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Original Investigation
November 8, 2017

Effectiveness of Online Collaborative Care for Treating Mood and Anxiety Disorders in Primary Care: A Randomized Clinical Trial

Author Affiliations
  • 1Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 3School of Information Science and Technology, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 5Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 6Center for Clinical Trials and Data Coordination, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 7Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, Pennsylvania
JAMA Psychiatry. 2018;75(1):56-64. doi:10.1001/jamapsychiatry.2017.3379
Key Points

Questions  Is combining an internet support group (ISG) with a care manager–guided computerized cognitive behavioral therapy (CCBT) program better at treating depression and anxiety than CCBT alone and better than primary care physicians’ usual care for these conditions?

Findings  Among 704 patients randomized to CCBT+ISG, CCBT alone, or their primary care physicians’ usual care, patients in the CCBT+ISG and CCBT alone cohorts reported similar improvements in mental health–related quality of life, mood, and anxiety symptoms, while patients in the CCBT alone cohort reported greater improvements in mood and anxiety than usual care.

Meaning  Providing moderated access to ISG provided no measurable benefit at treating depression and anxiety over care manager–supported CCBT; however, care manager–supported CCBT was more effective than primary care physicians’ usual care for these conditions.

Abstract

Importance  Collaborative care for depression and anxiety is superior to usual care from primary care physicians for these conditions; however, challenges limit its provision in routine practice and at scale. Advances in technology may overcome these barriers but have yet to be tested.

Objective  To examine the effectiveness of combining an internet support group (ISG) with an online computerized cognitive behavioral therapy (CCBT) provided via a collaborative care program for treating depression and anxiety vs CCBT alone and whether providing CCBT in this manner is more effective than usual care.

Design, Setting, and Participants  In this 3-arm randomized clinical trial with blinded outcome assessments, primary care physicians from 26 primary care practices in Pittsburgh, Pennsylvania, referred 2884 patients aged 18 to 75 years in response to an electronic medical record prompt from August 2012 to September 2014. Overall, 704 patients (24.4%) met all eligibility criteria and were randomized to CCBT alone (n = 301), CCBT+ISG (n = 302), or usual care (n = 101). Intent-to-treat analyses were conducted November 2015 to January 2017.

Interventions  Six months of guided access to an 8-session CCBT program provided by care managers who informed primary care physicians of their patients’ progress and promoted patient engagement with our online programs.

Main Outcomes and Measures  Mental health–related quality of life (12-Item Short-Form Health Survey Mental Health Composite Scale) and depression and anxiety symptoms (Patient-Reported Outcomes Measurement Information System) at 6-month follow-up, with treatment durability assessed 6 months later.

Results  Of the 704 randomized patients, 562 patients (79.8%) were female, and the mean (SD) age was 42.7 (14.3) years. A total of 604 patients (85.8%) completed our primary 6-month outcome assessment. At 6-month assessment, 254 of 301 patients (84.4%) receiving CCBT alone started the program (mean [SD] sessions completed, 5.4 [2.8]), and 228 of 302 patients (75.5%) in the CCBT+ISG cohort logged into the ISG at least once, of whom 141 (61.8%) provided 1 or more comments or posts (mean, 10.5; median [range], 3 [1-306]). Patients receiving CCBT+ISG reported similar 6-month improvements in mental health–related quality of life, mood, and anxiety symptoms compared with patients receiving CCBT alone. However, compared with patients receiving usual care, patients in the CCBT alone cohort reported significant 6-month effect size improvements in mood (effect size, 0.31; 95% CI, 0.09-0.53) and anxiety (effect size, 0.26; 95% CI, 0.05-0.48) that persisted 6 months later, and completing more CCBT sessions produced greater effect size improvements in mental health–related quality of life and symptoms.

Conclusions and Relevance  While providing moderated access to an ISG provided no additional benefit over guided CCBT at improving mental health–related quality of life, mood, and anxiety symptoms, guided CCBT alone is more effective than usual care for these conditions.

Trial Registration  clinicaltrials.gov Identifier: NCT01482806

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