Evidence-Based Psychotherapy in Primary Care

Although decades of research support the efficacy and effectiveness of psychological approaches in the treatment of mental health conditions (1–3), access to such interventions remains challenging. Previous studies have noted that fewer than half of individuals with anxiety and mood disorders receive some form of care for their mental health condition, with only a minority of these patients receiving evidence-based treatment (4). Primary care has been described as the “de facto” avenue for the management of mental health conditions, because these individuals tend to present in primary care much earlier than in specialty mental health centers (5). A significant opportunity therefore exists within primary care to adapt evidence-based psychological interventions for this setting. Although psychological treatments complement pharmacotherapy in the treatment of mental health conditions, they are advantageous in promoting treatment gains over time, enhancing self-efficacy, and lacking somatic side effects.

In an effort to reduce barriers to accessing evidence-based psychotherapy at the point of care, collaborative care and integrated behavioral health models are embedded within the primary care service. In addition to improving access, integration dramatically enhances communication between primary care and mental health providers. Real-time communications and shared medical records allow for primary care teams to monitor treatment plans and further reinforce patients' efforts on working toward specific treatment goals.

Cognitive-behavioral therapy (CBT) is a skills-based, goal-oriented psychological approach that focuses on modifying personal and environmental factors that are maintaining problems and impairments. Rooted within learning therapy and cognitive science, CBT emphasizes collaboration between the therapist and patient in identifying skills to better manage symptoms and improve function. CBT is particularly well suited to deliver within the primary care setting, given its strong evidence base and short-term nature, thereby maximizing the likelihood of obtaining high-quality care and maintaining access for all primary care patients with mental health needs. Furthermore, CBT can be delivered in individual and group formats that can further enhance accessibility to services and patient choice over step-care options.

Ensuring that patients are receiving high-quality, evidence-based CBT can be challenging. Given that CBT is essentially a learning-based approach, an important feature of this intervention is its emphasis on between-session homework. Introducing core concepts, modeling and refining relevant skills within session, and monitoring progress toward treatment goals require routine practice. Primary care providers, in many ways, can encourage patients to be good consumers of their mental health services. Box 1 provides a short list of questions that may prove useful in clarifying whether patients are engaging in important features of evidence-based psychological interventions.

The primary aim of this article is to summarize the prevalence of, primary care CBT literature in, and key evidence-based treatment principles for three frequently occurring conditions in primary care: anxiety, depression, and sleep disorders. When possible, we highlight meta-analytic studies and best examples of randomized trials using primary care populations from the empirical literature. The relative strength of the evidence from these studies is summarized in Table 1 (6–11). We highlight collaborative care and integrated behavioral health models of service delivery and outline future areas of development for primary care CBT.

Anxiety Disorders

Prevalence

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).

Primary Care CBT

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.

Key Evidence-Based Treatment Principles

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.

Depression

Prevalence

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).

Primary Care CBT

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.

Key Evidence-Based Treatment Principles

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.

Insomnia

Prevalence

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).

Primary Care CBT

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.

Key Evidence-Based Treatment Principles

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.

Discussion

Mental health conditions are common among primary care populations, yet when appropriate assessment and treatment for these conditions fail, the costs and burden on the patient, provider, society, and health care delivery system are substantial. Improving access to high-quality, evidence-based psychological interventions represents an essential step toward bridging the gap between the science and practice of health promotion. CBT has emerged as the psychological approach in the best position to be adapted and disseminated in primary care. Considerable evidence supports the value of CBT in the treatment of anxiety, depression, and insomnia, all of which are frequent problems among primary care patients. Advances in collaborative care and integrated behavioral health programs have dramatically improved access to evidence-based CBT and enhanced the likelihood that mental health conditions will be treated earlier during the course of the illness at the point of care. However, the large-scale dissemination of these programs has barely begun, and considerable barriers exist to accessing CBT within clinics, hospital systems, and communities.

An important step toward reducing barriers to high-quality CBT starts with educating both patients and providers to be good consumers of their mental health care. As outlined in Box 1, basic questions about the structure and content of therapy sessions can help identify factors that may be more indicative of an evidence-based approach. National organizations, such as the Anxiety and Depression Association of America (www.adaa.org) and the Association for Behavioral and Cognitive Therapies (www.abct.org), offer up-to-date information on the nature and evidence-based treatment of a variety of mental health conditions. Furthermore, both Web sites have a “find-a-therapist” locator function to help identify local-area providers and clinics that are more likely to be committed to delivering evidence-based CBT. Other organizations, such as the American Board of Professional Psychology (www.abpp.org) and the Academy of Cognitive Therapy (www.academyofct.org), offer more rigorous specialty certification requirements for CBT providers, which can be an index of higher-quality care.

An additional step toward improving access to CBT is the dissemination of high-impact, low-intensity interventions (43). This framework assumes a population-based approach to service options that either reduces or eliminates the reliance on face-to-face contact with a CBT specialist. Common examples of high-impact, low-intensity interventions involve traditional self-help materials, Internet-based platforms, and mobile-device applications that are built upon evidence-based CBT principles. The benefits of these approaches include wide dissemination potential, flexibility, portability, and cost effectiveness. This framework also serves an increasing number of mental health consumers who prefer a more technologically driven treatment modality. The relative disadvantages of these interventions include a lack of accountability, limited tailoring of the treatment to the individual, and insufficient utilization that may ultimately weaken the dose of treatment. Some studies have found that incorporating telephone support alongside a computerized CBT intervention for depression in primary care yielded improved outcomes in relation to using computerized CBT with minimal support (44). Emerging evidence suggests that using mobile-device applications based on CBT skills is effective in reducing self-reported symptoms of anxiety and depression (45). Table 5 lists a variety of high-impact, low-intensity CBT options for treatment of anxiety, depression, and insomnia (46–48).

Significant progress has been made in the development and dissemination of evidence-based psychological interventions. However, we need to invest in ongoing efforts to ensure that these evidence-based treatments are being delivered with high fidelity and quality (49). As rates of mental health conditions continue to rise, the demographics of the mental health consumer change, and technology advances, continual opportunities exist for evolving novel service delivery models that expand the reach of these interventions to the populations most in need.