Longitudinal analysis of the relationship between PTSD symptom clusters, cigarette use, and physical health-related quality of life.

PURPOSE: Posttraumatic stress disorder (PTSD) symptoms, particularly numbing and hyperarousal symptoms, are related to poor physical health-related quality of life (HRQoL). Tobacco dependence is also associated with poor HRQoL, and individuals with PTSD may smoke at higher rates than the general population. Our study aimed to examine the impact of quitting smoking and changes in PTSD symptoms over time on changes in physical HRQoL. METHODS: The study used archival data from enrollees (N = 943) in a smoking cessation clinical trial for veterans with PTSD (VA Cooperative study #519). RESULTS: Two of the physical HRQoL domains were sensitive to changes in PTSD symptoms over time: General Health and Vitality. CONCLUSIONS: Our findings suggest that particular physical HRQoL domains may be subject to improvement if PTSD symptoms decrease over time.

Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: a pilot study.

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resulting in full remission for most patients and (2) some patients maintained response after all treatments were withdrawn.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.

Meta-analysis comparing different behavioral treatments for late-life anxiety.

OBJECTIVE: To evaluate the efficacy of different types of behavioral treatments for geriatric anxiety (cognitive behavior therapy [CBT] alone, CBT with relaxation training [RT], and RT alone). METHOD: The authors compared effect sizes from 19 trials. Analyses were based on uncontrolled outcomes (comparing posttreatment and pretreatment scores) and effects relative to control conditions on both anxiety and depressive symptoms. RESULTS: Treatments for older adults with anxiety symptoms were, on average, more effective than active control conditions. Effect sizes were comparable to those reported elsewhere for CBT for anxiety in the general population or for pharmacotherapy in anxious older adults. CBT (alone or augmented with RT) does not seem to add anything beyond RT alone, although a direct comparison is challenging given differences in control conditions. Effects on depressive symptoms were smaller, with no differences among treatment types. CONCLUSION: Results suggest that behavioral treatments are effective for older adults with anxiety disorders and symptoms. Results must be interpreted with caution given the limitations of the literature, including differing sample characteristics and control conditions across studies.

Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization.

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed.

Relapse following combined treatment discontinuation in a placebo-controlled trial for panic disorder.

A recent double-blind, placebo-controlled trial (Barlow et al., 2000 JAMA. 283:2529-2536) examined separate and synergistic effects of psychological and pharmacological treatments for panic disorder. One finding warranting further investigation involved relatively high relapse rates of participants who received cognitive-behavioral therapy (CBT) + imipramine when compared with those receiving CBT + placebo. In this article, we investigate why CBT was less effective in protecting against relapse for individuals in the active drug condition. We hypothesized that participants correctly deduced treatment assignments and, for those taking imipramine, this was associated with the belief that they were no longer taking active drug after discontinuation, accounting for increased relapse rates. Contrary to hypothesis, there were no group differences in frequencies of guessing drug or placebo, nor were specific beliefs about taking drug or placebo differentially associated with relapse. Other possible reasons for differential relapse rates and treatment implications are discussed.

PTSD and depression as predictors of physical health-related quality of life in tobacco-dependent veterans.

OBJECTIVE: Smoking, depression and PTSD are related to poor physical health outcomes and health-related quality of life (HRQoL). Previous studies examining the effects of quitting smoking on HRQoL have been mixed. This study aimed to examine the effects of PTSD, depressive symptoms and smoking cessation on HRQoL in a sample receiving treatment for PTSD. METHOD: This study utilized archival interview and self-report data from a clinical trial (VA Cooperative Study 519) that recruited tobacco dependent veterans with chronic PTSD (N=943). RESULTS: Analyses were conducted using hierarchical linear modeling and indicated that PTSD and depressive symptoms differentially affected the various physical health status domains. Additionally, quitting smoking was associated with better self-perceived health status and social functioning. CONCLUSION: Our findings further explain the interrelationships of PTSD, depression, and smoking in the prediction of physical HRQoL and advocate the importance of integrated care.

Acceptance and Commitment Therapy for generalized anxiety disorder in older adults: a preliminary report.

Some evidence suggests that acceptance-based approaches such as Acceptance and Commitment Therapy (ACT) may be well-suited to geriatric generalized anxiety disorder (GAD). The primary goal of this project was to determine whether ACT was feasible for this population. Seven older primary-care patients with GAD received 12 individual sessions of ACT; another 9 were treated with cognitive-behavioral therapy. No patients dropped out of ACT, and worry and depression improved. Findings suggest that ACT may warrant a large-scale investigation with anxious older adults.

A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain.

Individuals reporting chronic, nonmalignant pain for at least 6 months (N=114) were randomly assigned to 8 weekly group sessions of acceptance and commitment therapy (ACT) or cognitive-behavioral therapy (CBT) after a 4-6 week pretreatment period and were assessed after treatment and at 6-month follow-up. The protocols were designed for use in a primary care rather than specialty pain clinic setting. All participants remained stable on other pain and mood treatments over the course of the intervention. ACT participants improved on pain interference, depression, and pain-related anxiety; there were no significant differences in improvement between the treatment conditions on any outcome variables. Although there were no differences in attrition between the groups, ACT participants who completed treatment reported significantly higher levels of satisfaction than did CBT participants. These findings suggest that ACT is an effective and acceptable adjunct intervention for patients with chronic pain.

Single Case Evaluation of an Intensive Cognitive Behavioral Treatment for Generalized Social Anxiety Disorder.

The present study investigated the efficacy of an 8-day, 6-session, intensive individual cognitive behavioral therapy protocol for social anxiety disorder using a multiple baseline across subjects design with 1, 2, and 3 months follow-up assessments. Participants were 5 outpatients with generalized social anxiety disorder. The intervention had variable effects on clinician-rated and self-report measures of anxiety and depression. The results question the efficacy of intensive psychotherapy as a general therapeutic strategy for social anxiety disorder. Directions for future research are discussed.