Anxiety Disorders: Churchill R

Watanabe N, Churchill R, Furukawa TA. · Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan, 467-8601. · Cochrane Database Syst Rev. · Pubmed #19160253 No free full text.

Abstract: BACKGROUND: The efficacy of combining psychotherapy and benzodiazepines for panic disorder is unclear, despite widespread use. OBJECTIVES: To examine the efficacy of the combination compared with either treatment alone. SEARCH STRATEGY: Randomised trials comparing the combination of psychotherapy and benzodiazepine with either therapy alone for panic disorder were identified. The Cochrane Depression, Anxiety and Neurosis Group Studies and References Registers were searched. References of relevant trials and other reviews were checked. Experts in the field were contacted. Additional unpublished data were sought from authors of the original trials. SELECTION CRITERIA: Two authors independently checked the records retrieved by the searches to identify randomised trials comparing the combined therapy versus either of the monotherapies, among adults with panic disorder. DATA COLLECTION AND ANALYSIS: Two authors independently checked eligibility, assessed quality and extracted data from the eligible trials using a standardised data extraction form. The primary outcome was "response" based on global judgement. Random-effects meta-analyses were conducted, combining data from included trials. MAIN RESULTS: Three trials met eligibility criteria. A 16-week behaviour therapy intervention was used in two trials, and a 12-week cognitive-behaviour therapy intervention in the third. Duration of follow-up varied, ranging from 0 to 12 months. Two trials (total 166 participants) provided data comparing combination with psychotherapy alone (both using behaviour therapy). No statistically significant differences were observed in response during the intervention (relative risk (RR) for combination 1.25, 95% CI 0.78 to 2.03, P = 0.35), at the end of the intervention (RR 0.78, 0.45 to 1.35, P = 0.37), or at the last follow-up time point, although the follow-up data suggested that the combination might be inferior to behaviour therapy alone (RR 0.62, 0.36 to 1.07, P = 0.08). One trial (77 participants) compared combination with a benzodiazepine alone. No differences were found in response during the intervention (RR 1.57, 0.83 to 2.98, P = 0.17). Although the combination appeared to be superior to the benzodiazepine alone at the end of treatment (RR 3.39, 1.03 to 11.21, P = 0.05) the finding was only borderline statistically significant, and no significant differences were observed at the 7-month follow-up (RR 2.31, 0.79 to 6.74, P = 0.12). AUTHORS' CONCLUSIONS: The review established the paucity of high quality evidence investigating the efficacy of psychotherapy combined with benzodiazepines for panic disorder. Currently, there is inadequate evidence to assess the clinical effects of psychotherapy combined with benzodiazepines for patients who are diagnosed with panic disorder.

Furukawa TA, Watanabe N, Omori IM, Churchill R. · Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. · BMC Psychiatry. · Pubmed #18093337 links to  free full text

Abstract: BACKGROUND: In a number of drug and psychotherapy comparative trials, psychotherapy-placebo combination has been assumed to represent psychotherapy. Whether psychotherapy plus pill placebo is the same as psychotherapy alone is an empirical question which however has to date never been examined systematically. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) that directly compared cognitive-behavior therapy (CBT) alone against CBT plus pill placebo in the treatment of panic disorder. RESULTS: Extensive literature search was able to identify three relevant RCTs. At the end of the acute phase treatment, patients who received CBT plus placebo had 26% (95%CI: 2 to 55%) increased chances of responding than those who received CBT alone. At follow-up the difference was no longer statistically significant (22%, 95%CI: -10% to 64%). CONCLUSION: The act of taking a pill placebo may enhance the placebo effect already contained in the effective psychotherapeutic intervention during the acute phase treatment. Theoretically this is an argument against the recently claimed null hypothesis of placebo effect in general and clinically it may point to some further room for enhancing the psychotherapeutic approach for panic disorder.

Watanabe N, Churchill R, Furukawa TA. · Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan. · BMC Psychiatry. · Pubmed #17501985 links to  free full text

Abstract: BACKGROUND: The efficacy of combined psychotherapy and benzodiazepine treatment for panic disorder is still unclear despite its widespread use. The present systematic review aims to examine its efficacy compared with either monotherapy alone. METHODS: All randomised trials comparing combined psychotherapy and benzodiazepine for panic disorder with either therapy alone were identified by comprehensive electronic search on the Cochrane Registers, by checking references of relevant studies and of other reviews, and by contacting experts in the field. Two reviewers independently checked eligibility of trials, assessed quality of trials and extracted data from eligible trials using a standardized data extraction form. Our primary outcome was "response" defined by global judgement. Authors of the original trials were contacted for further unpublished data. Meta-analyses were undertaken synthesizing data from all relevant trials. RESULTS: Only two studies, which compared the combination with behaviour (exposure) therapy, met our eligibility criteria. Both studies had a 16-week intervention. Unpublished data were retrieved for one study. The relative risk for response for the combination was 1.25 (95%CI: 0.78 to 2.03) during acute phase treatment, 0.78 (0.45 to 1.35) at the end of treatment, and 0.62 (0.36 to 1.07) at 6-12 months follow-up. Some secondary outcomes hinted at superiority of the combination during acute phase treatment.One study was identified comparing the combination to benzodiazepine. The relative risk for response was 1.57 (0.83 to 2.98), 3.39 (1.03 to 11.21, statistically significant) and 2.31 (0.79 to 6.74) respectively. The superiority of the combination was observed on secondary outcomes at all the time points. No sub-group analyses were conducted due to the limited number of included trials. CONCLUSION: Unlike some narrative reviews in the literature, our systematic search established the paucity of high quality evidence for or against the combined psychotherapy plus benzodiazepine therapy for panic disorder. Based on limited available published and unpublished data, however, the combined therapy is probably to be recommended over benzodiazepine alone for panic disorder with agoraphobia. The combination might be superior to behaviour therapy alone during the acute phase, but afterwards this trend may be reversed. We know little from these trials about their adverse effects.

Gava I, Barbui C, Aguglia E, Carlino D, Churchill R, De Vanna M, McGuire HF. · Mandala Clinic, PO Box 361, Gosford, New South Wales, Australia, 2250. · Cochrane Database Syst Rev. · Pubmed #17443583 No free full text.

Abstract: BACKGROUND: Obsessive compulsive disorder (OCD) is a chronic anxiety disorder associated with significant morbidity, social impairment and lower quality of life. Psychological treatments are a frequently used approach for OCD. OBJECTIVES: To perform a systematic review of randomised trials of psychological treatments for obsessive compulsive disorder in comparison with treatment as usual. SEARCH STRATEGY: We conducted an electronic search of CCDANCTR-Studies (31/10/2006), and other databases. We searched reference lists, and contacted experts in the field. SELECTION CRITERIA: Published and unpublished randomised trials of psychological treatments versus treatment as usual for adults with a diagnosis of OCD DATA COLLECTION AND ANALYSIS: Two review authors worked independently throughout the selection of trials and data extraction. Findings were compared and disagreements were discussed with a third review author. Full data extraction, using a standardised data extraction sheet, was performed on all studies included in the review. Results were synthesised using Review Manager software. For dichotomous data, odds ratios were calculated. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. Fixed and random effects models were used to pool the data. Reasons for heterogeneity in studies were explored and sensitivity analyses were performed by excluding trials of lower quality. MAIN RESULTS: Eight studies (11 study comparisons) were identified, all of which compared cognitive and/or behavioural treatments versus treatment as usual control groups. Seven studies (ten comparisons) had usable data for meta-analyses. These studies demonstrated that patients receiving any variant of cognitive behavioural treatment exhibited significantly fewer symptoms post-treatment than those receiving treatment as usual (SMD -1.24, 95% CI -1.61 to -0.87, I(2) test for heterogeneity 33.4%). Different types of cognitive and/or behavioural treatments showed similar differences in effect when compared with treatment as usual. The overall treatment effect appeared to be influenced by differences in baseline severity. AUTHORS' CONCLUSIONS: The findings of this review suggest that psychological treatments derived from cognitive behavioural models are an effective treatment for adult patients with obsessive compulsive disorder. Larger high quality randomised controlled trials involving longer follow up periods are needed, to further test cognitive behavioural treatments, and other psychological approaches, in comparison to each other and control conditions. Future trials should examine the predictors of response to each treatment, and also conduct cost-effectiveness evaluations.

Furukawa TA, Watanabe N, Churchill R. · Nagoya City University Graduate School of Medical Sciences, Dept of Psychiatry & Cognitive-Behavioural Medicine, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan, 467-8601. · Cochrane Database Syst Rev. · Pubmed #17253502 No free full text.

Abstract: BACKGROUND: Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established. OBJECTIVES: To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with either therapy alone. SEARCH STRATEGY: The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out. SELECTION CRITERIA: Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia. DATA COLLECTION AND ANALYSIS: Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of "response" i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects. MAIN RESULTS: We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16). AUTHORS' CONCLUSIONS: Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

Hunot V, Churchill R, Silva de Lima M, Teixeira V. · Institute of Psychiatry, Section of Evidence Based Mental Health, Health Services Research Department, PO Box 32, De Crespigny Park, London, UK, SE5 8AF. · Cochrane Database Syst Rev. · Pubmed #17253466 No free full text.

Abstract: BACKGROUND: Generalised anxiety disorder (GAD) is a highly prevalent condition, characterised by excessive worry or anxiety about everyday events and problems. The effectiveness and effectiveness of psychological therapies as a group has not yet been evaluated in the treatment of GAD. OBJECTIVES: To examine the efficacy and acceptability of psychological therapies, categorised as cognitive behavioural therapy (CBT), psychodynamic therapy and supportive therapy, compared with treatment as usual/waiting list (TAU/WL) and compared with one another, for patients with GAD. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, LILACS and controlledtrials.com in February 2006. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials conducted in non-inpatient settings, involving adults aged 18-75 years with a primary diagnosis of GAD, assigned to a psychological therapy condition compared with TAU/WL or another psychological therapy. DATA COLLECTION AND ANALYSIS: Data on patients, interventions and outcomes were extracted by two review authors independently, and the methodological quality of each study was assessed. The primary outcome was anxiety reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of symptom reduction, using the standardised mean difference (SMD), with 95% confidence intervals. MAIN RESULTS: Twenty five studies (1305 participants) were included in the review, of which 22 studies (1060 participants) contributed data to meta-analyses. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.63, 95%CI 0.55 to 0.73), and also in reducing anxiety, worry and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however significant heterogeneity was indicated, which was partly explained by the number of therapy sessions. AUTHORS' CONCLUSIONS: Psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective. Further studies examining non-CBT models are required to inform health care policy on the most appropriate forms of psychological therapy in treating GAD.

Furukawa TA, Watanabe N, Churchill R. · Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya City University Medical School, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. · Br J Psychiatry. · Pubmed #16582055 links to  free full text

Abstract: BACKGROUND: Panic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both. AIMS: To summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment. METHOD: Meta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response. RESULTS: We identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR=1.24,95% CI1.02-1.52) or psychotherapy (RR=1.16,95% CI1.03-1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR=1.61,95% CI1.23-2.11) and was as effective as psychotherapy (RR=0.96, 95% CI 0.79-1.16). CONCLUSIONS: Either combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

Rose S, Bisson J, Churchill R, Wessely S. · West Berkshire Traumatic Stress Service, Berkshire Healthcare NHS Trust, UK., Erleigh Road Clinic, 25 Erleigh Road, Reading, Berks, UK, RG1 5LR. · Cochrane Database Syst Rev. · Pubmed #12076399 No free full text.

Abstract: BACKGROUND: Over approximately the last last fifteen years early psychological interventions such as psychological 'debriefing' have been increasingly used to treat psychological trauma. While these intervention have become popular and their use spread to several settings - efficacy had largely not been tested empirically. In 1997 a systematic review of single session psychological "debriefing" was undertaken and this subsequently became a protocol and Cochrane Review published in 1998 (Issue2). This update forms the first substantive update of the original review. OBJECTIVES: To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder. SEARCH STRATEGY: Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health,SOCIOFILE, CINAHL, PSYCINFO, PSYNDEX, SIGLE, LILACS, CCTR, CINAHL, NRR, Hand search of Journal of Traumatic Stress. Contact with leading researchers. SELECTION CRITERIA: The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event. DATA COLLECTION AND ANALYSIS: 11 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised. Two trials involved the use of the intervention in an obstetric setting. MAIN RESULTS: Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (odds ratio 1.22 (95% ci 0.60 to 2.46 )). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.88 (1.11 to 7.53))odds ratio 95%). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety. REVIEWER'S CONCLUSIONS: There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.

Rose S, Bisson J, Churchill R, Wessely S. · West Berkshire Traumatic Stress Service, Berkshire Healthcare NHS Trust, UK., Erleigh Road Clinic, 25 Erleigh Road, Reading, Berks, UK, RG1 5LR. · Cochrane Database Syst Rev. · Pubmed #11686967 No free full text.

Abstract: BACKGROUND: Over approximately the last last fifteen years early psychological interventions such as psychological 'debriefing' have been increasingly used to treat psychological trauma. While these intervention have become popular and their use spread to several settings - efficacy had largely not been tested emprically. In 1997 a systmatic review of single session psychological "debriefing" was undertaken and this subsequently became a protocol and Cochrane Review published in 1998 (Issue2). This update forms the first substantive update of the original review. OBJECTIVES: To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder. SEARCH STRATEGY: Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health,SOCIOFILE, CINAHL, PSYCINFO, PSYNDEX, SIGLE, LILACS, CCTR, CINAHL, NRR, Hand search of Journal of Traumatic Stress. Contact with leading researchers. SELECTION CRITERIA: The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event. DATA COLLECTION AND ANALYSIS: 11 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised. Two trials involved the use of the intervention in an obstetric setting. MAIN RESULTS: Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (odds ratio 1.22 (95% ci 0.60 to 2.46 )). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.88 (1.11 to 7.53))odds ratio 95%). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety. REVIEWER'S CONCLUSIONS: There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.

Lima AR, Lima MS, Soares BG, Churchill R, Farrell M. · Department of Mental Health, Universidade Federal de Pelotas, Av. Duque de Caxias, 250, Pelotas, Rio Grande do Sul, Brazil, 96100. · Cochrane Database Syst Rev. · Pubmed #10796844 No free full text.

Abstract: BACKGROUND: Cocaine dependence has become a substantial public health problem, developing a significant number of medical, psychological and social problems, including the spread of infectious diseases (e.g. AIDS, hepatitis and tuberculosis), crime, violence and neonatal drug exposure. Although there is no consensus regarding how to treat cocaine dependence, effective pharmacotherapy has a potentially major role to play as part of a broader treatment milieu. The anti-convulsant carbamazepine, a tricyclic medication that is widely used to treat a variety of neurological and psychiatric disorder, has also been used for treatment of cocaine dependence, although its effectiveness has not been established. OBJECTIVES: To determine whether carbamazapine (CBZ) is effective on the treatment of cocaine dependence. SEARCH STRATEGY: Electronic searches of Cochrane Library, EMBASE, MEDLINE, PsycLIT, Biological Abstracts and LILACS; scan of reference list of relevant articles; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of cocaine dependence. SELECTION CRITERIA: The inclusion criteria for all randomised controlled trials were that they should focus on the use of carbamazepine drugs versus placebo on the treatment of cocaine dependence. Trials including patients with additional diagnosis such as opiate dependence were also eligible. DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently and Odds Ratios, weighted mean difference and number needed to treat were estimated. Qualitative assessments of the methodology of eligible studies were carried out using validated checklists. The reviewers assumed that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption. Where possible analysis was carried out according to the "intention to treat" principles. MAIN RESULTS: 5 studies were included in the review, with 455 people randomised. No differences were found regarding positive urine sample for cocaine metabolites. Scores on Spielberg State Anxiety Inventory slightly favoured carbamazepine, but didn't reach statistical significance. Dropouts were high in both groups up to 70% in the placebo group. Less dropout occurred in the Carbamazepine group (RR 0.87 95%CI 0.71-1.06). When no retention in treatment was due to side effects no differences were found. The number of participants presenting at least one side effect, reported in Kranzler (1995), was higher in the carbamazepine group (RR 4.33 95% CI 1.45-12.91). REVIEWER'S CONCLUSIONS: There is no current evidence supporting the clinical use of CBZ in the treatment of cocaine dependence. Larger randomised investigation must be considered taking into account that these time-consuming efforts should be reserved for medications showing more relevant and promising evidence.

Wahlbeck K, Churchill R, Wessely S, Bisson JI, Rose S. · · Duodecim. · Pubmed #16457079 No free full text.

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Weich S, Churchill R, Lewis G. · Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. · J Affect Disord. · Pubmed #12880939 No free full text.

Abstract: BACKGROUND: Dysfunctional attitudes may predispose to episodes of depression, although the evidence for this is poor. Most previous studies have been cross-sectional, or have followed up clinical samples. The aim of the study was to test the hypothesis that dysfunctional attitudes are associated with the onset and repeat prevalence of episodes of the common mental disorders among primary care attenders. METHODS: A 12-month prospective cohort study of 305 consecutive primary care attenders at a health centre in south London. RESULTS: Linear associations were found between (high) score on the Dysfunctional Attitude Scale (DAS) and both the onset and repeat prevalence of episodes of the common mental disorders over 12 months (unadjusted OR for episode onset 1.05, 95% CI 1.01-1.09) (P = 0.009). The association with episode onset, but not with repeat prevalence, remained statistically significant after adjusting for CIS-R score at baseline (OR 1.05, 95% CI 1.00-1.09) (P = 0.03). LIMITATIONS: This study was based in a single general practice, and had limited power to detect statistically significant interactions between DAS score and socio-economic adversity. CONCLUSIONS: Dysfunctional attitudes may be a risk factor for the onset (but not the outcome) of episodes of moderately severe, typically comorbid, anxiety and depression found in primary care settings.