Evidence-Based Psychotherapy in Primary Care

Anxiety disorders—including specific phobias, generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder—are among the most common mental health conditions, with lifetime prevalence rates nearing 30% (12). Anxiety disorders, especially generalized anxiety disorder and panic disorder, frequently present in primary care settings, with a 12-month prevalence rate of approximately 20% (13). Given that many somatic symptoms of anxiety mimic physical illnesses, they are often misdiagnosed and undertreated (14). The risk for anxiety disorders increases in a dose-dependent manner with compounding chronic medical conditions, such as diabetes, asthma, cardiovascular disease, and chronic pain (15). Likewise, rates of chronic disease risk factors—including cigarette smoking, alcohol use, and sedentary lifestyles—are also higher among those with anxiety disorders in relation to their nonanxious counterparts (16). Untreated anxiety can complicate medical management and further escalate health care costs (17).

The largest multisite randomized trial for primary care anxiety disorders (N=1,004) was the Coordinated Anxiety Learning and Management (CALM) study (6). Patients randomly assigned to the intervention group had the choice of pharmacotherapy, CBT, or both, with approximately 89% accepting CBT, which was delivered in primary care clinics. Novel aspects of the CALM trial included allowing patient choice and flexibility over treatment options and using anxiety specialists who had minimal CBT experience to deliver the intervention with the assistance of a computer program to demonstrate evidence-based skills (e.g., exposure and cognitive restructuring). In comparison to the “enhanced” usual care group, small effect sizes favored anxious patients in the intervention group on the Brief Symptom Inventory across six, 12, and 18 months. Disorder-specific analyses indicated that patients with generalized anxiety disorder, panic disorder, and social anxiety disorder were significantly improved on self-reported measures of anxiety in relation to the usual care group at six months, although between-groups differences did not reach a level of significance for patients with posttraumatic stress disorder during this time interval (18).

A recent meta-analysis of collaborative care studies comparing anxiety disorders to usual care at 12 months yielded a small but significant effect size, with data indicating moderate effect sizes for panic disorder (7). Although only six out of seven studies included some form of CBT and studies varied widely in how CBT was delivered, higher effect sizes were observed among studies that involved care coordinators and those offering stepped-care options. Table 1 summarizes the effect sizes for studies of CBT for anxiety disorders.

Table 2 outlines the key CBT principles used in the treatment of anxiety disorders. Exposure therapy, involving the systematic approach to feared stimuli, is the most effective intervention component in the treatment of anxiety disorders. A list of feared stimuli of increasing difficulty is generated with the patient (i.e., exposure hierarchy), which essentially serves as a roadmap for working toward treatment goals. Targets for exposure therapy can involve situations (e.g., crowds, social situations, public restrooms), uncomfortable physical sensations (e.g., shortness of breath, dizziness, tachycardia), and intrusive thoughts (e.g., obsessions, worries, flashbacks). Exposures are typically done in a predictable, controllable, and graduated manner, with repeated exposures across time being important for treatment gains. Several mechanisms may be responsible for treatment gains, including habituation, fear tolerance, disconfirmation of anxious beliefs, and opportunities to practice new skills. Although clinical practice guidelines encourage all patients with anxiety to be given instruction to gradually face their fears (19), exposure therapy is still an underutilized treatment approach (20).

Response prevention is another important intervention, often used in conjunction with exposure exercises. Anxious patients typically engage in a variety of safety behaviors that function to regulate their distress and strengthen their beliefs that these safety behaviors are needed to prevent negative consequences from occurring. Common safety behaviors include seeking reassurance from others, relying on the presence of trusted companions when entering feared situations, engaging in repetitive checking, and needing to have rescue medications close at hand. Ultimately, these safety behaviors need to be systematically but gradually eliminated over the course of treatment.

Cognitive interventions involve the direct challenging and reframing of negative beliefs about catastrophic consequences (e.g., unusual chest sensations as a sign of an impending heart attack), the probability that these consequences will occur, and the perceived inability to cope with or tolerate anxiety-provoking situations. Patients are encouraged to assume a scientific approach to evaluating their thoughts in a more objective manner (e.g., what objective evidence do I have to support this thought?) and to designing behavioral experiments to more objectively test their beliefs. A primary goal of cognitive reframing is to improve the flexibility of thinking under conditions of increased distress. In order to enhance the depth of learning, retention, and recall, an important feature of this approach requires the consistent use of structured worksheets.

Major depressive disorder is among the most common mental disorders, with approximately 16% lifetime prevalence and 8% prevalence during the past year (21). It is also among the most common presenting problems in primary care clinics (22). Depression is associated with a variety of negative health and quality-of-life outcomes, including poorer occupational and social functioning, increased risk of chronic medical illness, and high health care utilization (23). Major depression is associated with the highest disability burden among mental and behavioral disorders (24). Prevalence of depression is higher for individuals with chronic medical conditions (25), and risk for depression increases with an increasing number of medical comorbidities (26). Furthermore, risk is higher among those who have experienced a depressive episode in the past. At least half of patients have a recurrence of symptoms following their first episode, and chance of recurrence increases with each subsequent episode (27).

Although there are effective treatments for depression, the majority of people in the United States do not receive mental health care in primary care settings or elsewhere (28). A meta-analysis of 10 randomized controlled trials (RCTs) from 1995 to 2006 indicated that psychological interventions delivered in primary care are associated with superior outcomes in comparison with usual care, yielding small effect sizes. Moreover, primary care–based psychological interventions generated outcomes comparable to those with antidepressant medications (8). Another meta-analysis indicated that brief CBT, problem-solving therapy, and supportive counseling were each effective in improving depressive symptoms for patients in primary care, all generating small but significant effect sizes (9). Meta-analyses of behavioral activation studies have yielded small to medium effect sizes when compared with control conditions and medications, respectively (10). There are mixed findings on which specific modalities (i.e., computerized, face to face), provider types (i.e., physicians, therapists), and intervention components (i.e., problem solving, cognitive therapy, behavioral activation) are most effective for treatment of depression in primary care (8), and more research is needed to understand optimal treatment approaches in this setting. CBT in primary care can be effective for patients experiencing frequently co-occurring conditions, including problematic alcohol use (29). Table 1 summarizes the effect sizes for studies CBT for depression.

Table 3 includes key CBT principles for the treatment of major depression in primary care. Behavioral activation is an evidence-based intervention for depression that involves increasing the frequency of behaviors that lead to a greater sense of pleasure and mastery. This is thought to be effective because as individuals become depressed, they tend to become increasingly isolated and withdrawn. For example, a patient with depression might spend prolonged periods of time in bed because of loss of interest/motivation, fatigue, and low mood, which provides minimal opportunity for positive experiences. The purpose of behavioral activation, therefore, is to help reverse this process. Behavioral activation usually begins with monitoring daily activities to illustrate the relationship between activities and mood. Next, therapists work with patients to gradually increase engagement in activities that are likely to be reinforcing. This involves setting small behavioral goals and scheduling activities that are likely to improve mood or create opportunities for positive experiences (e.g., going for a five-minute walk, taking a shower and getting dressed, calling a friend). An important aspect of behavioral activation includes targeting barriers and avoidance behaviors that interfere with more adaptive behaviors (30).

Problem-solving therapy (PST) is a cognitive-behavioral intervention that focuses on training patients to use effective problem-solving skills. Effective problem solving is thought to mitigate the negative impact of stress on well-being (31). PST involves encouraging patients to adopt a positive problem orientation, which means viewing problems as challenges or opportunities that one can solve with time and effort (32). The specific steps of problem solving are conducted in four stages. First, it is important to define and clarify the problem and desired outcome. Second, patients brainstorm possible solutions. Patients are encouraged to generate as many solutions as they can think of in order to promote creative and solution-focused thinking. Third, patients review their ideas, weigh pros and cons, and identify their preferred solutions to try. In the fourth and final stage, patients implement their preferred solution. Afterward, patients evaluate the success of the attempted solution and perhaps try a new possible solution if the desired outcome was not achieved. Research supports the effectiveness of PST for depression (31), including when delivered within primary care ( 32).

Cognitive reframing or restructuring is a CBT technique that includes identifying and challenging thoughts, assumptions, and beliefs that are associated with depressed mood (e.g., self-criticism, thoughts of hopelessness). As discussed above for anxiety disorders, cognitive reframing typically begins when patients monitor their automatic thoughts and associated moods and behaviors. Next, patients attempt to take a more objective stance with their thoughts and begin to ask challenging questions (e.g., weighing the evidence for or against negative thoughts) to dispute unhelpful thinking styles and promote more adaptive, flexible, and alternative ways of thinking (e.g., “Missing that deadline at work is problematic, but it does not make me a complete failure, and I am unlikely to get fired because of it”). Patients are encouraged to use structured worksheets to enhance learning and to test their beliefs by using behavioral experiments.

Sleep disorders are common; approximately 21% of adults report at least one sleep problem, of which insomnia is the most commonly reported difficulty (33). In primary care, an estimated 19% of patients experience chronic insomnia symptoms (34). Insomnia can lead to cognitive, mood, functioning, and quality-of-life issues, in addition to complicating the course and clinical presentation of other clinical problems (35). Insomnia is not defined by a certain number of hours slept per night, but rather it involves persistent difficulty falling asleep, difficulty staying asleep, or waking too early for at least three nights per week for three months (36). Risk for insomnia is higher among individuals with other sleep disorders, especially sleep apnea (37), those experiencing psychological distress, and those with chronic pain or other medical concerns (38).

CBT for insomnia (CBT-I) is a first-line intervention for chronic insomnia. When delivered in primary care, this effective intervention can have a broader reach to patients with insomnia. Insomnia can be conceptualized as a conditioned problem that can result when an individual experiences sleeplessness (e.g., due to stress, travel, a medical condition) and then engages in coping or compensatory behaviors that become ineffective over time (e.g., napping during the day to make up for lost sleep) (39). Decades of research, including several meta-analyses, support the assertion that CBT-I improves insomnia symptoms, is durable over time, has short-term effects comparable to those of medications, and has superior long-term outcomes (40). Meta-analytic findings using CBT-I with middle- to older-age populations have found medium effect sizes on measures of sleep quality, sleep latency, and sleep efficiency (11). A recent meta-analysis also indicated that CBT-I is effective for improving insomnia among those with medical and psychiatric comorbidities (41). CBT-I is a brief individual or group-based intervention that is appropriate for delivery within the primary care setting (42). Table 1 summarizes the effect sizes for insomnia CBT studies.

A summary of CBT-I treatment components is included in Table 4. CBT-I typically begins with monitoring sleep with a sleep diary to understand patterns and factors that contribute to insomnia and to assess progress over the course of treatment. The active phase of CBT-I is characterized by two primary components: stimulus control and sleep restriction. Stimulus control is a method of decreasing conditioned sleep-related arousal and reconditioning a healthy sleep pattern, during which individuals are able to fall asleep reasonably quickly and stay sleep through most of the night. Factors that may contribute to a conditioned association between bed/nighttime and wakefulness (e.g., worrying/planning in bed, working in the middle of the night when unable to sleep, spending time in bed during the day, sleeping late if unable to sleep the night before) are assessed and then modified (e.g., if unable to sleep for more than 15–20 minutes, get out of bed and do something boring/relaxing until sleepy, then return to bed; get out of bed at the same time every morning and do not nap, regardless of how much sleep was obtained the night before). Sleep restriction involves eliminating the excess time spent awake in bed. In this phase of treatment, time in bed is restricted to the average number of hours of actual sleep time. For example, if an individual is in bed for a total of 10 hours but gets only six hours of sleep, that individual would restrict time in bed to six hours total per night. After patients are able to sleep for the majority of that time (i.e., sleep efficiency is improved), time in bed is gradually increased until it reaches an optimal level.

Relaxation strategies, such as diaphragmatic breathing and progressive muscle relaxation, can help patients to decrease physiological arousal, which may increase the likelihood of falling asleep. These strategies can also be used for stress management throughout the day, which can also improve sleep. Cognitive reframing, as discussed previously, is used in CBT-I to challenge thoughts that contribute to distress and sleeplessness (e.g., anticipating a bad night’s sleep; overestimating the consequences of not sleeping well the night before). Sleep hygiene strategies, or healthy sleep habits, are encouraged as indicated, such as decreasing caffeine and alcohol use, participating in exercise during the day, and setting a regular sleep schedule. Stress management can also be useful in addressing precipitating factors for insomnia.