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CBT improves worry severity in older adults with GAD in primary care

ED FROM Stanley MA, Wilson NL, Novy DM, et al. Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial. JAMA 2009;301:1460–7. Correspondence to: Melinda A Stanley, Menninger Department of Psychiatry and Behavioural Sciences, Baylor College of Medicine, Houston Centre for Quality Care and Utilization Studies (MEDVAMC 152) 2002 Holcombe Blvd, Houston, TX 77030, USA. mstanley@bcm.tmc.edu Sources of funding: National Institute of Mental Health and Houston VA Health Services Research and Development Centre of Excellence. Generalised anxiety disorder (GAD) is the most common anxiety disorder in primary care (~7% prevalence) and is associated with poorer clinical outcomes, including cognitive impairments in older adults. Few GAD treatment trials have been conducted in primary care settings,1 and the only one that involved older adults relied on pharmacotherapy2 which many older adults are reluctant to use. Stanley and colleagues report the fi rst effectiveness trial of a cognitive behavioural therapy (CBT) intervention for primary care patients with late life GAD. Several trial features strengthen their fi ndings, including its randomised design; broad subject inclusion criteria that allowed concomitant use of psychotropic medications; high treatment fi delity; use of an ‘enhanced’ usual care (EUC) control condition to partly offset for the extra attention received by CBT patients; follow-up assessments to assess the 12 month durability of their intervention; low subject attrition rate; and intention-totreat and other appropriate statistical analyses of subject dropouts. At 3 months, intervention patients had a mean of 7–8 face to face CBT sessions yet reported a large effect size improvement on their primary outcome. Moreover, 40% versus 22% of EUC patients met the criteria for a treatment response (numbers needed to treat 5.6) and these improvements were sustained 12 months later. By comparison, improvements observed in a trial of escitalopram versus placebo for late life GAD were much smaller.2 Although a substantial proportion of GAD patients failed to meet criteria for treatment response, it is noteworthy that a relatively brief course of expert delivered CBT provided relatively speedy (<3 months) and durable symptom relief. While it remains to be established in head to head trials, CBT may also provide better and more durable symptom relief than pharmacotherapy.2 Additional data describing the impact of the intervention on health services utilisation and costs would be useful to support Stanley and colleagues’ treatment strategy in ‘real world’ settings. Indeed, many elderly patients, particularly those with a signifi cant burden of medical comorbidity and transportation challenges, are either unwilling or unable to adhere with multiple face to face counselling sessions with a therapist. Thus, testing other CBT delivery modalities, including telephone and internet,3 holds great promise to expand access to evidence based care. Bruce L Rollman, MD, MPH Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; rollmanbl@upmc.edu Competing interests: None 1. Rollman BL, Belnap BH, Mazumdar S, et al. A randomized trial to improve the quality of treatment for panic and generalized anxiety disorders in primary care. Arch Gen Psychiatry 2005;62:1332–41. 2. Lenze EJ, Rollman BL, Shear MK, et al. Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial. JAMA 2009;301:295–303. 3. Marks I, Cavanagh K. Computer-aided psychological treatments: evolving issues. Annu Rev Clin Psychol 2009;5:121–41. CO M M EN TA RY 16_EBMH1012.indd 20 1/20/2010 7:24:36 PM