAD were the strongest both statistically and in terms of effect sizes, which is particularly important since GAD is among the most commonly presenting anxiety disorders in primary care.5,42”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] Kroenke K Spitzer RL Williams JB Monahan PO Lowe B Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection Ann Intern Med 2007 146 317 325 17339617

      Not checked in the free run.

    • cites [42] Weisberg RB Overview of generalized anxiety disorder: epidemiology, presentation, and course J Clin Psychiatry 2009 70 suppl 2 4 9 19371500

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Statistical significance between ITV and UC for comorbid GAD, PTSD, and PD symptoms may have been mitigated by sample size, and/or overall improvement due to nonspecific treatment effects or passage of time.

    “Also, statistical significance between ITV and UC for GAD, PTSD and PD symptoms may have been mitigated by sample size, and/or an overall improvement in comorbid symptoms due to either nonspecific treatment effects shared between ITV and UC or the passage of time alone.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    ITV was statistically superior to UC at 6 months for GAD, PD, and SAD; at 12 months for GAD and PD; and at 18 months for GAD.

    “In terms of principal anxiety disorder outcomes, ITV was statistically superior to UC across 6 months for GAD, PD and SAD, at 12 months for GAD and PD, and at 18 months for GAD.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    This is the first study to evaluate differences in intervention effects relative to UC on comorbid disorder outcomes in a generalizable sample and using dimensional measures of comorbidity.

    “This is the first study to evaluate differences in intervention effects relative to UC on comorbid disorder outcomes in a generalizable sample and using dimensional measures of comorbidity.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The intervention was superior to usual care at one or more time points for each principal anxiety disorder, although effects were not statistically significant for PTSD.

    “The effect sizes indicated that our intervention was superior to usual care at one or more time points in the treatment of each principal anxiety disorder, although effects were not statistically significant for PTSD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Retention in the study and participation in the CALM intervention were relatively similar across the four anxiety disorders.

    “Retention in the study and participation in the CALM intervention were relatively similar across the four anxiety disorders.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    For PTSD, results were nonsignificant at each follow-up, but statistical significance was mitigated by relatively small sample size, as effect sizes for PTSD were equivalent to those for other principal anxiety disorders.

    “For PTSD, the results were nonsignificant at each follow-up time point. However, the statistical significance for PTSD comparisons was mitigated by the relatively small sample size, as the effect sizes for PTSD were actually equivalent to the effect sizes for the other principal anxiety disorders, including GAD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The active nature of UC likely contributed to the low to moderate between-group effect sizes, the pattern of continued improvement in UC, and the lack of differences between ITV and UC for PD and SAD at 18 months.

    “The active nature of UC in this study likely contributed to the low to moderate between-group effect sizes, the pattern of mostly continued improvement in the UC group over time, and the lack of differences between ITV and UC for PD and SAD groups at the 18 month time point.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Average ACS competency was 5.3 (+/− 1.4) on a 7-point scale, with no differences across the four principal anxiety disorder groups.

    “Similarly, average ACS competency was 5.3 (+/− 1.4) (on a 7-point scale), with no differences across the four principal anxiety disorder groups, F(3, 258)=2.7, ns.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The equal capability of ACSs with PTSD highlights the value of the computer-guided program, given the common assumption that PTSD is more difficult for inexperienced therapists.

    “That they were equally capable with PTSD compared to the other disorders highlights the value of the computer-guided program, since it is often generally assumed that PTSD is more difficult than other anxiety disorders for inexperienced therapists.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: PTSD is more difficult than other anxiety disorders for inexperienced therapists.

  • May combine two claims.

    Interpretationown data

    The CALM intervention tended to have a greater positive effect on all comorbid symptoms, but effects were only statistically significant for comorbid social anxiety symptoms.

    “In addition, the CALM intervention tended to have a greater positive effect on all comorbid symptoms, but the effects were only statistically significant for comorbid social anxiety symptoms.”
    Quote in the paperSubstantial claim
39 of 39

  • The paper relies on this without support.

    Effective evidence-based psychosocial and pharmacological treatments for anxiety disorders are often unavailable or delivered suboptimally in practice.

    “Although effective evidence-based psychosocial (i.e., cognitive behavioral therapy, CBT) and pharmacological treatments for anxiety disorders exist, these treatments often are not available (i.e., CBT), or sub-optimally delivered (i.e., pharmacotherapy).”

  • The authors state this as an assumption.

    The repeated-measures analyses assume that missing outcome data are missing at random.

    “which produces valid estimates under the missing-at-random assumption.36”

  • The authors state this as an assumption.

    PTSD is more difficult than other anxiety disorders for inexperienced therapists.

    “since it is often generally assumed that PTSD is more difficult than other anxiety disorders for inexperienced therapists.”

  • The paper relies on this without support.

    Effectiveness trials typically yield lower effect sizes than efficacy trials because they tolerate more noise in recreating the real world.

    “Effectiveness trials typically yield lower effect sizes even with the very same treatment protocol because they tolerate more “noise” in attempting to recreate the “real world.””
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Statistics that don’t add up

Each reported p-value recomputed from its test statistic and degrees of freedom.

  • Inconsistent p-value: F(3, 258)=2.7, ns.

    Minor

    The paper reports a non-significant result (n.s.) here; recomputing from the test statistic and its degrees of freedom gives p = .046. The check cannot tell whether the statistic or the p-value is the misprint.

1 of 1

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Doesn’t add upF(3, 258) = 2.7reported n.s. · recomputed p = .046

    “F(3, 258)=2.7, ns.”

  • Consistentχ²(3) = 2.9reported n.s. · recomputed p = .407

    “X2 (3) = 2.9, ns”

  • ConsistentF(3, 258) = 0.62reported n.s. · recomputed p = .603

    “F(3,258)=.62, ns.”

3 of 3

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Self-check results appear here once an independent check has confirmed them.

Cites

Flagged first, then by citations

Cited by

Sorted by citations

Related

Authors
Craske, M. G., Stein, M. B., Sullivan, G., Sherbourne, C., Bystritsky, A., Rose, R. D., Lang, A. J., Welch, S., Campbell-Sills, L., Golinelli, D., & Roy-Byrne, P.
Affiliations
  • University of California, Los Angeles (US)
  • University of California San Diego (US)
  • University of Arkansas for Medical Sciences (US)
  • RAND Corporation (US)
  • University of Washington (US)
ORCID
Venue
Archives of General Psychiatry
Publisher
American Medical Association (AMA)
Published
2011-04-04
Volume
68
Issue
4
Pages
378
ISSN
0003-990X (ISSN-L)
DOI
10.1001/archgenpsychiatry.2011.25
PMC
PMC3074172
OpenAlex
W2089496028
Semantic Scholar
31e5ab66c6c62562531c15cd730b828e86acf3de
Cited by
132
References
50
Citations by year
2026: 2 · 2025: 3 · 2024: 4 · 2023: 7 · 2022: 4 · 2021: 9 · 2020: 7 · 2019: 8 · 2018: 7 · 2017: 11 · 2016: 7 · 2015: 12 · 2014: 13 · 2013: 17 · 2012: 18
FWCI
21.02
Type
journal article
Language
en
Open access
Locations
  • Archives of General Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (U01MH057835, K24MH065324, K24MH064122, R01MH057835, R01MH058915, K24MH64122, R01MH057858, U01MH070022, U01MH070018, U01MH057858, U01MH058915)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
anxiety disorders, primary care, cognitive behavioral therapy, generalized anxiety disorder, panic disorder, social anxiety disorder, post-traumatic stress disorder, comorbidities, usual care, treatment efficacy, primary care referral, access to mental health care, relapse
MeSH terms
Adult, Antidepressive Agents, Anxiety Disorders, Female, Humans, Male, Primary Health Care, Anti-Anxiety Agents, Cognitive Behavioral Therapy, Evidence-Based Medicine

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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