Psychotherapy Helps Prevent Anxiety Relapse After Course of SSRI in Elderly

June 03, 2013

By Anne Harding

NEW YORK (Reuters Health) Jun 03 - Older patients with generalized anxiety disorder on maintenance treatment with escitalopram have a better chance of avoiding relapse when going off the medication if they are also receiving cognitive behavioral therapy (CBT), a new 73-patient study shows.

The findings should be "reassuring" to patients who are hesitant to receive drug treatment for anxiety, because they show that shorter-term drug treatment can be effective if it is augmented with CBT, study leader Dr. Julie Loebach Wetherell of the VA San Diego Health Care System told Reuters Health.

As many as 7.3% of older adults living in the community have generalized anxiety disorder, "making it possibly the most common psychiatric illness in late life," Dr. Wetherell and her team wrote in their paper, published online May 17 in the American Journal of Psychiatry.

While selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective and safe for treating anxiety in older patients, they may be less effective for reducing symptoms of worry in these patients.

To investigate whether augmenting SSRI treatment with CBT might further improve symptoms of worry and anxiety, and to determine if drug treatment or CBT would be more effective than placebo as maintenance treatment for preventing relapse, the researchers treated 73 patients age 60 and older with 12 weeks of open-label escitalopram.

Then, patients were assigned to one of four different protocols:

(1) escitalopram plus CBT for 16 weeks (augmentation phase) followed by escitalopram for 28 weeks (maintenance phase);

(2) escitalopram alone for both phases;

(3) escitalopram plus CBT for 16 weeks, followed by placebo for 28 weeks; or

(4) escitalopram alone for 16 weeks, followed by placebo.

Adding CBT did not reduce Hamilton Anxiety Rating Scale (HAM-A) scores, once the researchers had adjusted for HAM-A score at the beginning of the augmentation phase. However, patients who received CBT were about three times as likely to show improvement on the Penn State Worry Questionnaire.

Just 2.7% of patients who were taking escitalopram during the maintenance phase relapsed, versus 46.1% of patients on placebo. One-quarter of patients on placebo maintenance who received CBT relapsed, versus 66.4% of those who did not have CBT.

While medication is effective for somatic anxiety symptoms, Dr. Wetherell noted, it does not seem to help reduce pathological worry. "This seems to be a little bit harder to tackle with medication, so the therapy seems to be more effective for those cognitive processes."

Starting out by treating patients with medication may allow them to get their physical symptoms under control, she added, while adding therapy can then help to reduce worry.

She and her colleagues conclude: "The sequence of antidepressant medication augmented with CBT leads to worry-reduction in the short term. Continued medication prevents relapse, but for many individuals CBT would allow sustained remission without requiring long-term pharmacotherapy."

SOURCE: http://bit.ly/10TxRsB

Am J Psychiatry 2013.

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