Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial

Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: a pilot study

OBJECTIVE

Generalized anxiety disorder (GAD) is a prevalent psychiatric condition in older adults with deleterious effects on health and cognition. Although selective serotonin reuptake inhibitor (SSRI) medications have some efficacy as acute treatments for geriatric GAD, incomplete response is the most common outcome of monotherapy. We therefore developed a novel sequential treatment strategy, using personalized, modular cognitive-behavioral therapy (mCBT) to augment SSRI medication.

METHOD

In an open label pilot study (N = 10), subjects received a sequenced trial of 12 weeks of escitalopram followed by 16 weeks of escitalopram augmented with mCBT. We also examined the maintenance effects of mCBT over a 28-week follow-up period following drug discontinuation and termination of psychotherapy.

RESULTS

Results suggest that (1) adding mCBT to escitalopram significantly reduced anxiety symptoms and pathological worry, resulting in full remission for most patients and (2) some patients maintained response after all treatments were withdrawn.

CONCLUSION

Findings suggest that mCBT may be an effective augmentation strategy when added to SSRI medication and provide limited support for the long-term benefit of mCBT after discontinuation of pharmacotherapy.

Late-life anxiety disorders: a review

Anxiety disorders are a major clinical problem in late life; estimated prevalence rates vary from 6% to 10%, and the disease impact is considerable and equal to that of depression. However, anxiety disorders often remain undetected and untreated in older adults. This discrepancy may be accounted for by a combination of patient variables (eg, a lack of help-seeking behavior and long duration of illness) and variables related to current clinical practice (eg, a lack of knowledge regarding late-life anxiety and ageism). Because anxiety disorders usually have an age at onset earlier in life, patients and mental health professionals may be inclined to attribute the anxiety and avoidance symptoms to personality factors instead of a treatable syndrome. Comorbidity with other psychiatric disorders, such as depressive disorder, may complicate the appropriate diagnosis. Identification may be further obscured because the phenomenology of anxiety disorders in older adults tends to differ from the phenomenology in younger adults. Randomized controlled trials have yielded support for the effectiveness of cognitive-behavioral therapy and serotonergic antidepressants. However, both treatments seem hampered by relatively high dropout rates, and the available data are based primarily on a relatively healthy, well-educated, and "young" older population. The dissemination of knowledge regarding late-life anxiety disorders is vital, as evidence-based treatments are available but are still rarely implemented.

Cognitive-behavioral therapy for sleep disturbance decreases inflammatory cytokines and oxidative stress in hemodialysis patients

Sleep disturbance is common in dialysis patients and is associated with the development of enhanced inflammatory responses. Cognitive-behavioral therapy is effective for sleep disturbance and reduces inflammation experienced by peritoneal dialysis patients; however, this has not been studied in hemodialysis patients. To determine whether alleviation of sleep disturbance in hemodialysis patients also leads to less inflammation, we conducted a randomized controlled interventional study of 72 sleep-disturbed hemodialysis patients. Within this patient cohort, 37 received tri-weekly cognitive-behavioral therapy lasting 6 weeks and the remaining 35, who received sleep hygiene education, served as controls. The adjusted post-trial primary outcome scores of the Pittsburgh Sleep Quality Index, the Fatigue Severity Scale, the Beck Depression Inventory, and the Beck Anxiety Inventory were all significantly improved from baseline by therapy compared with the control group. The post-trial secondary outcomes of high-sensitive C-reactive protein, IL-18, and oxidized low-density lipoprotein levels significantly declined with cognitive-behavioral therapy in comparison with the control group. Thus, our results suggest that cognitive-behavioral therapy is effective for correcting disorganized sleep patterns, and for reducing inflammation and oxidative stress in hemodialysis patients.

The involvement of multiple caregivers in cognitive-behavior therapy for anxiety in persons with dementia

OBJECTIVES

Peaceful Mind, a cognitive-behavioral therapy for treating anxiety in persons with dementia, is a promising new treatment currently under investigation. This article reports results of our examination of a modification of the treatment protocol in two cases that included multiple caregivers in treating two persons with dementia.

METHOD

Two case presentations of the benefits and challenges of including multiple caregivers in treatment are discussed. Treatment outcome data for these cases were collected as part of a larger investigation of Peaceful Mind.

RESULTS

The involvement of multiple collaterals resulted in several benefits, including increased family communication, as well as increased opportunities for the practice of new skills. These cases have also presented unique challenges requiring alterations in therapy structure and attention to issues of family conflict.

CONCLUSIONS

Including multiple collaterals in cognitive-behavioral therapy for treating anxiety in persons with dementia is feasible and may be beneficial in maximizing treatment gains and increasing the family's investment in therapy.

Older adults' preferences for religion/spirituality in treatment for anxiety and depression

OBJECTIVES

To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors.

METHOD

Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearman's rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling.

RESULTS

Most participants (77-83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important.

CONCLUSION

For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.

Concordance of self- and proxy-reported suicide ideation in depressed adults 50 years of age or older

OBJECTIVE

To assess whether social supports (proxies) can detect the presence of suicide ideation in a clinical sample of depressed adults 50 years of age or older, and to additionally assess the potential impact of depression symptom severity on patient-proxy concordance in reports of patient suicide ideation.

METHOD

Cross-sectional data were collected regarding Axis I diagnoses, severity of depressive symptoms, and suicide ideation in a clinical sample of 109 patients 50 years of age and older. Patients were administered study measures by trained interviewers. Patients' social supports completed proxy measures of these same variables. We assessed concordance in self- and proxy-reported suicide ideation, employing global suicide ideation items derived from depression scales and more fine-grained suicide ideation items drawn from multi-item suicide ideation measures. We investigated patient-proxy concordance regarding the presence of patient suicide ideation.

RESULTS

Patients who endorsed suicide ideation and were concordantly seen by their social supports to be suicidal reported significantly greater depressive symptom severity than patients concordantly reported to be nonsuicidal. Patients' social supports reported significantly less depressive symptom severity in patients who endorsed suicide ideation yet who did not appear to be suicidal to them.

CONCLUSIONS

Our findings suggest that family and friends can broadly ascertain the presence of suicide ideation in depressed middle-aged and older adults, yet in doing so may largely be responding to their broad perceptions of depressive symptom severity in patients and not specifically to the presence of suicidal thoughts.

Early response to psychotherapy and long-term change in worry symptoms in older adults with generalized anxiety disorder

OBJECTIVES

To determine the association of early and long-term reductions in worry symptoms after cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults.

DESIGN

Substudy of larger randomized controlled trial.

SETTING

Family medicine clinic and large multispecialty health organization in Houston, TX, between March 2004 and August 2006.

PARTICIPANTS

Patients (N = 76) aged 60 years or older with a principal or coprincipal diagnosis of GAD, excluding those with significant cognitive impairment, bipolar disorder, psychosis, or active substance abuse.

INTERVENTION

CBT, up to 10 sessions for 12 weeks, or enhanced usual care (regular, brief telephone calls, and referrals to primary care provider as needed).

MEASUREMENTS

Penn State Worry Questionnaire (PSWQ) administered by telephone at baseline, 1 month (mid treatment), 3 months (posttreatment), and at 3-month intervals through 15 months (1-year follow-up). The authors used binary logistic regression analysis to determine the association between early (1 month) response and treatment responder status (reduction of more than 8.5 points on the PSWQ) at 3 and 15 months. The authors also used hierarchical linear modeling to determine the relationship of early response to the trajectory of score change after posttreatment.

RESULTS

Reduction in PSWQ scores after the first month predicted treatment response at posttreatment and follow-up, controlling for treatment arm and baseline PSWQ score. The magnitude of early reduction also predicted the slope of score change from posttreatment through the 15-month assessment.

CONCLUSION

Early symptom reduction is associated with long-term outcomes after psychotherapy in older adults with GAD.

Acceptance and Commitment Therapy for generalized anxiety disorder in older adults: a preliminary report

Some evidence suggests that acceptance-based approaches such as Acceptance and Commitment Therapy (ACT) may be well-suited to geriatric generalized anxiety disorder (GAD). The primary goal of this project was to determine whether ACT was feasible for this population. Seven older primary-care patients with GAD received 12 individual sessions of ACT; another 9 were treated with cognitive-behavioral therapy. No patients dropped out of ACT, and worry and depression improved. Findings suggest that ACT may warrant a large-scale investigation with anxious older adults.

Reducing the fear of falling among community-dwelling elderly adults through cognitive-behavioural strategies and intense Tai Chi exercise: a randomized controlled trial

AIM

To examine the effectiveness of cognitive-behavioural strategies with/without intense Tai Chi exercise in reducing fear of falling among community-dwelling elderly adults. Background.  Fear of falling is a major health problem among community-dwelling older persons. The prevalence of this fear ranges from 29% to 77%, indicating the importance of developing effective strategies to reduce fear of falling among elderly adults.

METHODS

Data were collected from January to December 2007. A randomized controlled trial with three groups (control, cognitive-behavioural and cognitive-behavioural with Tai Chi). Participants were assessed at baseline for demographic data, falls-related history, and fear of falling. Data on these variables plus falls, mobility, social support behaviour and satisfaction, and quality of life were also collected at 2 and 5 months after interventions.

RESULTS

Participants in the three groups differed significantly in both measures of fear of falling (F = 20·89, P < 0·001; F = 6·09, P < 0·001) and mobility (F = 30·33, P < 0·001), social support behaviour and satisfaction (F = 3·32, P < 0·05 and F = 6·35, P < 0·001, respectively), and quality of life (F = 16·66, P< 0·001). In addition, participants who received the cognitive-behavioural intervention with Tai Chi had significantly lower fear of falling scores (P < 0·001) and higher mobility (P < 0·001), social support satisfaction (P < 0·01) and quality of life (P < 0·001) than the cognitive-behavioural alone and control groups at 5 months. The three groups did not differ significantly in falls.

CONCLUSION

The results of this trial suggest that the cognitive-behavioural intervention with Tai Chi exercise helped community-dwelling elderly adults to enhance their mobility, to manage their fear of falling and to increase their quality of life.

Psychotropic drug use among older people in general practice: discrepancies between opinion and practice

BACKGROUND

The use of psychotropic drugs has increased over recent years in France. GPs are the first prescribers, especially for older patients.

AIM

To analyse discrepancies between GPs' opinions and practice when prescribing psychotropic drugs to older patients.

SETTING

Postal surveys sent to GPs all over mainland France.

DESIGN OF STUDY

Cross-sectional postal study.

METHOD

A questionnaire collected data on characteristics of GPs' practices, their opinions about psychotropic drug consumption in older people, and a full description of their last older patient receiving a psychotropic drug and seen last by the GP on that particular day.

RESULTS

A total of 350 participating GPs saw 2498 patients aged > or =65 years. Among these patients, the prevalence of psychotropic use was 32.1% (803/2498) for anxiolytics/hypnotics, and 17.5% for antidepressants (438/2498). A total of 91% of GPs agreed that it was possible to reduce or stop psychotropic drugs for these patients. Characteristics of 339 patients taking psychotropic drug were reported: 85.8% (291/339) received at least one anxiolytic/hypnotic and 56.9% (193/339) received at least one antidepressant; there were prescribed for more than 1 year in 68.4% (199/291) and 43.5% (84/193) of the cases respectively. GPs stated that it was possible to reduce or stop anxiolytic/hypnotic drugs for only 27% (79/291) of these patients. Barriers to doing this were patients' refusal (79%), and the absence of any local offer of psychotherapy (73%) or alternative therapy (70%).

CONCLUSION

A mismatch exists between GPs' intent (91%) and practice (27%) regarding reduction of psychotropic prescription in individuals aged > or =65 years. The barriers encountered should be examined further to help physicians improve management of psychotropic prescription.

The past, present, and future of comparative effectiveness research in the US Department of Veterans Affairs

A particular challenge for the healthcare provider and the patient is to choose among competing therapeutic approaches for a particular condition. Often, the relative benefits and risks of potential therapies are not uniformly available from the existing scientific information. Many have pointed to the need for more comparative effectiveness research (CER) to aide in these decisions. The US Department of Veterans Affairs (VA) has a long history of conducting CER. The success of the VA CER program has been facilitated by several important aspects of scientific infrastructure related to (1) research question refinement, (2) study design, planning and coordination, (3) evidence synthesis, and (4) implementation research. In publications that had VA coauthors in 2 major medical journals, 25% of the published studies were classified as CER. The most frequent categories of study were pharmaceutical and behavioral interventions. In the future, the CER enterprise will move toward increased input from clinicians in research topic choice and enhanced consideration of other methodologies besides the randomized controlled trial.

An approach to the patient with anxiety

Patients seen in primary care and in specialty medical settings often have prominent anxiety. This article presents the epidemiology, etiology, manifestations, and treatment of anxiety disorders.

Assessing and maintaining mental health in elderly individuals

This article provides detailed information about assessing the mental health needs of older adults as well as strategies to maintain mental health. An overview of the public health needs of older adults is provided that includes examples of policies that ensure minimum physical and mental health for older adults. Multiple resources are described that will enable clinicians to access information that will increase their knowledge of assessment of mental health needs of older adults.

Peaceful Mind: an open trial of cognitive-behavioral therapy for anxiety in persons with dementia

BACKGROUND

Anxiety has a high prevalence among individuals with dementia, and it has a significant negative impact on their functioning; yet intervention studies are lacking. We developed Peaceful Mind, a cognitive-behavioral intervention for persons with dementia. In this paper, we describe the intervention and results of an open trial evaluating the feasibility and utility of the intervention and assessment procedures.

METHODS

Peaceful Mind is implemented over a period of three months in the participant's home with involvement of a caregiver or "collateral." Dyads are followed for an additional three months via telephone. An assortment of simplified skills is offered, including self-awareness, breathing, behavioral activation, calming thoughts, and sleep skills.

RESULTS

Nine participants were enrolled, eight completed the three-month assessment, and seven completed the six-month assessment. Overall, participants and collaterals were satisfied with the intervention and reported that they benefited in terms of anxiety, depression, and collateral distress.

CONCLUSIONS

A randomized controlled trial would help determine whether this promising new treatment has a statistically significant impact on anxiety in this population.

The Effectiveness of a Stimulation Program on Cognitive Capacity Among Individuals Older Than 60

The purpose of this study was to test the effects of a multistimulant home-based intervention program on cognitive function, anxiety, and depression among older adults with cognitive impairment. This research is quasi-experimental and was designed in an effort to increase the cognitive capacity of individuals above the age of 60 with reduced cognitive capacities. Each senior received a total of seven home visits, including intervention conversation, newspaper/ book reading, painting/handcraft activities, and physical exercise. The Mini Mental State Test scores of the participants statistically increased, whereas the Beck Anxiety and the Geriatric Depression Scale scores showed a decrease ( p < .05) after the intervention. Findings demonstrate that the multistimulant approach to improve cognitive capacity among individuals older than 60 years was successful.

Psychodynamic Psychotherapy With Adjunctive Hypnosis for Social and Performance Anxiety in Emerging Adulthood

This is a single case study of a college aged woman with generalized anxiety disorder. Treatment consisted of psychodynamic psychotherapy, with an emphasis on facilitating separation and individuation, using hypnosis as a supportive, self-regulation skill for anxiety management. The patient’s symptoms were tracked using daily subjective, self-report measures over the 13-month treatment period. The simulation modeling approach for time-series (SMATS) was used to assess the phase change from baseline to treatment. Symptoms tracked included anxiety peaks, preoccupation with time, interpersonal closeness, and self-sacrificing of self for others. The patient’s worries about time decreased significantly over the course of treatment. There was also a trend of both less interference of anxiety in the patient’s daily tasks and less self-sacrificing behaviors in her interpersonal relationships. Utility of an idiographic and also quantified research methodology for treatment outcome studies is discussed.

Prevalence and correlates of poor self-rated health in the United States: the national elder mistreatment study

OBJECTIVES

Despite its subjective nature, self-report of health status is strongly correlated with long-term physical morbidity and mortality. Among the most reliable predictors of self-reported poor health is older age. In younger adult populations, the second reliable predictor of reported poor health is the experience of domestic and other interpersonal violence. However, very little research exits on the connection between elder mistreatment and self-reports of poor health. The aim of this study was to examine the level of, and correlates for, poor self-rated health in a community sample of older adults with particular emphasis on elder mistreatment history, demographics, and social dependency variables.

DESIGN

Random digit dialing telephone survey methodology.

SETTING

A national representative phone survey of noninstitutionalized U.S. household population.

PARTICIPANTS

Five thousand seven hundred seventy-seven U.S. adults, aged 60 years and older.

MEASUREMENTS

Individuals participated in a structured interview assessing elder mistreatment history, demographics, and social dependency variables.

RESULTS

Poor self-rated health was endorsed by 22.3% of the sample. Final multivariable logistic regression models showed that poor self-rated health was associated with unemployment, marital status, low income, low social support, use of social services, needing help in activities of daily living, and being bothered by emotional problems. Secondary analyses revealed a mediational role of emotional symptoms in the association between physical maltreatment and poor health.

CONCLUSIONS

Results suggest that poor health is common among older adults. This study also identified correlates of poor health that may be useful in identification of those in need of intervention.

Predictive validity of the classification schema for functional mobility tests in instrumental activities of daily living decline among older adults

OBJECTIVE

To determine predictive validity for cut points of the Timed Up & Go (TUG) test and life-space assessment (LSA) on decline in instrumental activities of daily living (IADLs) among older adults.

DESIGN

Cross-sectional and 1-year follow-up study.

SETTING

Preventive health care services.

PARTICIPANTS

In a cross-sectional study, 2404 older adults (65-100 y) were recruited to determine cut points for the TUG and LSA for IADLs limitation. For longitudinal analysis, 436 older adults (65-100 y) were followed over 1 year to explore the validity of a classification model using the cut points to predict incident IADLs decline.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The TUG, LSA, and Tokyo Metropolitan Institute of Gerontology index of IADLs measurement.

RESULTS

The cut points associated with IADLs limitations for the TUG and LSA were 12 seconds and 56 points, respectively. Participants were classified into fast/high (most able; TUG <12 and LSA >56), fast/low, slow/high, and slow/low (vulnerable; TUG > or =12 and LSA < or =56) groups; there were 813 (34%), 385 (16%), 246 (10%), and 960 (40%) participants in each group, respectively. The proportions of participants with IADLs limitation in the most able, fast/low, slow/high, and vulnerable groups were 19%, 64%, 61%, and 89%, respectively. The vulnerable group included significantly more participants with IADLs limitation than any other group (P<.001). Compared with a most able group, the odds ratios of IADLs decline for the fast/low and vulnerable groups were 2.52 (95% confidence interval 1.15-5.53, P<.05) and 2.87 (95% confidence interval 1.38-5.96, P<.01), respectively.

CONCLUSIONS

The combination of TUG and LSA identifies persons with future IADLs decline and has the potential to be used by community health care services to target individualized interventions.

Novel approaches to treatment of generalized anxiety disorder

PURPOSE OF REVIEW

The present paper reviews recent studies on the clinical presentation of generalized anxiety disorder (GAD) and the current level of evidence for treatment with medications and psychotherapy.

RECENT FINDINGS

An apprehensive state of mind, regardless of the quality of stimuli, is at the core of GAD, causing a pervasive cognitive dysfunction that is separate from that seen in depression and obsessive compulsive disorder. When treatments reduce anxiety-related symptoms and insomnia, patients report a restoration of social functioning, probably as a consequence of improved decision-making, cooperative skills, and risk assessment. Late-onset GAD symptoms in the elderly may be caused or aggravated by cerebrovascular events, loneliness, bereavement, substance use, and the prospect of death. Insomnia in GAD may be primary or caused by common medications. Practice guidelines fail to capture the needs of the entire range of patients with GAD as they build on patients without comorbidity who have been selected for phase III trials. They are also biased to reduce cost.

SUMMARY

The past 10 years have seen a range of safe and effective treatments for GAD. Late-onset GAD presents a new challenge to researchers and practitioners. The current state of knowledge about GAD does not justify radical revisions of the diagnostic criteria in the ongoing revisions of the Diagnostic and Statistical Manual of Mental Disorders-IV and the International Statistical Classification of Diseases-10 nosologies.

Long-term effectiveness and prediction of treatment outcome in cognitive behavioral therapy and sertraline for late-life anxiety disorders

BACKGROUND

Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders.

METHODS

Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established.

RESULTS

Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants.

CONCLUSIONS

Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Innovative psychosocial approaches in old age psychiatry

PURPOSE OF REVIEW

To identify and discuss recent research studies that propose innovative psychosocial interventions in old age psychiatry.

RECENT FINDINGS

Studies have shown that cognitive training research for healthy elderly has advanced in several ways, particularly in the refinement of study design and methodology. Studies have included larger samples and longer training protocols. Interestingly, new research has shown changes in biological markers associated with learning and memory after cognitive training. Among mild cognitive impairment patients, results have demonstrated that they benefit from interventions displaying cognitive plasticity.Rehabilitation studies involving dementia patients have suggested the efficacy of combined treatment approaches, and light and music therapies have shown promising effects. For psychiatric disorders, innovations have included improvements in well known techniques such as cognitive behavior therapy, studies in subpopulations with comorbidities, as well as the use of new computer-aided resources.

SUMMARY

Research evidence on innovative interventions in old age psychiatry suggests that this exciting field is moving forward by means of methodological refinements and testing of creative new ideas.

Psychotherapy for generalized anxiety disorder: don't worry, it works!

Generalized anxiety disorder (GAD) differs from other anxiety disorders. Patients do not fear a specific external object or situation; there is no distinct symptomatic reaction pattern; and the feared scenarios are not bizarre, improbable, or inflexible. Avoidance, although central, is less obvious and often is prominent only on the cognitive-emotional level. The key component of GAD, uncontrollable and persistent worrying, is easily confused with the lay concept of worry, and comorbid disorders often make the recognition of GAD difficult. This article discusses the challenges and the innovative, promising, and specific new developments in treating GAD.