The clinicians (n=13) judged the CALM Tools for Living program very highly. Five questions were rated on a 1-7 point Likert scales. The mean rating to the question “How well did the computer program work during your meetings?” was 6.23 (SD=0.73). Corresponding items and mean responses are as follows: “How easy was it for you to use the computer program?”, 6.15 (SD=0.69); “How easy was the language used in the program for your patients to understand?”, 5.39 (SD=0.77); “What was your patients' overall opinion of the computer program?”, 5.69 (SD=1.25); and “What was your overall opinion of the computer program?”, 6.08 (SD=0.95). In responses to open-ended questions, clinicians appreciated the way in which the program provided a clear agenda per session and overall structure, as well as an easy-to-use guide for CBT concepts. They also cited the comprehensiveness of the information, the print functions for creating individualized-patient “workbooks”, the video demonstrates of specific skills, and the interactive nature of the program as strengths of Calm Tools for Living. Clinicians noted areas for improvement, including simplification of the language, reduction in the amount of text and elimination of redundancy, and greater flexibility. Future versions will be modified based on this type of feedback to further optimize user-friendliness of the program.
Patient Characteristics and Attendance
To date, 290 patients completed 12 months (i.e., the maximum duration of the intervention phase of the study) since they entered the CALM intervention. Of those, 261 received at least one CBT session, and of these, 53.6% were taking antidepressants, 27.6% benzodiazepines, and 18% other psychotropic medications. 69.7% were taking one or more medications, although not necessarily at optimal doses or for optimal durations. This group of 261 patients attended on average 7.63 (SD = 3.39) computer-assisted CBT sessions with a clinician (range = 1 - 19). The average number did not differ across the four targeted anxiety disorders (F(3, 74) = .10, ns). The rate of attendance indicates patients' willingness to participate in the program, especially given our general aim of limiting the number of CBT sessions to 8 to 10. The number of sessions attended did not correlate with initial session scores on the OASIS (r=-.15), PHQ (r=-.18), outcome expectancies (r=.02) or self efficacy expectancies (r=.15).
Assessment Module Data
Self rating and quiz performance data from the 261 patients who received at least one CBT session indicate that the material was well understood. In terms of self rating (0-100 point scale) of understanding the material, mean ratings for each module were as follows: Education, 80.3 (SD=21.4); Calm Recording, 87.2 (SD=12.9); Calm List, 85.4 (SD=14.2); Calm Breathing, 91.6 (SD=9.3); Calm Thinking, 91.4 (SD=9.0); Calm Living, 90.7 (SD=11.9); Calm Feeling, 91.5 (SD=9.8). The Keep Going module did not include self ratings of understanding. In terms of quiz performance, rates of percentage accurate for each module were as follows: Education, 97% (SD=.08); Calm Recording, 97% (SD=.09); Calm List, 90% (SD=.20); Calm Breathing, 95% (SD=.09); Calm Thinking, 86% (SD=.14); Calm Living, 95% (SD=.09); and Calm Feeling, 94% (SD=.11). There were no differences in self ratings of understanding or quiz performance across patients targeting the different anxiety disorders.
Of the 261 patients who received at least one CBT session, engagement in the CALM Tools for Living program was substantial and did not vary based on the specific anxiety disorder targeted. For example, they practiced CALM breathing skills on average 6.5 times (SD=3.6) between when they were first introduced to this skill and their next session with the clinician (typically this interval was one week). The corresponding numbers were 4.2 times (SD=3.5) for in vivo exposure practices to feared situations, and 4.1 times (SD=1.6) for exposure to feared memories, images or physical sensations, again with no differences across the four anxiety disorder targets. Thus, compliance with homework assignments was very good.
Patient Symptom Data
Self reported levels of anxiety and depression symptoms as well as expectancies for improvement were evaluated across randomly selected subsets whose treatment targeted generalized anxiety disorder (n=20), social anxiety disorder (n=20) and panic disorder (n=20), and all patients whose treatment targeted posttraumatic stress disorder (n=14). Means and standard deviations for the first and last CBT session are presented in .
Table 1 Patient ratings of anxiety, depression, and expectancies from the first to the last CBT session in randomly selected participants whose treatment targeted panic disorder, generalized anxiety disorder, and social anxiety disorder, and all participants (more ...)
OASIS scores decreased significantly and substantially from the first to the last Calm Tools for Living session (F(1, 66) = 56.3, p < .001, ES = .46), and did not differ across the four targeted anxiety disorders (F(3,66) = .59, ns) Nor were the results moderated by the presence (n=49) or absence (n=25) of taking psychotropic medication (F(1,66) = .58, ns). OASIS scores reduced on average by half. Nor did presence of benzodiazepines in particular moderate effects (F(1,66 = .26, ns). Scores for PHQ depression items also decreased significantly (F(1, 65) = 33.3, p < .001, ES = .34), and were not moderated by the type of anxiety disorder targeted in CBT (F(3,65) = .56, ns) or the presence of any psychotropic medication (F(1,65) = 1.0, ns) or, in particular, benzodiazepines (F91,65) = .33, ns). Expectancies in general were already at high levels at the first CBT session. Nonetheless, expectancies for the success of treatment increased significantly from the first to the last session (F (1, 65) = 27.5, p < .001, ES = .30). These changes were not moderated by type of anxiety disorder targeted (F(3,65) = .97, ns) or presence of any psychoptropic medication (F(1,65) = 1.56, ns) or, particularly, benzodiazepines (F(1,65) = 3.1, ns). The same was the case for expectancies for being able to carry out the requirements of treatment, which increased significantly, F(1, 65) = 3.92, p = .05, ES = .06. Increases again were not moderated by the anxiety disorder targeted (F(3,65) = .31, ns) or the presence of any psychotropic medication (F(1,65) = .55, ns). However, the presence of benzodiazepines, in particular, significantly moderated changes in self efficacy (F(1,65) = 6.1, p < .05, ES = .10). Self efficacy increased from the first to last session for those not taking benzodiazepines (t (52) = -3.59, p < .01), whereas it did not significantly change for those taking benzodiazepines (t(19) = .77, ns).
The degree to which OASIS scores changed from the first to the last CBT session correlated with patient ratings of the degree to which they understood the following CALM Tools for Living modules; Calm List, r=.36, p < .05; Calm Breathing, r=.37, p < .05; Calm Living, r = .43, p < .05; and Calm Feeling, r = .44, p < .05. Other module ratings of understanding (i.e., Education, Calm Recording, and Calm Thinking) did not correlate with outcomes. Also, outcomes did not correlate with quiz performance for any module, possibly due to the truncated range of scores.
Finally, a hierarchical regression approach was used to predict OASIS scores at the final session: first session OASIS scores were entered on Step I, type of anxiety disorder targeted and number of sessions attended were entered on Step II, self efficacy and outcome expectancies at the first session were entered on Step III, and patient rated understanding of the module that most highly correlated with outcomes (i.e., Calm Living) was tested on Step IV. Only patient rated understanding of the Calm Living module predicted final session OASIS scores, even after controlling for all other variables. Understanding contributed 21% unique variance, R2 = .21, Beta = -.48, p < .05.