Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: a pilot study
Corresponding Author
Julie Loebach Wetherell
VA San Diego Healthcare System, San Diego, California, USA
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
VA San Diego Healthcare System, San Diego, California, USASearch for more papers by this authorJill A. Stoddard
Department of Psychology, Alliant International University, San Diego, California, USA
Search for more papers by this authorKamila S. White
Department of Psychology, University of Missouri, St. Louis, Missouri, USA
Search for more papers by this authorSander Kornblith
Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Search for more papers by this authorHoang Nguyen
VA San Diego Healthcare System, San Diego, California, USA
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
Search for more papers by this authorCarmen Andreescu
Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Search for more papers by this authorSidney Zisook
VA San Diego Healthcare System, San Diego, California, USA
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
Search for more papers by this authorEric J. Lenze
Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
Search for more papers by this authorCorresponding Author
Julie Loebach Wetherell
VA San Diego Healthcare System, San Diego, California, USA
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
VA San Diego Healthcare System, San Diego, California, USASearch for more papers by this authorJill A. Stoddard
Department of Psychology, Alliant International University, San Diego, California, USA
Search for more papers by this authorKamila S. White
Department of Psychology, University of Missouri, St. Louis, Missouri, USA
Search for more papers by this authorSander Kornblith
Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Search for more papers by this authorHoang Nguyen
VA San Diego Healthcare System, San Diego, California, USA
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
Search for more papers by this authorCarmen Andreescu
Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Search for more papers by this authorSidney Zisook
VA San Diego Healthcare System, San Diego, California, USA
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
Search for more papers by this authorEric J. Lenze
Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
Search for more papers by this authorAbstract
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. Copyright © 2010 John Wiley & Sons, Ltd.
References
- Allgulander C, Florea I, Huusom AK. 2006. Prevention of relapse in generalized anxiety disorder by escitalopram treatment. Int J Neuropsychopharmacol 9: 495–505.
- Arce E, Simmons AN, Lovero KL, Stein MB, Paulus MP. 2008. Escitalopram effects on insula and amygdala BOLD activation during emotional processing. Psychopharmacology (Berl) 196: 661–672.
- Association AP. 2000. Diagnostic and Statistical Manual for Mental Disorders ( 4th edn, test revision). American Psychiatric Association: Washinton DC.
- Beekman AT, Bremmer MA, Deeg DJ, et al. 1998. Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry 13: 717–726.
- Beekman AT, Deeg DJ, Braam AW, Smit JH, Van Tilburg W. 1997. Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychol Med 27: 1397–1409.
- Benitez CI, Smith K, Vasile RG, et al. 2008. Use of benzodiazepines and selective serotonin reuptake inhibitors in middle-aged and older adults with anxiety disorders: a longitudinal and prospective study. Am J Geriatr Psychiatry 16: 5–13.
- Blackburn IM, Moore RG. 1997. Controlled acute and follow-up trial of cognitive therapy and pharmacotherapy in out-patients with recurrent depression. Br J Psychiatry 171: 328–334.
- Blank S, Lenze EJ, Mulsant BH, et al. 2006. Outcomes of late-life anxiety disorders during 32 weeks of citalopram treatment. J Clin Psychiatry 67: 468–472.
- Bockting CL, Schene AH, Spinhoven P, et al. 2005. Preventing relapse/recurrence in recurrent depression with cognitive therapy: a randomized controlled trial. J Consult Clin Psychol 73: 647–657.
- Butler AC, Chapman JE, Forman EM, Beck AT. 2006. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 26: 17–31.
- Chou KL. 2009. Age at onset of generalized anxiety disorder in older adults. Am J Geriatr Psychiatry 17: 455–464.
- de Beurs E, Beekman AT, van Balkom AJ, et al. 1999. Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol Med 29: 583–593.
- Diefenbach GJ, Stanley MA, beck JG, Novy DM, Averill P. 2001. Examination of the Hamilton Scales in assessment of anxious older adults: a replication and extension. J Psychopathol Behav Assess 23: 117–124.
- Fava GA, Park SK, Sonino N. 2006. Treatment of recurrent depression. Expert Rev Neurother 6: 1735–1740.
- Fava GA, Ruini C, Rafanelli C. 2005. Sequential treatment of mood and anxiety disorders. J Clin Psychiatry 66: 1392–1400.
- MB First, RL Spitzer, M Gibbon (eds). 1996. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID), Clinician Version: Administration Booklet. American Psychiatric Press: Washington, DC.
- Folstein MF, Folstein SE, McHugh PR. 1975. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12: 189–198.
- Gray SL, LaCroix AZ, Hanlon JT, et al. 2006. Benzodiazepine use and physical disability in community-dwelling older adults. J Am Geriatr Soc 54: 224–230.
- Gum AM, King-Kallimanis B, Kohn R. 2009. Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication. Am J Geriatr Psychiatry 17: 769–781.
- Hamilton M. 1959. The assessment of anxiety states by rating. Br J Med Psychol 32: 50–55.
- Hofmann SG, Sawyer AT, Korte KJ, Smits JA. 2009. Is it beneficial to add pharmacotherapy to cognitive-behavioral therapy when treating anxiety disorders? A meta-analytic review. Int J Cogn Ther 2: 160–175.
- Hollon SD, DeRubeis RJ, Shelton RC, et al. 2005. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psychiatry 62: 417–422.
- Koepke HH, Gold RL, Linden ME, Lion JR, Rickels K. 1982. Multicenter controlled study of oxazepam in anxious elderly outpatients. Psychosomatics 23: 641–645.
- Le Roux H, Gatz M, Wetherell JL. 2005. Age at onset of generalized anxiety disorder in older adults. Am J Geriatr Psychiatry 13: 23–30.
- Lenze EJ, Mulsant BH, Mohlman J, et al. 2005. Generalized anxiety disorder in late life: lifetime course and comorbidity with major depressive disorder. Am J Geriatr Psychiatry 13: 77–80.
- Lenze EJ, Rollman BL, Shear MK, et al. 2009. Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial. JAMA 301: 295–303.
- Lenze EJ, Wetherell JL. 2009. Bringing the bedside to the bench, and then to the community: a prospectus for intervention research in late-life anxiety disorders. Int J Geriatr Psychiatry 24: 1–14.
- Ma SH, Teasdale JD. 2004. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol 72: 31–40.
- Mantella RC, Butters MA, Amico JA, et al. 2008. Salivary cortisol is associated with diagnosis and severity of late-life generalized anxiety disorder. Psychoneuroendocrinology 33: 773–781.
- McHugh RK, Barlow DH. 2010. The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. Am Psychol 65: 73–84.
- McNally RJ. 2007. Mechanisms of exposure therapy: how neuroscience can improve psychological treatments for anxiety disorders. Clin Psychol Rev 27: 750–759.
- Meyer TJ, Miller ML, Metzger RL, Borkovec TD. 1990. Development and validation of the Penn State Worry Questionnaire. Behav Res Ther 28: 487–495.
- Miller MD, Paradis CF, Houck PR, et al. 1992. Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res 41: 237–248.
- Pariente A, Dartigues JF, Benichou J, et al. 2008. Benzodiazepines and injurious falls in community dwelling elders. Drugs Aging 25: 61–70.
- Paterniti S, Alperovitch A, Ducimetiere P, et al. 1999. Anxiety but not depression is associated with elevated blood pressure in a community group of French elderly. Psychosom Med 61: 77–83.
- Paykel ES, Scott J, Cornwall PL, et al. 2005. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol Med 35: 59–68.
- Porensky EK, Dew MA, Karp JF, et al. 2009. The burden of late-life generalized anxiety disorder: effects on disability, health-related quality of life, and healthcare utilization. Am J Geriatr Psychiatry 17: 473–482.
-
Rubio G,
Lopez-Ibor JJ.
2007.
Generalized anxiety disorder: a 40-year follow-up study.
Acta Psychiatr Scand
115:
372–379.
10.1111/j.1600-0447.2006.00896.x Google Scholar
- Schoevers RA, Beekman AT, Deeg DJ, Jonker C, van Tilburg W. 2003. Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: results from the AMSTEL study. Int J Geriatr Psychiatry 18: 994–1001.
- Schuurmans J, Comijs H, Emmelkamp PM, et al. 2006. A randomized, controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults. Am J Geriatr Psychiatry 14: 255–263.
- Schuurmans J, Comijs H, Emmelkamp PM, et al. 2009. Long-term effectiveness and prediction of treatment outcome in cognitive behavioral therapy and sertraline for late-life anxiety disorders. Int Psychogeriatr 21: 1148–1159.
- Sinoff G, Werner P. 2003. Anxiety disorder and accompanying subjective memory loss in the elderly as a predictor of future cognitive decline. Int J Geriatr Psychiatry 18: 951–959.
- Stanley MA, Wilson NL, Novy DM, et al. 2009. Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial. JAMA 301: 1460–1467.
- Trollor JN, Anderson TM, Sachdev PS, Brodaty H, Andrews G. 2007. Prevalence of mental disorders in the elderly: the Australian National Mental Health and Well-Being Survey. Am J Geriatr Psychiatry 15: 455–466.
- Unutzer J, Katon W, Callahan CM, et al. 2002. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 288: 2836–2845.
- Wetherell JL, Ayers CR, Sorrell JT, et al. 2009. Modular psychotherapy for anxiety in older primary care patients. Am J Geriatr Psychiatry 17: 483–492.
- Wetherell JL, Thorp SR, Patterson TL, et al. 2004. Quality of life in geriatric generalized anxiety disorder: a preliminary investigation. J Psychiatr Res 38: 305–312.
- Wilkinson P, Alder N, Juszczak E, et al. 2009. A pilot randomised controlled trial of a brief cognitive behavioural group intervention to reduce recurrence rates in late life depression. Int J Geriatr Psychiatry 24: 68–75.
- Wright RM, Roumani YF, Boudreau R, et al. 2009. Effect of central nervous system medication use on decline in cognition in community-dwelling older adults: findings from the Health, Aging And Body Composition Study. J Am Geriatr Soc 57: 243–250.
