Brief internet-delivered cognitive behavioral therapy for anxiety in older adults: a feasibility trial

This study examined the efficacy of an Internet-delivered cognitive-behavior therapy program developed for older adults. Twenty-two participants with elevated scores (≥8) on the Generalized Anxiety Disorder 7-Item Scale (GAD-7) participated in the course, which consisted of five lessons, homework tasks, additional resources, a moderated discussion forum, and weekly telephone support from a Clinical Psychologist. Ninety-five percent of the sample met diagnostic criteria for an anxiety disorder at pre-treatment. All participants completed the five lessons within the allotted eight weeks. Three-month follow-up data was collected from 95% of participants. Reductions in symptoms of anxiety and stress, with large within-group effect sizes (Cohen's d) were found on the GAD-7 (d=1.03) and the Depression, Anxiety and Stress Scales - 21 Items (d=0.98) at follow-up. Participants reported high levels of satisfaction with the program. These encouraging results provide tentative support for the online treatment of older adults with anxiety.     

Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: a meta-analysis

OBJECTIVES: The goal of the present study was to assess the effects of psychotherapy and other behavioral interventions on depressive symptoms in clinically depressed older patients. METHODS: We used meta-analysis to examine the effects of 57 controlled intervention studies. RESULTS: On average, self-rated depression improved by d=0.84 standard deviation units and clinician-rated depression improved by d=0.93. Effect sizes were large for cognitive and behavioral therapy (CBT) and reminiscence; and medium for psychodynamic therapy, psychoeducation, physical exercise and supportive interventions. Age differences in treatment effects were not observed. Weaker effects were found in studies that used an active control group and in studies of physically ill or cognitively impaired patients. Studies of samples comprised exclusively of patients suffering from major depression (versus other mood disorders) also yielded weaker intervention effects. On average, 18.9% of participants did not complete the intervention, with higher dropout rates reported in group (versus individual) interventions and in longer interventions. CONCLUSIONS: We conclude that cognitive-behavioral therapy and reminiscence are particularly well-established and acceptable forms of depression treatment. Interventions with 7-12 sessions may optimize effectiveness while minimizing dropout rates. For physically and cognitively impaired patients, modifications in treatment format and/or content might be useful, such as combining psychotherapy with social work interventions and pharmacotherapy.     

Effects of relaxation interventions on depression and anxiety among older adults: a systematic review

Objectives: This systematic review examined empirical evidence of the effects of relaxation interventions on anxiety and depression among older adults.

Method: A comprehensive literature search identified studies that satisfied the pre-set inclusion and exclusion criteria. We focused on 15 published and non-published studies – 12 randomised controlled trials and three non-randomised controlled trials – undertaken in the past 20 years (1994–2014). Three reviewers selected studies, extracted data, and appraised the methodological quality. We then computed Hedges’ effect sizes and used these to represent the effects of intervention.

Results: Our findings suggested that older adults who received relaxation interventions experienced greater reductions in depression and anxiety than controls in most studies. Progressive muscle relaxation training, music intervention, and yoga had the strongest intervention effects on depression. Music intervention, yoga, and combined relaxation training most effectively reduced anxiety symptoms among older adults. Furthermore, the impact of some relaxation interventions remained in effect for between 14 and 24 weeks after the interventions.

Conclusion: This systematic review supported the positive effects of relaxation interventions on depression and anxiety among older adults. Health care providers may integrate relaxation interventions into standard care for older adults in community and hospital settings, taking into consideration the participant's preference and health care policy.     

Integrating behavioral and pharmacological interventions in treating clients with psychiatric disorders and mental retardation

While the literature on treatment of dually diagnosed individuals continues to grow, few studies have examined the potential interactions between behavioral interventions and pharmacological interventions in treating persons with a developmental disability and a concurrent psychiatric disorder. The current theoretical paper discusses different manners in which psychotropic medications and behavioral interventions can interact, including the potential for facilitative or inhibitory effects of one treatment modality on the other. Possible permutations of these interactions are discussed. Case examples, including objective measures of psychiatric and behavioral symptoms over time, representing possible illustrations of these permutations, are presented. The authors argue that in many cases the potential effect of one treatment procedure on the efficacy of another may be an important consideration in treating dually diagnosed individuals.     

Weight management interventions in adults with a serious mental illness: A meta-analytic review

Persons with a serious mental illness have more physical health problems and shorter life expectancy compared to the general population, in part due to modifiable at-risk health behaviors like obesity. This study provides a systematic review and meta-analysis of the available evidence on the efficacy of weight management interventions when compared to treatment as usual. Fourteen studies were included in the meta-analysis, analyzing data from a total of 1779 participants. Across all studies, an effect in favor of the intervention groups, with a reduction in mean absolute weight of ?2.01 kg, compared to control groups (95% CI: ?2.93 kg to ?1.10 kg, p< 0.001) over a period ranging from 3 months to 12 months. Subgroup meta-analyses indicate programs that incorporate individual sessions and are implemented at the onset of illness may have the greatest impact on weight management for this population. Despite the statistically significant findings of mean weight change in the intervention groups compared to controls, the reported weight loss only equates to a 2% change from the initial body weight. This falls short of the clinically significant target of 5% weight loss in order to reduce related health complications. The current research was not consistent in capturing data on other metrics that could supplement mean weight loss in assessing positive health outcomes. Due the current health epidemic faced by this population, it is imperative for future research to include adequate follow-up periods, provide protocols, and employ better control methods.     

Memory training interventions for older adults: a meta-analysis

A systematic review and meta-analysis of memory training research was conducted to characterize the effect of memory strategies on memory performance among cognitively intact, community-dwelling older adults, and to identify characteristics of individuals and of programs associated with improved memory. The review identified 402 publications, of which 35 studies met criteria for inclusion. The overall effect size estimate, representing the mean standardized difference in pre-post change between memory-trained and control groups, was 0.31 standard deviations (SD; 95% confidence interval (CI): 0.22, 0.39). The pre-post training effect for memory-trained interventions was 0.43 SD (95% CI: 0.29, 0.57) and the practice effect for control groups was 0.06 SD (95% CI: 0.05, 0.16). Among 10 distinct memory strategies identified in studies, meta-analytic methods revealed that training multiple strategies was associated with larger training gains (p=0.04), although this association did not reach statistical significance after adjusting for multiple comparisons. Treatment gains among memory-trained individuals were not better after training in any particular strategy, or by the average age of participants, session length, or type of control condition. These findings can inform the design of future memory training programs for older adults.     

Sleep and its disorders in older adults.

For many older adults, aging is associated with significant changes in sleep. There are a variety of potential causes, including primary sleep disorders, circadian rhythm disturbances, insomnia, depression, medical illness, and medications. As with younger adults, the diagnosis requires a thorough sleep history and an overnight sleep recording when appropriate. Treatment should address the primary sleep problem and can result in significant improvement in quality of life and daytime functioning in older adults.     

Treatment of perinatal mood and anxiety disorders: a review.

OBJECTIVES: To review the nonpharmacologic and pharmacologic treatment modalities for perinatal mood and anxiety disorders and to discuss the importance of weighing the risks and the benefits of exposing the fetus or baby to maternal mental illness as opposed to exposure to antidepressant medications. METHODS: We conducted a literature search of the PubMed and MEDLINE databases. Key words included the following: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, psychotherapy, and treatment. RESULTS: Recent literature reflects that both pharmacologic and nonpharmacologic treatments for perinatal women are associated with positive and negative outcomes. No treatment decision was found to be risk-free. The detrimental effects of untreated mental illness on the mother, as well as on the baby, highlight the need for treatment intervention. The long-term effects of exposure to either medications or maternal mental illness are unknown, as yet. CONCLUSION: Women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. Although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical.     

Anxiety disorders in older adults: a comprehensive review

This review aims to address issues unique to older adults with anxiety disorders in order to inform potential changes in the DSM‐V. Prevalence and symptom expression of anxiety disorders in late life, as well as risk factors, comorbidity, cognitive decline, age of onset, and treatment efficacy for older adults are reviewed. Overall, the current literature suggests: (a) anxiety disorders are common among older age individuals, but less common than in younger adults; (b) overlap exists between anxiety symptoms of younger and older adults, although there are some differences as well as limitations to the assessment of symptoms among older adults; (c) anxiety disorders are highly comorbid with depression in older adults; (d) anxiety disorders are highly comorbid with a number of medical illnesses; (e) associations between cognitive decline and anxiety have been observed; (f) late age of onset is infrequent; and (g) both pharmacotherapy and CBT have demonstrated efficacy for older adults with anxiety. The implications of these findings are discussed and recommendations for the DSM‐V are provided, including extending the text section on age‐specific features of anxiety disorders in late life and providing information about the complexities of diagnosing anxiety disorders in older adults. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Psychopharmacology interventions for pediatric anxiety disorders: a research update

Pediatric anxiety disorders are commonly occurring mental health disorders of childhood and are associated with significant distress, impairment, and risk for ongoing morbidity. During the past decade, significant progress has been made in developing safe and effective therapeutic approaches to these disorders. This article focuses on the scientific literature supporting the use of a variety of medication approaches to the treatment of the various anxiety disorders of childhood and adolescence.     

Silexan in anxiety disorders: Clinical data and pharmacological background

Objectives: Silexan is a lavender oil preparation available in 80-mg capsules. Here we review clinical trials investigating its anxiolytic efficacy, safety and tolerability in humans, as well as preclinical investigations supporting this therapeutic use.

Methods: Besides three selected publications reporting preclinical investigations, seven clinical trials are included, of which five had a treatment duration of 6 or 10 weeks. Primary outcome measure was the HAM-A total score reduction, while single items were assessed with regard to effects on concomitant depressive symptoms and on quality of sleep.

Results: In patients with subthreshold (subsyndromal) anxiety or generalised anxiety disorder (GAD), an anxiolytic effect of Silexan was evident after 2 weeks. HAM-A total score reductions between baseline and end of treatment were significantly superior to placebo in patients with subthreshold anxiety and comparable with those achieved under lorazepam or paroxetine in patients with GAD. In addition, Silexan had beneficial effects on typical concomitant symptoms of anxiety disorders, such as impaired sleep, somatic complaints, co-morbid depression or decreased quality of life. Except for mild gastrointestinal symptoms, Silexan did not induce any adverse effects and did not cause drug interactions, sedation or withdrawal symptoms at daily doses of 80 or 160?mg.

Conclusions: Silexan is a safe and effective treatment in anxiety disorders.     

Mental health service use among Canadian older adults with anxiety disorders and clinically significant anxiety symptoms

Objectives: Despite evidence of disproportionate underutilization of mental health services by older adults and by individuals with anxiety disorders, little is known specifically about service use by older adults with anxiety. This study examines the prevalence of mental health service use among older adults with anxiety disorders and clinically significant anxiety symptoms, as well as factors associated with service use.

Method: The authors used data from the Canadian Community Health Survey–Mental Health and Well-Being, a nationally representative survey of community-dwelling Canadians. This study examined past-year use of mental health services in both the specialty mental health and general medical sectors by adults aged 55+ (N = 12,792). Logistic regression analyses examined predictors of service use among those with anxiety disorders (N = 279) and clinically significant anxiety symptoms (N = 880).

Results: Only 20.8% of older adults with an anxiety disorder and no mood disorder used services in the past year, compared to 43.1% of those with a mood disorder and 72.7% of those with comorbid disorders. In the final logistic regression models, only need variables were significant predictors of service use among older adults with anxiety disorders and among those with significant anxiety symptoms.

Conclusion: Findings indicate that anxious older adults are less likely to use mental health services than those who are depressed. While predisposing and enabling factors do not appear to impede service use, the need for help does. Anxious older adults and those they interact with may not be interpreting their anxiety symptoms as warranting services.     

Use of benzodiazepines and selective serotonin reuptake inhibitors in middle-aged and older adults with anxiety disorders: a longitudinal and prospective study.

OBJECTIVE: The purpose of this study was to examine the use of benzodiazepines (BZs) and selective serotonin reuptake inhibitors/selective norepinephrine reuptake inhibitors (SSRIs/SNRIs) over nine years of follow-up in middle-aged and older adults with diagnoses of panic disorder with or without agoraphobia, social phobia, or generalized anxiety disorder. SETTING AND PARTICIPANTS: Participants in this study were enrolled in the Harvard/Brown Anxiety Research Project (HARP). HARP is a naturalistic, longitudinal, multisite study of adults with anxiety disorders who are recruited from psychiatric settings. The analytic sample consisted of 51 participants with anxiety disorders who were 55 to 70 years old at baseline and a younger cohort of 211 participants added for comparative analysis. DESIGN: The authors examined patterns of medication use (BZs and SSRIs/SNRIs) in participants with anxiety disorders as they aged, by assessing the proportion of participants taking these medications using generalized estimating equation modeling. MEASUREMENTS: The present data were derived from the structured diagnostic interview administered at enrollment using a combination of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Third Edition-R Non-Affective Disorder, Patient Version, Research Diagnostic Criteria Schedule for Affective Disorders-Lifetime, and subsequent follow-up interviews over a nine-year period using the Longitudinal Interval Follow-up Evaluation-Pharmacia & Upjohn to assess the weekly course of disorders to indicate syndrome severity and document medication use by specific type and dose on a weekly basis. RESULTS: Findings showed that rates of BZ use were high among both the older (53% at baseline) and the younger (57.4%) age groups and did not significantly decrease over time, after controlling for time in episode of their anxiety disorders. There was a statistically significant increase in SSRI/SNRI use over time in both groups. At the beginning of the study, 18% of the older group and 21% of the younger group were using SSRIs/SNRIs; however, at the end of the study, the rates increased to 35% and 43%, respectively. CONCLUSIONS: Although there was an increase in SSRI/SNRI use in older participants with anxiety disorders over the course of study, at nine years of follow-up, only 35% of participants were utilizing SSRI/SNRI medication, while more than one-half of the same participants were continuing to use BZs. To the authors' knowledge, there are no randomized clinical trials that have addressed comparative efficacy and safety of BZs and SSRIs/SNRIs in this population. However, there is documented evidence of adverse effects of chronic BZ use and the risk of developing dependency in older populations.     

Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults

ObjectiveThe primary objectives of this study were to examine the likelihood of anxiety disorders among respondents with common physical health conditions and to explore the associations between this comorbidity and older adults' perceived mental and physical health.MethodThe sample consisted of older adults from the Canadian Community Health Survey 1.2 (n=12,792). Trained lay interviewers assessed psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Physical health conditions were based on self-reported diagnoses by health professionals. Multiple logistic regressions examined whether suffering from a physical health condition increased the odds of any assessed anxiety disorder (panic, agoraphobia, social phobia and posttraumatic stress disorder). Multiple linear regressions examined associations between self-rated health and comorbid physical health conditions and anxiety.ResultsAfter adjusting for confounding variables, the presence of chronically painful conditions (i.e., arthritis, back pain and migraine) and of other commonly occurring diseases (i.e., allergies, cataracts and gastrointestinal, lung and heart disease) were positively associated with anxiety. The comorbidity of anxiety with allergies, cataracts, arthritis and lung disease resulted in poorer self-rated physical and/or mental health after adjusting for confounding variables.ConclusionHealth problems in older adults are associated with increased odds of anxiety, and this comorbidity is associated with poorer self-reported health than medical problems or anxiety alone. These findings have important clinical implications for health professionals.     

Self-help interventions for anxiety disorders: An overview

Anxiety disorders are highly prevalent and are associated with a marked impairment in quality of life and a huge economic cost to society. Unfortunately, a considerable number of people who struggle with anxiety do not seek or receive adequate treatment. Self-help interventions have been proposed to constitute a relatively cheap, effective, efficient, and low-threshold intervention for anxiety disorders. This paper offers a critical discussion of their advantages and disadvantages and the evidence for their effectiveness. We conclude that guided self-help can play a major role in mental health care for patients with anxiety disorders. However, several research questions need to be answered before broad-scale dissemination is possible. The Internet will continue to play a prominent role in the further development of this field of research and clinical practice.     

A meta-analytic review of psychosocial interventions for substance use disorders

OBJECTIVE: Despite significant advances in psychosocial treatments for substance use disorders, the relative success of these approaches has not been well documented. In this meta-analysis, the authors provide effect sizes for various types of psychosocial treatments, as well as abstinence and treatment-retention rates for cannabis, cocaine, opiate, and polysubstance abuse and dependence treatment trials. METHOD: With a comprehensive series of literature searches, the authors identified a total of 34 well-controlled treatment conditions-five for cannabis, nine for cocaine, seven for opiate, and 13 for polysubstance users-representing the treatment of 2,340 patients. Psychosocial treatments evaluated included contingency management, relapse prevention, general cognitive behavior therapy, and treatments combining cognitive behavior therapy and contingency management. RESULTS: Overall, controlled trial data suggest that psychosocial treatments provide benefits reflecting a moderate effect size according to Cohen's standards. These interventions were most efficacious for cannabis use and least efficacious for polysubstance use. The strongest effect was found for contingency management interventions. Approximately one-third of participants across all psychosocial treatments dropped out before treatment completion compared to 44.6% for the control conditions. CONCLUSIONS: Effect sizes for psychosocial treatments for illicit drugs ranged from the low-moderate to high-moderate range, depending on the substance disorder and treatment under study. Given the long-term social, emotional, and cognitive impairments associated with substance use disorders, these effect sizes are noteworthy and comparable to those for other efficacious treatments in psychiatry.