A contemporary protocol to assist primary care physicians in the treatment of panic and generalized anxiety disorders Bruce L. Rollman, M.D., M.P.H.* ,a , Bea Herbeck Belnap, Ph.D. a , Charles F. Reynolds, M.D. b , Herbert C. Schulberg, Ph.D. c , M. Katherine Shear, M.D. b a Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA b Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA c Department of Psychiatry, Weill Medical College, Cornell University, White Plains, NY Abstract Anxiety disorders are prevalent in primary care practice and generate a significant excess of morbidity, health services utilization, and health care expenditures. Complexities in delivering effective care for such disorders have led to stepped collaborative care models that involve nonphysician care managers following guideline-based protocols under the direction of patients’ primary care physicians and a medical specialist. With the goal of aiding colleagues attempting to improve the primary care for panic and generalized anxiety disorders, we detail the collaborative care strategy for treatment of these conditions used by our National Institute of Mental Health (NIMH)-funded clinical trial in which a telephone-based care manager performs timely, patient-specific clinical and case management tasks. We illustrate the clinical considerations underlying the steps taken to implement and then sustain our care manager intervention at four geographically dispersed primary care practices linked by a common electronic medical record system and the modifications made as we encountered clinical situations common to typical practice settings. This report serves to familiarize physicians contemplating use of a similar strategy for improving the quality of primary care for an anxiety disorder or any other chronic mental health condition. © 2003 Elsevier Science Inc. All rights reserved. Keywords: Anxiety; Panic; Primary care; Collaborative care; Disease self-management; Human 1. Introduction Anxiety disorders are prevalent in primary care practice and generate a significant excess of morbidity, health ser- vices utilization, and health care expenditures [1– 4]. Ap- proximately 12–22% of primary care patients present for care with symptoms of distress related to anxiety [5,6]. Among the various anxiety disorders, panic disorder (PD; 1–13% prevalence [7–11]) and generalized anxiety disorder (GAD; 5–16% prevalence [8 –10]) create the largest burden of illness. However, they are often ineffectively treated by primary care physicians (PCPs) who care for the majority of these individuals [12–14]. Several reasons potentially explain the poor treatment outcomes experienced by primary care patients with PD and GAD. First, PCPs may fail to recognize these disorders because these patients typically present with multiple so- matic symptoms that dominate their concerns and compete for the PCPs’ attention within the time constraints of the clinical encounter [12–14]. Second, PCPs may be unfamil- iar with proven effective treatments developed in specialty care settings [15]. Third, patients may resist a psychiatric diagnosis because of stigma and thus inadequately adhere with recommended care. We are conducting a clinical trial that examines the effectiveness of strategies for improving the recognition and quality of care for primary care patients with PD and GAD. Our intervention combines several elements including: 1) screening patients for these conditions with the Primary Care Evaluation of Mental Disorders (PRIME-MD) rapid screening and interview procedure [10]; 2) informing pa- tients’ PCP of the diagnosis(es) and seeking their agreement with it via an interactive electronic medical record (EMR) * Corresponding author. Tel.: +1-412-692-4853; fax: +1-412-692- 4838. E-mail address: rollmanbl@msx.upmc.edu (B. Rollman). General Hospital Psychiatry 25 (2003) 74-82 0163-8343/03/$ – see front matter © 2003 Elsevier Science Inc. All rights reserved. doi:10.1016/S0163-8343(03)00004-5