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Implementation of the CALM intervention for anxiety disorders: a qualitative study

Geoffrey M Curran12*, Greer Sullivan13, Peter Mendel4, Michelle G Craske5, Cathy D Sherbourne4, Murray B Stein6, Ashley McDaniel3 and Peter Roy-Byrne78

Author Affiliations

1 Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA

2 Mental Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA

3 VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA

4 RAND Corporation, Santa Monica, CA, USA

5 David Geffen School of Medicine, University of California, Los Angeles, CA, USA

6 Departments of Psychiatry and Family and Preventive Medicine, University of California, San Diego, CA, USA

7 Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA

8 Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP), Seattle, WA, USA

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Implementation Science 2012, 7:14  doi:10.1186/1748-5908-7-14

Published: 9 March 2012



Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) []) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed?


Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes.


Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS.


The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.