***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Thus far collaborative stepped care ( CSC ) studies have not incorporated self-help as a first step . AIMS To evaluate the effectiveness of CSC  in the treatment of common mental disorders . METHOD An 8-month cluster r and omised controlled trial comparing CSC to care as usual ( CAU ) ( Dutch Trial Register identifier NTR1224 ) . The CSC consisted of a stepped care approach guided by a psychiatric nurse in primary care with the addition of antidepressants dependent on the severity of the disorder , followed by cognitive-behavioural therapy in mental healthcare . RESULTS Twenty general practitioners ( GPs ) and 8 psychiatric nurses were r and omised to provide CSC or CAU . The GPs recruited 163 patients of whom 85 % completed the post-test measurements . At 4-month mid-test CSC was superior to CAU : 74.7 % ( n = 68 ) v. 50.8 % ( n = 31 ) responders ( P = 0.003 ) . At 8-month post-test and 12-month follow-up no significant differences were found as the patients in the CAU group improved as well . CONCLUSIONS Treatment within a CSC model result ed in an earlier treatment response compared with CAU BACKGROUND Panic disorder is a prevalent , often disabling condition among patients in the primary care setting . Although numerous studies have assessed the effectiveness of treatments for depression in primary care , few such studies have been conducted for panic disorder . OBJECTIVE To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting . DESIGN R and omized , controlled study comparing intervention to treatment as usual . SETTING Six primary care clinics associated with 3 university medical schools , serving an ethnically and socioeconomically diverse patient population . PARTICIPANTS Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder . Comorbid mental and physical disorders were permitted , provided these did not contraindicate the treatment to be provided and were not acutely life threatening . INTERVENTION Patients were r and omized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions ( across 12 weeks ) of cognitive-behavioral therapy ( CBT ) modified for the primary care setting , with up to 6 follow-up telephone contacts during the next 9 months , and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist . Behavioral health specialists , the majority inexperienced in CBT for panic disorder , were trained to deliver the CBT and coordinated overall care , including pharmacotherapy . MAIN OUTCOMES MEASURES Proportion of subjects remitted ( no panic attacks in the past month , minimal anticipatory anxiety , and agoraphobia subscale score < 10 on Fear Question naire ) and responding ( Anxiety Sensitivity Index score < 20 ) and change over time in World Health Organization Disability Scale and short form 12 scores . RESULTS The combined cognitive-behavioral and pharmacotherapeutic intervention result ed in sustained and gradually increasing improvement relative to treatment as usual , with significantly higher rates at all points of both the proportion of subjects remitted ( 3 months , 20 % vs 12 % ; 12 months , 29 % vs 16 % ) and responding ( 3 months , 46 % vs 27 % ; 12 months , 63 % vs 38 % ) and significantly greater improvements in World Health Organization Disability Scale ( all points ) and short form 12 mental health functioning ( 3 and 6 months ) scores . These effects were obtained in spite of similar rates of delivery of guideline -concordant pharmacotherapy to the 2 groups . CONCLUSION Delivery of evidence -based CBT and medication using the collaborative care model and a CBT-naive , midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder CONTEXT Panic disorder and generalized anxiety disorder are prevalent in primary care , associated with poor functional outcomes , and are often unrecognized and ineffectively treated by primary care physicians . OBJECTIVE To examine whether telephone-based collaborative care for panic and generalized anxiety disorders improves clinical and functional outcomes more than the usual care provided by primary care physicians . DESIGN R and omized controlled trial . SETTING Four Pittsburgh area primary care practice s linked by a common electronic medical record system . Patients A total of 191 adults aged 18 to 64 years with panic and /or generalized anxiety disorder who were recruited from July 2000 to April 2002 . Intervention Patients were r and omly assigned to a telephone-based care management intervention ( n = 116 ) or to notification alone of the anxiety disorder to patients and their physicians ( usual care , n = 75 ) . The intervention involved non-mental health professionals who provided patients with psychoeducation , assessed preferences for guideline -based care , monitored treatment responses , and informed physicians of their patients ' care preferences and progress via an electronic medical record system under the direction of study investigators . MAIN OUTCOME MEASURES Independent blinded assessment s of anxiety and depressive symptoms , mental health-related quality of life , and employment status at baseline , 2- , 4- , 8- , and 12-month follow-up . RESULTS At 12-month follow-up , intervention patients reported reduced anxiety ( effect size [ ES ] , 0.33 - 0.38 ; 95 % confidence interval [ CI ] , 0.04 to 0.67 ; P</=.02 ) and depressive symptoms ( ES , 0.35 ; 95 % CI , 0.25 - 0.46 ; P = .03 ) ; improved mental health-related quality of life ( ES , 0.39 ; 95 % CI , 0.10 to 0.68 ; P = .01 ) ; and larger improvements relative to baseline in hours worked per week ( 5.7 ; 95 % CI , 0.1 to 11.3 ; P = .05 ) and fewer work days absent in the past month ( -2.6 ; 95 % CI , - 4.8 to -0.3 ; P = .03 ) than usual care patients . If working at baseline , more intervention patients than usual care patients remained working at 12-month follow-up ( 94 % vs 79 % [ 15 % absolute difference , 0.7%-28.6 % ] ; P = .04 ) . CONCLUSIONS Telephone-based collaborative care for panic disorder and generalized anxiety disorder is more effective than usual care at improving anxiety symptoms , health-related quality of life , and work-related outcomes Background Panic disorder ( PD ) and generalized anxiety disorder ( GAD ) are two of the most disabling and costly anxiety disorders seen in primary care . However , treatment quality of these disorders in primary care generally falls beneath the st and ard of international guidelines . Collaborative stepped care is recommended for improving treatment of anxiety disorders , but cost-effectiveness of such an intervention has not yet been assessed in primary care . This article describes the aims and design of a study that is currently underway . The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual . Methods / design The study is a two armed , cluster r and omized controlled trial . Care managers and their primary care practice s will be r and omized to deliver either collaborative stepped care ( CSC ) or care as usual ( CAU ) . In the CSC group a general practitioner , care manager and psychiatrist work together in a collaborative care framework . Stepped care is provided in three steps : 1 ) guided self-help , 2 ) cognitive behavioral therapy and 3 ) antidepressant medication .  Primary care patients with a DSM-IV diagnosis of PD and /or GAD will be included . 134 completers are needed to attain sufficient power to show a clinical ly significant effect of 1/2 SD on the primary outcome measure , the Beck Anxiety Inventory ( BAI ) . Data on anxiety symptoms , mental and physical health , quality of life , health re source use and productivity will be collected at baseline and after three , six , nine and twelve months . Discussion It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual . The pragmatic design of this study will enable the research ers to evaluate what is possible in real clinical practice , rather than under ideal circumstances . Many requirements for a high quality trial are being met . Results of this study will contribute to treatment options for GAD and PD in the primary care setting . Results will become available in 2011.Trial registration BACKGROUND Effectiveness studies have tested interventions to improve quality of care for depression in primary care , but none , to our knowledge , have been completed for panic disorder ( PD ) in this setting . This study sought to test the clinical effectiveness of PD pharmacotherapy embedded in a disease management framework of " collaborative care " ( CC ) . METHODS One hundred fifteen patients with PD from 3 primary care clinics were r and omized to CC or " usual care " ( UC ) . Patients in CC ( n = 57 ) received educational videotapes and pamphlets ; pharmacotherapy with the selective serotonin reuptake inhibitor paroxetine ; 2 psychiatrist visits and 2 telephone calls in the first 8 weeks ; and up to 5 telephone calls between 3 and 12 months ' follow-up . Usual care patients ( n = 58 ) were treated by their primary care physician . Telephone assessment s of panic , anxiety sensitivity , depression , and disability variables were performed at 3 , 6 , 9 , and 12 months ' follow-up . Adequacy of pharmacotherapy was assessed with an algorithm based on a review of efficacy studies . RESULTS Patients in CC were more likely to receive adequate ( type , dose , duration ) medication and more likely to adhere to this medication at 3 and 6 months . R and om regression analyses showed that CC patients improved significantly more over time compared with UC patients on anxiety , depression , and disability measures , with the greatest effects at 3 and 6 months . CONCLUSIONS Compared with UC , CC interventions significantly improved both quality of care and clinical and functional outcomes in primary care PD patients . Clinical differences were greatest in the first 6 months , corresponding to the greater quality of care and the greater intensity of intervention CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research setting s into real-world practice setting s. Although such advances have been made for depression , little work has been performed for anxiety disorders . OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders ( panic , generalized anxiety , social anxiety , and posttraumatic stress disorders ) would be better than usual care ( UC ) . DESIGN , SETTING , AND PATIENTS A r and omized controlled effectiveness trial of Coordinated Anxiety Learning and Management ( CALM ) compared with UC in 17 primary care clinics in 4 US cities . Between June 2006 and April 2008 , 1004 patients with anxiety disorders ( with or without major depression ) , aged 18 to 75 years , English- or Spanish-speaking , were enrolled and subsequently received treatment for 3 to 12 months . Blinded follow-up assessment s at 6 , 12 , and 18 months after baseline were completed in October 2009 . INTERVENTION CALM allowed choice of cognitive behavioral therapy ( CBT ) , medication , or both ; included real-time Web-based outcomes monitoring to optimize treatment decisions ; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications . MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory ( BSI-12 ) anxiety and somatic symptoms score . Secondary outcomes included proportion of responders ( > or = 50 % reduction from pretreatment BSI-12 score ) and remitters ( total BSI-12 score < 6 ) . RESULTS A significantly greater improvement for  CALM vs UC  in global anxiety symptoms was found ( BSI-12 group mean differences of -2.49 [ 95 % confidence interval { CI } , -3.59 to -1.40 ] , -2.63 [ 95 % CI , -3.73 to -1.54 ] , and -1.63 [ 95 % CI , -2.73 to -0.53 ] at 6 , 12 , and 18 months , respectively ) . At 12 months , response and remission rates ( CALM vs UC ) were 63.66 % ( 95 % CI , 58.95%-68.37 % ) vs 44.68 % ( 95 % CI , 39.76%-49.59 % ) , and 51.49 % ( 95 % CI , 46.60%-56.38 % ) vs 33.28 % ( 95 % CI , 28.62%-37.93 % ) , with a number needed to treat of 5.27 ( 95 % CI , 4.18 - 7.13 ) for response and 5.50 ( 95 % CI , 4.32 - 7.55 ) for remission . CONCLUSION For patients with anxiety disorders treated in primary care clinics , CALM compared with UC result ed in greater improvement in anxiety symptoms , depression symptoms , functional disability , and quality of care during 18 months of follow-up . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00347269 BACKGROUND Individuals with anxiety disorders often do not receive an accurate diagnosis or adequ 
    Output:
    
Conclusions Collaborative care seems to be a promising strategy for improving primary care for anxiety disorders , in particular panic disorder .