Cognitive Behavioral Therapy Effective in Older Adults With Generalized Anxiety Disorder

Laurie Barclay, MD

April 29, 2009

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April 29, 2009 — Cognitive behavioral therapy (CBT) may be effective in older adults with generalized anxiety disorder (GAD), according to the results of a randomized controlled trial reported in the April 8 issue of the Journal of the American Medical Association.

"...CBT can be effective for late-life...GAD, but only pilot studies have been conducted in primary care, where older adults most often seek treatment," write Melinda A. Stanley, PhD, from Baylor College of Medicine in Houston, Texas, and colleagues. "...CBT within a collaborative-care framework in primary care has been effective for younger patients with panic disorder, GAD, or both as well as for older patients with depression, although effect sizes and treatment-response rates were lower than in academic clinical trials. The late-life anxiety literature lags behind these other areas, with only 2 pilot studies addressing treatment in primary care."

The goal of this study was to determine the effects of CBT vs enhanced usual care (EUC) in older adults with GAD in primary care. From March 2004 to August 2006, a total of 134 older adults (mean age, 66.9 years) were recruited in 2 primary care settings, randomly assigned to receive CBT (n = 70) or EUC (n = 64), and treated for 3 months. CBT, which was performed in the primary care clinics, included education and awareness, motivational interviewing, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients in the EUC group received biweekly telephone calls to monitor patient safety and offer minimal support.

Patients were evaluated at baseline; at the conclusion of treatment (3 months); and during follow-up at 6, 9, 12, and 15 months. Main endpoints of the study included worry severity, measured with the Penn State Worry Questionnaire (PSWQ), and GAD severity, measured with the GAD Severity Scale (GADSS). Secondary endpoints were anxiety ratings on the Hamilton Anxiety Rating Scale and Beck Anxiety Inventory, coexistent depressive symptoms rated with the Beck Depression Inventory II, and physical/mental health quality of life measured with the 12-Item Short-Form Health Survey (SF-12).

Compared with EUC, CBT was associated with significant reductions in worry severity (45.6; 95% confidence interval [CI], 43.4 - 47.8 vs 54.4; 95% CI, 51.4 - 57.3, respectively; P < .001) and in depressive symptoms (10.2; 95% CI, 8.5 - 11.9 vs 12.8; 95% CI, 10.5 - 15.1; P = .02), and improvement in general mental health (49.6; 95% CI, 47.4 - 51.8 vs 45.3; 95% CI, 42.6 - 47.9; = .008).

However, GAD severity was not significantly different in patients receiving CBT vs those receiving EUC (8.6; 95% CI, 7.7 - 9.5 vs 9.9; 95% CI, 8.7 - 11.1; P = .19). Response rates defined based on worry severity were higher at 3 months after CBT vs after EUC, according to intent-to-treat analyses (40.0% [28/70] vs 21.9% [14/64]; P = .02).

"Compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care," the study authors write. "However, a measure of GAD severity did not indicate greater improvement with CBT."

Limitations of this study were that the sample was not representative of older patients in primary care with regard to age, sex, and education; clinicians providing CBT and EUC had significant expertise in late-life anxiety and CBT; treatment with CBT was delivered during weekly in-person sessions of approximately 1 hour; and the telephone contacts in the EUC condition did not completely control for the increased attention for the patients receiving CBT.

"...CBT is useful for older adults with GAD in primary care," the study authors conclude. "In future studies, it will be important to examine the impact of treatment delivered by clinicians without specialized CBT expertise. Improved integration with ongoing care would be facilitated through use of an electronic medical record to identify patients and communicate with clinicians, and collaborative models of care that incorporate both CBT and medication need to be tested."

The National Institute of Mental Health and the Houston Veterans Administration Health Services Research and Development Center of Excellence (Houston Center for Quality of Care and Utilization Studies) supported this study. The study authors have disclosed no relevant financial relationships.

JAMA. 2009;301:1460-1467.

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