Category: Treatment - CBT


A Hybrid Type III Random Controlled Trial of the CALM Tool in VHA Community-Based Outpatient Clinics

Sunday, November 19
10:15 AM - 11:45 AM
Location: Indigo Ballroom E, Level 2, Indigo Level

Keywords: Anxiety | Depression | Treatment Integrity / Adherence / Compliance
Presentation Type: Symposium

Background: Although the VHA is committed to providing evidence-based psychotherapies (EBPs) for mental health treatment,1 many rural Veterans remain without care. This hybrid type III trial of the Coordinated Anxiety Learning and Management (CALM) tool2 will compare use of a computer-based tool with manualized delivery of CBT to patients with a range of disorders (including panic, generalized anxiety, social anxiety, posttraumatic stress [PTSD]) and comorbid depression in community-based outpatient clinics (CBOCs), and evaluate provider fidelity to treatment (primary outcome), which patient outcomes should reflect (secondary outcome.3). 

Methods: For redesigning the CALM tool, qualitative data were collected from CBOC mental health providers in the South Central VHA region, Veterans with an anxiety disorder or PTSD with or without depression, expert CBT clinicians and VHA experts in implementing EBPs. Qualitative data were collected in focus groups, which provided to provide feedback on tool redesign. Rapid data analytic techniques were used to analyze information, with feedback summaries used to develop categories for revision. Then an RCT will compare the effect of the modified CALM tool vs. that of a manualized version on provider fidelity to CBT. Thirty-four mental health providers were randomized to receive CBT training plus the CALM tool or a manualized version. All received the same training, except for 4 hours’ practice with each delivery method; all will receive consultation for 3 months and ongoing technical support. External facilitation will support implementation of both delivery types.4 Fidelity to CBT will be evaluated, with CBT experts rating audio recordings of a midpoint patient and the last patient receiving at least 4 treatments from each provider.  Clinical status will be assessed at baseline and at 3 and 6 months posttreatment. There will also be an implementation needs assessment with providers and directors.


Conclusions: This study will help determine whether a modified CALM tool is more effective than manualized CBT in VHA CBOCs.



1. National VA Uniform Mental Health Services Handbook

2. Craske MG, Rose RD, Lang A, et al. Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-cae settings. Depress Anxiety 2009;26:235-42.

3. Cucciare MA, Curran GM, Craske MG, et al. Assessing fidelity of cognitive behavioral therapy in rural VA clinics: Design of a randomized implementation effectiveness (hybrid type III) trial. Implement Sci 2016;11:65.

Jan Lindsay

VA South Central MIRECC


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A Hybrid Type III Random Controlled Trial of the CALM Tool in VHA Community-Based Outpatient Clinics

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