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Brief Report |
Received February 5, 2002; revised April 8, April 18, 2002; accepted April 25, 2002. From the University of Texas–Houston Medical School (MAS,DRH,GJD,SLB,PW) and Kelsey-Seybold Clinic and the Kelsey Research Foundation, Houston, TX (HR). Address correspondence to Dr. Stanley, Department of Psychiatry and Behavioral Sciences, University of Texas–Houston Medical School, 1300 Moursund Dr., Houston, TX 77030-3496. e-mail: Melinda.A.Stanley{at}uth.tmc.edu
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ABSTRACT |
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Key Words: Generalized Anxiety Disorder • Cognitive-Behavioral Therapy • Primary Care
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INTRODUCTION |
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Recent research has addressed the psychosocial treatment of late-life GAD, focusing largely on the effects of cognitive–behavior therapy (CBT), given the difficulties (for example, increased adverse effects, potential drug interactions) in prescribing psychotropic medications for older adults and the documented efficacy of CBT for GAD in younger adults.6 There now is evidence of the usefulness of CBT among older adults with GAD,7,8 with significant improvements in symptoms of worry, anxiety, and depression and with improved quality of life.
Available data, however, may not generalize to medical patients or settings. First, older adults in previous clinical trials have been relatively young, mostly white, well educated, physically healthy, and high-functioning. Thus, generalizability to more heterogeneous and dysfunctional patient groups who present to medical settings is questionable. Also, existing CBT interventions are not optimal for "real-world" settings. They require too many sessions (three to five), omit potentially important treatment components, and lack flexibility in the structure of treatment. A briefer, broader, and more flexible approach is needed in primary care.
The pilot program of research described here was initiated to develop, refine, and test the initial outcomes of CBT-GAD/PC, a version of CBT that targets the needs of older adults with GAD in primary care. The study tested outcomes in a small, randomized trial comparing CBT-GAD/PC with usual care (UC). Although the model of patient identification and treatment is focused on research goals and may not represent real-world practice, the study serves as an important first step in identifying appropriate patients and examining outcomes in primary care.
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METHODS |
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A total of 928 patients were screened, 32 of whom screened positive. Diagnostic assessments were completed for 27 patients. Fifteen were excluded because there was no GAD diagnosis (n=14) or presence of psychosis (n=1). Demographic and clinical data for included patients are presented in Table 1. Forty-two percent were diagnosed with GAD only. Coexistent diagnoses included major depression (n=5; 42%), specific phobia (n=2; 17%), and social phobia (n=1; 8%).
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Treatment Development and Description
CBT-GAD/PC was developed on the basis of cognitive–behavioral procedures with demonstrated efficacy in academic clinical trials of late-life GAD,7,8 with modifications to meet the needs of older medical patients. Initially, a six-session CBT-GAD/PC manual was developed and administered in an open trial to eight medical patients with GAD. Data from this open trial suggested the potential usefulness of CBT-GAD/PC. However, we subsequently refined the manual to enhance outcome and address qualitative feedback from therapists and patients about usability of treatment. The duration of treatment was increased from six to eight sessions, with two additional sessions allowed for patients experiencing immediate crises or needing additional time to learn coping skills. Many treatment procedures (e.g., mnemonic aids, terminology used) and homework forms also were simplified. This eight-session version of CBT-GAD/PC was used here.
Treatment components included education, relaxation, cognitive therapy, problem-solving, exposure, and sleep-management skills. Relaxation involved breathing retraining and progressive deep-muscle relaxation. Cognitive components included thought-stopping, coping self-statements, and training in alternative thoughts and logical errors. Graduated exposure involved practicing coping skills in increasingly anxiety-producing situations. Problem-solving was based on procedures outlined by Meichenbaum,9 and sleep management followed Morin and colleagues.10 Therapists were asked to administer the interventions in a flexible fashion, reviewing all skills for each patient but allocating different amounts of time, depending upon patients' needs. Flexibility was recommended in the use of terminology, mode of presentation, and homework format to fit individual differences in educational backgrounds, cognitive skills, and sensory capacity. Therapists were encouraged to be flexible with the schedule of sessions to accommodate individual patient needs.
Procedures
After screening and diagnostic evaluation, patients were given pretreatment assessments and assigned randomly to CBT-GAD/PC (n=6) or UC (n=6), with one exception, to balance therapists equally across conditions. Therapists were postdoctoral- and residency-level clinicians supervised by the first author. CBT-GAD/PC was administered in either the medical clinic or the patient's home. Patients in UC received weekly telephone calls to assess symptom severity and the need for immediate treatment (e.g., for suicidal ideation). Medical staff was notified of patient participation by a note in the medical record.
Three patients (25.0%) dropped out of the study, two in UC and one in CBT-GAD/PC. One UC participant discontinued the study because of dissatisfaction with UC, and the other died during the treatment interval. The CBT-GAD/PC participant dropped out of the study because of the time commitment. All patients who completed CBT-GAD/PC did so in eight sessions, with an average duration of 8 weeks (standard deviation [SD]: 0.71). Patients in UC were contacted by telephone over an average of 8.8 weeks (SD: 3.59). All outcome measures were administered at pre- and post-treatment, and the PSWQ and BDI also were administered weekly, by telephone in UC and orally during treatment sessions in CBT-GAD/PC, to facilitate end-point analyses. For patients in CBT-GAD/PC, the ERS was administered after Session 1 and the CSQ at post-treatment.
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RESULTS |
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Categorical data also suggested positive outcomes for CBT-GAD/PC. All five patients who completed CBT-GAD/PC met response criteria, defined as 20%-or-more improvement in two of three measures of worry and anxiety (GAD severity, PSWQ, BAI). Only one patient in UC (25%) met the same response criteria. This difference was significant (Fisher's exact test; p <0.05). The number of patients who no longer met criteria for GAD at post-treatment did not differ significantly in the two groups (two in CBT, one in UC).
Satisfaction with CBT-GAD/PC was high (CSQ=30.8 [SD: 1.10]; range: 4–32). CBT-GAD/PC patients also had high expectations for treatment success (Expectancy: 90% [SD: 10.00]; possible range: 0%–100%) and high ratings of credibility (Credibility: 9.0 [SD: 1.01]; possible range: 0–10).
Patients in UC and CBT-GAD/PC reported similar types of usual care over the study period. There were no significant differences in the number of mental health visits (0.25 in UC; 0.0 in CBT-GAD/PC), mental health referrals (1 in UC; 1 in CBT-GAD/PC), new psychotropic medications (1 in UC; 1 in CBT-GAD/PC), or total number of medical visits (1.75 in UC; 2.4 in CBT) over the treatment interval.
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DISCUSSION |
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A number of study limitations suggest specific needs for future work. First, larger samples are clearly needed, as are independent evaluations of patient improvement and treatment integrity. In larger outcome trials, the impact of potential predictor variables, including recruitment source (e.g., waiting room screen versus physician referral), severity of coexistent medical conditions, and pretreatment severity of psychiatric symptoms, can be examined. Second, the potentially synergistic impact of CBT and medication needs to be examined, as does the long-term impact of treatment on service utilization, including medication use, and economic variables. Third, we need data regarding the long-term benefits of treatment and the potential importance of continued clinician contact and/or other forms of booster sessions. Finally, future research will need to examine the usefulness of services that are better integrated into the primary-care system. Here, significant effort was exerted in recruiting patients, and mental health specialists with expertise in late-life anxiety conducted assessments and treatment. For the intervention to be of optimal benefit, it will be necessary to investigate the ease with which staff already providing clinical care can be trained to identify GAD and provide treatment in the context of ongoing services. Despite these limitations, however, the data provide promising preliminary findings that may ultimately improve the provision of care for older medical patients with anxiety.
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ACKNOWLEDGMENTS |
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Portions of the work were presented at the 35th Annual Convention of the Association for Advancement of Behavior Therapy, Philadelphia, PA, November 2001.
The authors thank Dr. Diane Novy, Dr. Mark Kunik, and three anonymous reviewers for comments on an earlier version of this work.
Dr. Hopko is now at the Department of Psychology, University of Tennessee, Knoxville; Dr. Diefenbach is at Hartford Hospital, The Institute of Living, Hartford, CT; and Dr. Bourland is in private practice in Houston, TX.
This research was supported in part by a grant from the NIMH (RO1-MH53932) to the first author.
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This article has been cited by other articles:
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  M. Pinquart and P. R. Duberstein Treatment of Anxiety Disorders in Older Adults: A Meta-analytic Comparison of Behavioral and Pharmacological Interventions Am J Geriatr Psychiatry, August 1, 2007; 15(8): 639 - 651. [Abstract] [Full Text] [PDF]
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 J. L. Wetherell, J. T. Sorrell, S. R. Thorp, and T. L. Patterson Psychological Interventions for Late-Life Anxiety: A Review and Early Lessons From the CALM Study J Geriatr Psychiatry Neurol, June 1, 2005; 18(2): 72 - 82. [Abstract] [PDF]
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 M. A. Stanley, G. J. Diefenbach, and D. R. Hopko Cognitive Behavioral Treatment for Older Adults with Generalized Anxiety Disorder: A Therapist Manual for Primary Care Settings Behav Modif, January 1, 2004; 28(1): 73 - 117. [Abstract] [PDF]
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P. A. Arean Advances in Psychotherapy for Mental Illness in Late Life Am J Geriatr Psychiatry, February 1, 2003; 11(1): 4 - 6. [Full Text] [PDF]
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