An Examination of Positive and Negative Dementia Caregiving Experiences.

OBJECTIVES: We examined associations among three measures of caregiver experiences (i.e., positive aspects of caring [PAC], caregiver burden, and mutuality) in 228 dyads involving persons with dementia (PWD) and their informal caregivers. The associations between predisposing, enabling, and need factors and each of these three measures of caregiver experiences were also examined. METHODS: We used baseline data from a randomized controlled trial of a psychosocial intervention aimed at preventing aggression in PWD. Associations among PAC, caregiver burden, and mutuality were examined. The Behavioral Model of Health Services Utilization guided the selection of predisposing, enabling, and need components. RESULTS: Enabling characteristics (e.g., race/ethnicity, caregiver education and employment and PWD education) and most predisposing characteristics (e.g., caregiver age, PWD age, relationship type) were not associated with any caregiving experience measures. Need characteristics (e.g., levels of memory and functional impairment, behavioral problems, depression, pleasant events) were associated with the caregiving experience. CONCLUSIONS: Bivariate correlations between PAC, caregiver burden, and mutuality were between -0.20 and -0.58. Predisposing, enabling, and need factors were differentially associated with outcomes, with need characteristics being most frequently associated with various aspects of caregiving. CLINICAL IMPLICATIONS: Assessment of both positive and negative aspects of caregiving is important. Particular attention to depression and interventions that improve depressive symptoms may increase PAC and mutuality and reduce caregiver burden.

Aggression Prevention Training for Individuals With Dementia and Their Caregivers: A Randomized Controlled Trial.

OBJECTIVE: International appeals call for interventions to prevent aggression and other behavioral problems in individuals with dementia (IWD). Aggression Prevention Training (APT), based on intervening in three contributors to development of aggression (IWD pain, IWD depression, and caregiver-IWD relationship problems) aims to reduce incidence of aggression in IWD over 1 year. DESIGN: Randomized, controlled trial. SETTING: Three clinics that assess, diagnose, and treat dementia. PARTICIPANTS: Two hundred twenty-eight caregiver-IWD dyads who screened positive for IWD pain, IWD depression, or caregiver-IWD relationship problems randomized to APT or Enhanced Usual Primary Care (EU-PC). INTERVENTION: APT, a skills-based intervention delivered over 3 months to address pain/depression/caregiver-IWD relationship issues. EU-PC included printed material on dementia and community resources; and eight brief, weekly support calls. MEASUREMENTS: The primary outcome was incidence of aggression over 1 year, determined by the Cohen Mansfield Agitation Inventory-Aggression Subscale. Secondary outcomes included pain, depression, caregiver-IWD relationship, caregiver burden, positive caregiving, behavior problems, and anxiety. RESULTS: Aggression incidence and secondary outcomes did not differ between groups. However, in those screening positive for IWD depression or caregiver-IWD relationship problems, those receiving EU-PC had significant increases in depression and significant decreases in quality of the caregiver-IWD relationship, whereas those receiving APT showed no changes in these outcomes over time. CONCLUSION: The cost to patients, family, and society of behavioral problems in IWD, along with modest efficacy of most pharmacologic and nonpharmacologic interventions, calls for more study of novel preventive approaches.

Identifying psychiatric diagnostic errors with the Safer Dx Instrument.

OBJECTIVE: Diagnostic errors in psychiatry are understudied partly because they are difficult to measure. The current study aimed to adapt and test the Safer Dx Instrument, a structured tool to review electronic health records (EHR) for errors in medical diagnoses, to evaluate errors in anxiety diagnoses to improve measurement of psychiatric diagnostic errors. DESIGN: The iterative adaptation process included a review of the revised Safer Dx-Mental Health Instrument by mental health providers to ensure content and face validity and review by a psychometrician to ensure methodologic validity and pilot testing of the revised instrument. SETTINGS: None. PARTICIPANTS: Pilot testing was conducted on 128 records of patients diagnosed with anxiety in integrated primary care mental health clinics. Cases with anxiety diagnoses documented in progress notes but not included as a diagnosis for the encounter (n = 25) were excluded. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULTS: Of 103 records meeting the inclusion criteria, 62 likely involved a diagnostic error (42 from use of unspecified anxiety diagnosis when a specific anxiety diagnosis was warranted; 20 from use of unspecified anxiety diagnosis when anxiety symptoms were either undocumented or documented but not severe enough to warrant diagnosis). Reviewer agreement on presence/absence of errors was 88% (κ = 0.71). CONCLUSION: The revised Safer Dx-Mental Health Instrument has a high reliability for detecting anxiety-related diagnostic errors and deserves testing in additional psychiatric populations and clinical settings.

Psychometric properties of worry and anxiety measures in a sample of african american and caucasian older adults.

Objective: The aim of our study was to examine the psychometric properties of commonly used anxiety and worry assessment measures in a community-based, low-income sample of African American and Caucasian older adults.Method: African American and Caucasian participants from three community-based clinical trials testing treatments for late-life worry/anxiety were pooled to examine the factor structure, internal consistency reliability, and convergent, discriminant, and predictive validity of the Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Generalized Anxiety Disorder-7 (GAD-7) and Geriatric Anxiety Inventory-short form (GAI-SF).Results: All three measures demonstrated an adequate fit to a one-factor structure. Internal consistency reliability was adequate for the PSWQ-A and GAD-7 in the total sample and racial subgroups but was acceptable for the GAI-SF only in the African American subgroup. The PSWQ-A and GAD-7 demonstrated good convergent, discriminant, and predictive validity. The GAI-SF has adequate convergent and divergent validity in the African American subgroup.Conclusion: Our study offers preliminary evidence for use of the PSWQ-A and GAD-7 for assessment of anxiety in a sample of low-income, predominantly African American participants. These measures may facilitate identification of anxiety symptoms, which are often overlooked in this population. More research is needed to examine the accuracy of these measures in other racial/ethnic groups.

The impact of social support and morally injurious events on PTSD symptoms in Veterans.

Potentially morally injurious events (PMIEs), including committing transgressions (Transgressions-Self) and perceiving betrayals, have been positively associated with posttraumatic stress disorder (PTSD). A proposed mechanism for the association between PMIEs and PTSD symptoms is social disconnection. However, research on PMIEs and social disconnection is limited. Secondary data analysis from a larger study examined the moderating role of different sources of perceived social support (Family, Friends, and Significant Other) on the relation between PMIEs (Transgressions-Self and Betrayal) and PTSD. The interaction of Transgressions-Self and perceived social support subscales did not predict PTSD symptoms. However, the interaction of Betrayals and perceived social support (Significant Other and Family) predicted PTSD symptoms. Results suggest that perceived social support provides a protective effect for low to mean levels of perceived betrayals; however, for Veterans reporting high levels of betrayal, perceived social support did not attenuate PTSD symptom severity. Additional research on perceived betrayals and the association with PTSD is needed, especially for Veterans who experience high levels of perceived betrayals.

Positive and negative religious coping as predictors of distress among minority older adults.

OBJECTIVES: The study replicated and extended previous findings by investigating relationships between positive and negative religious coping and psychological distress in minority older adults. METHODS: Older adults were evaluated during screening and baseline procedures of a psychotherapy clinical trial for late-life worry and anxiety. Participants were age 50 years or older and recruited from low-income and predominantly minority neighborhoods. Participants screening positive for worry (PSWQ-A ≥ 23) with no significant cognitive impairment (Six-Item Screener for cognitive impairment ≤2) completed a diagnostic interview and baseline assessments. Positive and negative religious coping were assessed with the positive and negative coping subscales of the Brief Religious Coping scale. Psychological distress was assessed with measures of depression, anxiety, and worry. A set of multiple linear regression models were used to evaluate the relationship between religious coping and each measure of psychological distress. RESULTS: Negative religious coping was associated with greater anxiety, worry, and depression. Positive and negative religious coping interacted such that positive religious coping buffered the effects of negative religious coping on anxiety and depression. Significant main effects and interactions remained after controlling for age, gender, race, years of education, and study. CONCLUSIONS: The findings of this study are consistent with prior work showing that negative religious coping is associated with greater psychological distress. This study replicates previous findings that positive religious coping may buffer the harmful effects of negative religious coping and extends understandings of the specific psychological impacts that positive and negative religious coping may have on older, minority adults.

Community-Based Outreach and Treatment for Underserved Older Adults With Clinically Significant Worry: A Randomized Controlled Trial.

OBJECTIVE: To determine whether Calmer Life (CL) improved worry, generalized anxiety disorder-related (GAD-related) symptoms, anxiety, depression, sleep, trauma-related symptoms, functional status, and quality of life better than Enhanced Community Care with Resource Counseling (ECC-RC) at 6 months and 9 months. METHODS: A randomized, controlled, comparative-effectiveness study involving underserved, low-income, mostly minority neighborhoods in Houston, Texas, looked at individuals ≥50 with significant worry and interest in psychosocial treatment. Interventions were CL, cognitive behavioral therapy with resource counseling, facilitation of communication with primary care providers about worry/anxiety, integration of religion/spirituality, person-centered skill content and delivery and nontraditional community providers, ECC-RC, and enhanced standard community-based information/ resource counseling addressing basic unmet and mental health needs. Primary outcomes were worry and GAD-related symptom severity. Secondary outcomes were anxiety, depression, sleep difficulties, trauma-related symptoms, functional status, quality of life, service use and satisfaction. RESULTS: Similar, moderate improvements followed CL and ECC-RC on worry, GAD-related symptoms, anxiety, depression, sleep, trauma-related symptoms, and mental health quality of life at 6 and 9 months, but with symptoms at both times and higher satisfaction with CL at both. Fewer ECC-RC participants reported a hospital admission in the prior 3 months than those in CL at 6 and 9 months; at 9 months, fewer reported a visit with a provider in the previous 3 months. CONCLUSION: Both interventions showed similar improvements at 6 and 9 months, but symptoms remained that might require care. Either intervention or a combination may be useful for low-income older adults with identified worry/anxiety.

Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A Pragmatic Randomized Clinical Trial.

BACKGROUND: Few studies have examined the practical effectiveness and implementation potential of brief psychotherapies that integrate mental and physical health. OBJECTIVE: To determine whether an integrated brief cognitive behavioral therapy (bCBT), delivered by mental health providers in primary care, would improve depression, anxiety and quality of life for medically ill veterans. DESIGN: Pragmatic patient-randomized trial comparing bCBT to enhanced usual care (EUC). PARTICIPANTS: A total of 302 participants with heart failure and/or chronic obstructive pulmonary disease (COPD) with elevated symptoms of depression and/or anxiety were enrolled from two Veterans Health Administration primary care clinics. INTERVENTION: bCBT was delivered to 180 participants by staff mental health providers (n = 19). bCBT addressed physical and emotional health using a modular, skill-based approach. bCBT was delivered in person or by telephone over 4 months. Participants randomized to EUC (n = 122) received a mental health assessment documented in their medical record. MAIN MEASURES: Primary outcomes included depression (Patient Health Questionnaire) and anxiety (Beck Anxiety Inventory). Secondary outcomes included health-related quality of life. Assessments occurred at baseline, posttreatment (4 months), and 8- and 12-month follow-up. KEY RESULTS: Participants received, on average, 3.9 bCBT sessions with 63.3% completing treatment (4+ sessions). bCBT improved symptoms of depression (p = 0.004; effect size, d = 0.33) and anxiety (p < 0.001; d = 0.37) relative to EUC at posttreatment, with effects maintained at 8 and 12 months. Health-related quality of life improved posttreatment for bCBT participants with COPD but not for heart failure. Health-related quality of life outcomes were not maintained at 12 months. CONCLUSIONS: Integrated bCBT is acceptable to participants and providers, appears feasible for delivery in primary care settings and is effective for medically ill veterans with depression and anxiety. Improvements for both depression and anxiety were modest but persistent, and the impact on physical health outcomes was limited to shorter-term effects and COPD participants. Clinical trials.Gov identifier: NCT01149772.

Teaching Caregivers of Persons with Dementia to Address Pain.

OBJECTIVES: To compare the efficacy of Preventing Aggression in Veterans with Dementia (PAVeD) with that of usual care in decreasing incidence of aggression (primary outcome) and pain and improving depression, pleasant events, caregiver burden, and patient-caregiver relationship quality (secondary outcomes). DESIGN: Randomized controlled trial with assessments at baseline and 3, 6, 9, and 12 months SETTING: Houston, TX. PARTICIPANTS: A total of 203 community-dwelling veterans with pain and dementia and their caregivers. INTERVENTION: PAVeD, 6 to 8 weekly sessions of 45-minute home visits with masters-level clinicians providing instruction to caregivers on recognizing pain, enhancing communication, and making daily activities pleasant and enjoyable, and at least two elective sessions. MEASUREMENTS: Cohen-Mansfield Agitation Inventory (primary outcome), Philadelphia Geriatric Pain Intensity Scale, Geriatric Depression Scale, Pleasant Events Schedule-AD, Burden Interview, Mutuality Scale (secondary outcomes), Client Satisfaction Questionnaire. RESULTS: There were no significant differences in aggression incidence between intervention and control groups, although the PAVeD group had significantly better mutuality than controls. CONCLUSIONS: PAVeD may need to address a broader range and more in-depth coverage of aggression risk factors with person-centered tailoring to target certain types of distress. Interventions to prevent aggression may also need to address medical providers in addition to caregivers.

Sedative-Hypnotic Use Among Older Adults Participating in Anxiety Research.

Older adults are prescribed sedative-hypnotic medications at higher rates than younger adults. These are not recommended for older adults due to risk of sedation, cognitive impairment, and falls. Severe generalized anxiety disorder (GAD) is a possibly appropriate use of these medications in older people, but little is available on use of sedative-hypnotic medications among older adults with GAD. This study examined the frequency and predictors of sedative-hypnotic medication use among older adults screening positive for anxiety. 25.88% ( n = 125) of participants reported taking sedative-hypnotics over the past 3 months; 16.36% ( n = 79) reported taking benzodiazepines, and 12.22% ( n = 59) reported taking hypnotic sleep medications. Depressive symptoms were more strongly associated with sedative-hypnotic use than insomnia or worry. Major depressive disorder and posttraumatic stress disorder, but not GAD, predicted sedative-hypnotic use. Other medications and treatments are more appropriate and efficacious for depression, anxiety, and insomnia in this population.

Vida Calma: CBT for Anxiety with a Spanish-Speaking Hispanic Adult.

BACKGROUND: Hispanic adults aged 55 years and older are the fastest growing ethnic minority group in the United States facing significant mental health disparities. Barriers in accessing care have been attributed to low income, poor education, language barriers, and stigma. Cultural adaptations to existing evidence-based treatments have been encouraged to improve access. However, little is known about mental health treatments translated from English to Spanish targeting anxiety among this Hispanic age group. Objctive: This case study offers an example of how an established, manualized, cognitive-behavioral treatment for adults 55 years and older with generalized anxiety disorder (known as "Calmer Life") was translated to Spanish ("Vida Calma") and delivered to a monolingual, Hispanic 55-year-old woman. RESULTS: Pre- and post-treatment measures showed improvements in symptoms of anxiety, depression, and life satisfaction. CONCLUSION: Findings suggest Vida Calma is a feasible treatment to use with a 55-year-old Spanish-speaking adult woman. CLINICAL IMPLICATIONS: Vida Calma, a Spanish language version of Calmer Life, was acceptable and feasible to deliver with a 55-year-old participant with GAD. Treatment outcomes demonstrate that Vida Calma improved the participant's anxiety, depression, and life satisfaction.

Telephone-Delivered Cognitive-Behavioral Therapy for Older, Rural Veterans with Depression and Anxiety in Home-Based Primary Care.

OBJECTIVES: Rural, homebound older adults are at increased risk for anxiety and depression and have limited access to mental health services. These individuals face many barriers to receiving evidence-based mental health treatment and would benefit from interventions that increase access to and efficiency of care. The aim of this study was to evaluate use of a telephone-delivered, modular, cognitive behavioral therapy (CBT) intervention for both late-life depression and anxiety delivered to rural, homebound Veterans. METHODS: Three cases are presented to illustrate the flexible adaptation of the intervention for use among older Veterans enrolled in home-based primary care, with varying symptom presentations and functional limitations. The Veterans received 7 to 9 sessions of the CBT intervention, with ordering of skill modules based on symptom presentation and determined collaboratively between patient and therapist. RESULTS: The three Veterans showed improvement in depression and/or anxiety symptoms following treatment and provided positive feedback regarding their experiences in this program. CONCLUSIONS: These results suggest that telephone-delivered CBT is acceptable to older adults and can be tailored to individual patient needs. CLINICAL IMPLICATIONS: Clinicians should consider telephone-delivered CBT as an alternate mode of therapy to increase access to mental health care for rural, homebound individuals with depression and anxiety.

Predictors of Outcomes for Older Adults Participating in Calmer Life, a Culturally Tailored Intervention for Anxiety.

OBJECTIVE: Determine predictors of reduced worry and anxiety for older adults participating in the pilot phase of Calmer Life, a modular, personalized cognitive-behavioral treatment for worry. METHODS: Underserved adults (N = 54) over age 50 participated. Therapists were either experts (Ph.D. or Master's) or nonexpert providers (case managers, community health workers, and bachelor's level). Participants completed the Penn State Worry Questionnaire-Abbreviated (PSWQ-A) and the Geriatric Anxiety Inventory-Short Form (GAI-SF) before treatment and at 3 months. RESULTS: Demographic and clinical variables were individually entered into separate regression equations, controlling for pretreatment scores, to determine their associations with post-treatment 1) PSWQ-A and 2) GAI-SF scores. Only younger age and African American race were significant (p < .05) univariate predictors of higher post-treatment PSWQ-A scores. African American race was also a significant predictor of higher post-treatment GAI-SF scores. CONCLUSIONS: African American participants had higher post-treatment PSWQ-A and GAI-SF scores than White and Hispanic participants. Younger age was also associated with more severe PSWQ-A post-treatment scores. CLINICAL IMPLICATIONS: Younger participants may experience additional stressors (e.g., caregiving, working) compared with older participants. Smaller decreases in anxiety in African Americans point to the need for continued focus and additional modification of interventions.

Calmer Life: A Culturally Tailored Intervention for Anxiety in Underserved Older Adults.

OBJECTIVES: To evaluate the feasibility of the Calmer Life and Enhanced Community Care interventions delivered by community and expert providers and test their preliminary effectiveness on worry, generalized anxiety disorder (GAD) severity, anxiety, depression, sleep, health-related quality of life, and satisfaction. DESIGN: Small randomized trial, with measurements at baseline and 3 months. SETTING: Underserved, low-income, mostly minority communities in Houston, TX. PARTICIPANTS: Forty underserved adults 50 years and older, with significant worry and principal or coprincipal GAD or anxiety disorder not otherwise specified. INTERVENTION: Combination of person-centered, flexible skills training to reduce worry; resource counseling to target unmet basic needs; and facilitation of communication with primary care providers developed through a community-academic partnership with social service and faith-based organizations. Religion/spirituality may be incorporated. PRIMARY OUTCOMES: worry (Penn State Worry Questionnaire-Abbreviated), GAD severity (GAD-7), anxiety (Geriatric Anxiety Inventory-Short Form). SECONDARY OUTCOMES: depression (Patient Health Questionnaire-8 and Geriatric Depression Scale-Short Form), sleep (Insomnia Severity Index), health-related quality of life (12-item Medical Outcomes Study Short Form), satisfaction (Client Satisfaction Questionnaire and exit interviews). RESULTS: Provider training was valid; mean ratings for community providers were well above average, with none less than adequate. Reach was excellent. Participants receiving the Calmer Life intervention had greater improvement in GAD severity and depression than those receiving Enhanced Community Care. Satisfaction with both treatments was equivalent. CONCLUSIONS: A larger comparative-effectiveness trial needs to examine outcomes following the Calmer Life intervention relative to standard community-based care and to evaluate more fully issues of implementation potential.

A Pilot Study of a Cognitive-Behavioral Treatment for Anxiety and Depression in Patients With Parkinson Disease.

Anxiety and depression often remain unrecognized or inadequately treated in patients with Parkinson disease (PD). Cognitive-behavioral therapy (CBT) is effective, but limited evidence supports its use for anxiety and depression in patients with PD. Sixteen patients with PD having significant anxiety and/or depressive symptoms were assigned to CBT or enhanced usual care. Assessments occurred at baseline, posttreatment, and 1-month follow-up. The CBT intervention included tools for anxiety, depression, and healthy living with PD symptoms. Individual sessions were delivered by telephone or in person, based on patient preference. Treatment was feasible with participants choosing 67% of sessions by telephone and 80% completed treatment. The between-group effect sizes for change scores from baseline to posttreatment and baseline to 1-month follow-up were large (posttreatment: d = 1.49 for depression and 1.44 for anxiety; 1-month follow-up: d = .73 for depression and 1.24 for anxiety), although only the posttreatment effect size for depression was significant. This pilot CBT program is feasible for treatment of anxiety and depression in patients with PD.

Predictors of change in quality of life in older adults with generalized anxiety disorder.

BACKGROUND: Quality of life (QOL) is lower in older adults with generalized anxiety disorder (GAD). QOL generally improves following cognitive-behavioral treatment for GAD. Little is known, however, about additional variables predicting changes in QOL in older adults with GAD. This study examined predictors of change in QOL among older participants in a randomized clinical trial of cognitive behavioral therapy (CBT) for GAD, relative to enhanced usual care (EUC). METHODS: Hierarchical multilevel mixed-model analyses were used to examine inter-individual and intra-individual factors that predicted QOL over time. Predictors were categorized into treatment, personal and clinical characteristics. RESULTS: QOL improved over time, and there was significant variability between participants in change in QOL. Controlling for treatment condition, baseline general self-efficacy, baseline social support, within-person variation in worry and depression and average levels of depression across different time points predicted changes in QOL. CONCLUSIONS: QOL has increasingly been used as an outcome measure in treatment outcome studies to focus on overall improvement in functioning. Attention to improvement in symptoms of depression and worry, along with psychosocial variables, such as social support and self-efficacy, may help improve QOL in older adults with GAD. This study was a secondary study of data from a randomized clinical trial (NCT00308724) registered with clinical.trials.gov.

Identification of Anxiety Symptom Clusters in Patients with COPD: Implications for Assessment and Treatment.

BACKGROUND: Treatment of chronic obstructive pulmonary disease (COPD) is palliative, and quality of life is important. Increased understanding of correlates of quality of life and its domains could help clinicians and researchers better tailor COPD treatments and better support patients engaging in those treatments or other important self-management behaviors. PURPOSE: Anxiety is common in those with COPD; however, overlap of physical and emotional symptoms complicates its assessment. The current study aimed to identify anxiety symptom clusters and to assess the association of these symptom clusters with COPD-related quality of life. METHODS: Participants (N = 162) with COPD completed the Beck Anxiety Inventory (BAI), Chronic Respiratory Disease Questionnaire, Patient Health Questionnaire-9, and Medical Research Council dyspnea scale. Anxiety clusters were identified, using principal component analysis (PCA) on the BAI's 21 items. Anxiety clusters, along with factors previously associated with quality of life, were entered into a multiple regression designed to predict COPD-related quality of life. RESULTS: PCA identified four symptom clusters related to (1) general somatic distress, (2) fear, (3) nervousness, and (4) respiration-related distress. Multiple regression analyses indicated that greater fear was associated with less perceived mastery over COPD (ß = -0.19, t(149) = -2.69, p < 0.01). CONCLUSION: Anxiety symptoms associated with fear appear to be an important indicator of anxiety in patients with COPD. In particular, fear was associated with perceptions of mastery, an important psychological construct linked to disease self-management. Assessing the BAI symptom cluster associated with fear (five items) may be a valuable rapid assessment tool to improve COPD treatment and physical health outcomes.

Santa Clara Strength of Religious Faith Questionnaire: psychometric analysis in older adults.

OBJECTIVES: To assist researchers and clinicians considering using the Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ) with older-adult samples, the current study analyzed the psychometrics of SCSRFQ scores in two older-adult samples. METHOD: Adults of age 55 or older who had formerly participated in studies of cognitive-behavioral therapy for anxiety and/or depression were recruited to complete questionnaires. In Study 1 (N = 66), the authors assessed the relations between the SCSRFQ and other measures of religiousness/spirituality, mental health, and demographic variables, using bivariate correlations and nonparametric tests. In Study 2 (N = 223), the authors also conducted confirmatory and exploratory factor analyses of the SCSRFQ, as well as an item response theory analysis. RESULTS: The SCSRFQ was moderately to highly positively correlated with all measures of religiousness/spirituality. Relations with mental health were weak and differed across samples. Ethnic minorities scored higher than White participants on the SCSRFQ, but only in Study 2. Factor analyses showed that a single-factor model fit the SCSRFQ best. According to item response theory analysis, SCSRFQ items discriminated well between participants with low-to-moderate levels of the construct but provided little information at higher levels. CONCLUSION: Although the SCSRFQ scores had adequate psychometric characteristics, the measure's usefulness may be limited in samples of older adults.

Alcohol use, anxiety, and insomnia in older adults with generalized anxiety disorder.

OBJECTIVES: To examine alcohol consumption among older primary care patients with generalized anxiety disorder (GAD); its relationship to demographic variables, insomnia, worry, and anxiety; and its moderating role on the anxiety-insomnia relationship. We expected alcohol use to be similar to previous reports, correlate with higher anxiety and insomnia, and worsen the anxiety-insomnia relationship. DESIGN: Baseline data from a randomized controlled trial. SETTING: Michael E. DeBakey VA Medical Center and Baylor College of Medicine. PARTICIPANTS: 223 patients, 60 years and older, with GAD. MEASUREMENTS: Frequency of alcohol use, insomnia (Insomnia Severity Index), worry (Penn State Worry Questionnaire - Abbreviated, Generalized Anxiety Disorder Severity Scale), and anxiety (State-Trait Anxiety Inventory - Trait subscale, Structured Interview Guide for the Hamilton Anxiety Rating Scale [SIGH-A]). RESULTS: Most patients endorsed alcohol use, but frequency was low. Presence and frequency were greater than in previous reports of primary care samples. Alcohol use was associated with higher education, female gender, less severe insomnia, and lower worry (Generalized Anxiety Disorder Severity Scale) and anxiety (State-Trait Anxiety Inventory-Trait subscale; SIGH-A). Whites reported more drinks/week than African-Americans. More drinks/week were associated with higher education and lower anxiety (SIGH-A). Weaker relationships between worry/anxiety and insomnia occurred for those drinking. Drink frequency moderated the positive association between the Penn State Worry Questionnaire-Abbreviated and insomnia, which was lower with higher frequency of drinking. CONCLUSIONS: Older adults with GAD use alcohol at an increased rate, but mild to moderate drinkers do not experience sleep difficulties. A modest amount of alcohol may minimize the association between anxiety/worry and insomnia among this group.

Lay providers can deliver effective cognitive behavior therapy for older adults with generalized anxiety disorder: a randomized trial.

BACKGROUND: The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor-level providers (BLP) relative to Ph.D.-level expert providers (PLP), and usual care (UC) in older adults with GAD. METHODS: Participants were 223 older adults (mean age, 66.9 years) with GAD recruited from primary care clinics at two sites and assigned randomly to BLP (n = 76), PLP (n = 74), or UC (n = 73). Assessments occurred at baseline and 6 months. CBT in BLP and PLP included core and elective modules (3 months: skills training; 3 months: skills review) delivered in person and by telephone, according to patient choice. RESULTS: CBT in both BLP and PLP groups significantly improved GAD severity (GAD Severity Scale), anxiety (Spielberger State-Trait Anxiety Inventory; Structured Interview Guide for the Hamilton Anxiety Scale), depression (Patient Health Questionnaire), insomnia (Insomnia Severity Index), and mental health quality of life (Short-Form-12), relative to UC. Response rates defined by 20% reduction from pre- to posttreatment in at least three of four primary outcomes were higher for study completers in BLP and PLP relative to UC (BLP: 38.5%; PLP: 40.0%; UC: 19.1%). CONCLUSION: Lay providers, working under the supervision of licensed providers, can deliver effective CBT.