Improving secondary stroke self-care among underserved ethnic minority individuals: a randomized clinical trial of a pilot intervention.

The overall purpose of this study was to pilot a multibehavioral, brief, stroke self-care treatment adapted for implementation with underserved racial/ethnic minority groups and to test the moderating effects of anxiety and depression on engagement in secondary stroke-prevention behaviors. Fifty-two participants were randomized to the secondary stroke prevention (STOP) (N = 27) or usual care (N = 25) group. The STOP program consisted of 3 culturally tailored information sessions and goal-setting activities that were delivered in person by a research assistant. Participants were assessed at baseline and 4-week follow-up for stroke knowledge, exercise, fruit and vegetable consumption, tobacco and alcohol use, and medication adherence (primary outcomes) and anxiety and depression (moderator variables). Between-groups analysis of covariance and logistic multiple regressions revealed significant between-group differences for stroke knowledge, tobacco use and moderating effects between tobacco and anxiety, and improved alcohol use. The STOP program decreased secondary stroke risk factors among underserved racial/ethnic minorities and should be tested in large-scale trials.

The peaceful mind program: a pilot test of a cognitive-behavioral therapy-based intervention for anxious patients with dementia.

OBJECTIVES: To assess feasibility and to conduct a preliminary evaluation of outcomes following Peaceful Mind, a cognitive-behavioral therapy-based intervention for anxiety in dementia, relative to usual care. DESIGN: Pilot randomized controlled trial including assessments at baseline and 3 and 6 months. SETTING: Houston, TX. PARTICIPANTS: Thirty-two outpatients diagnosed with mild (47%) or moderate (53%) dementia receiving care through outpatient clinics at the Veterans Affairs medical center, Baylor College of Medicine, Harris County Hospital District, and community day centers for dementia, and their collaterals, who spent at least 8 hours a week with them. INTERVENTION: Peaceful Mind included up to 12 weekly in-home sessions (mean: 8.7, SD: 2.27) during the initial 3 months and up to eight brief telephone sessions (mean: 5.4, SD: 3.17) during months 3-6, involving self-monitoring for anxiety, deep breathing, and optional skills (coping self-statements, behavioral activation, and sleep management). Patients learned skills, and collaterals served as coaches. In usual care, patients received diagnostic feedback, and providers were informed of inclusion status. MEASUREMENTS: Neuropsychiatric Inventory-Anxiety subscale, Rating Anxiety in Dementia scale, Penn State Worry Questionnaire-Abbreviated, Geriatric Anxiety Inventory, Geriatric Depression Scale, Quality of Life in Alzheimer disease, Patient Health Questionnaire, and Client Satisfaction Questionnaire. RESULTS: Feasibility was demonstrated with regard to recruitment, attrition, and treatment characteristics. At 3 months, clinicians rated patients receiving Peaceful Mind as less anxious, and patients rated themselves as having higher quality of life; collaterals reported less distress related to loved ones' anxiety. Although significant positive effects were not noted in other outcomes or at 6-month follow-up, the pilot nature of the trial prohibits conclusions about efficacy. CONCLUSIONS: Results support that Peaceful Mind is ready for future comparative clinical trials.

Treating late-life generalized anxiety disorder in primary care: an effectiveness pilot study.

To increase the sustainability of cognitive behavior therapy (CBT) in primary care for late-life anxiety, we incorporated nonexpert counselors, options for telephone meetings, and integration with primary care clinicians. This open trial examines the feasibility, satisfaction, and clinical outcomes of CBT delivered by experienced and nonexperienced counselors for older adults with generalized anxiety disorder (GAD). Clinical outcomes assessed worry (Penn State Worry Questionnaire), GAD (Generalized Anxiety Disorder Severity Scale), and anxiety (Beck Anxiety Inventory and Structured Interview Guide for Hamilton Anxiety Scale). After 3 months of treatment, Cohen's d effect sizes for worry and anxiety ranged from 0.48 to 0.78. Patients treated by experienced and nonexperienced counselors had similar reductions in worry and anxiety, although treatment outcomes were more improved on the Beck Anxiety Inventory for experienced therapists. Preliminary results suggest that adapted CBT can effectively reduce worry. The piloted modifications can provide acceptable and feasible evidence-based care.

Hemoglobin A1c improvements and better diabetes-specific quality of life among participants completing diabetes self-management programs: a nested cohort study.

BACKGROUND: Numerous primary care innovations emphasize patient-centered processes of care. Within the context of these innovations, greater understanding is needed of the relationship between improvements in clinical endpoints and patient-centered outcomes. To address this gap, we evaluated the association between glycosylated hemoglobin (HbA1c) and diabetes-specific quality of life among patients completing diabetes self-management programs. METHODS: We conducted a retrospective cohort study nested within a randomized comparative effectiveness trial of diabetes self-management interventions in 75 diabetic patients. Multiple linear regression models were developed to examine the relationship between change in HbA1c from baseline to one-year follow-up and Diabetes-39 (a diabetes-specific quality of life measure) at one year. RESULTS: HbA1c levels improved for the overall cohort from baseline to one-year follow-up (t (74) = 3.09, p = .0029). One-year follow up HbA1c was correlated with worse overall quality of life (r = 0.33, p = 0.004). Improvements in HbA1c from baseline to one-year follow-up were associated with greater D-39 diabetes control (ß = 0.23, p = .04) and D-39 sexual functioning (ß = 0.25, p = .03) quality of life subscales. CONCLUSIONS: Improvements in HbA1c among participants completing a diabetes self-management program were associated with better diabetes-specific quality of life. Innovations in primary care that engage patients in self-management and improve clinical biomarkers, such as HbA1c, may also be associated with better quality of life, a key outcome from the patient perspective.

Psychometric properties of a structured interview guide for the rating for anxiety in dementia.

OBJECTIVES: The Rating Anxiety in Dementia (RAID; Shankar, K.K., Walker, M., Frost, D., & Orrell, M.W. (1999). The development of a valid and reliable scale for rating anxiety in dementia (RAID). Aging and Mental Health, 3, 39-49.) is a clinical rating scale developed to evaluate anxiety in persons with dementia. This report explores the psychometric properties and clinical utility of a new structured interview format of the RAID (RAID-SI), developed to standardize administration and scoring based on information obtained from the patient, an identified collateral, and rater observation. METHOD: The RAID-SI was administered by trained master's level raters. Participants were 32 persons with dementia who qualified for an anxiety treatment outcome study. Self-report anxiety, depression, and quality of life measures were administered to both the person with dementia and a collateral. RESULTS: The RAID-SI exhibited adequate internal consistency reliability and inter-rater reliability. There was also some evidence of construct validity as indicated by significant correlations with other measures of patient-reported and collateral-reported anxiety, and non-significant correlations with collateral reports of patient depression and quality of life. Further, RAID-SI scores were significantly higher in persons with an anxiety diagnosis compared to those without an anxiety diagnosis. CONCLUSION: There is evidence that the RAID-SI exhibits good reliability and validity in older adults with dementia. The advantage of the structured interview format is increased standardization in administration and scoring, which may be particularly important when RAID raters are not experienced clinicians.

Treatment response for late-life generalized anxiety disorder: moving beyond symptom-based measures.

Response to treatment of late-life generalized anxiety disorder has been defined by a variety of methods, all based on statistically significant reductions in symptom severity. However, it is unknown whether these improvements in symptom severity are associated with meaningful differences in everyday functioning. The current study used four methods to define response to treatment for 115 primary-care patients 60 years and older, with a principal or coprincipal diagnosis of generalized anxiety disorder. The methods examined included percentage of improvement, reliable change index, and minimal clinically significant differences. Agreement among classification methods and their associations with general and mental health-related quality of life were assessed. Results indicated moderate agreement among symptom-based classification methods and significant associations with measures of quality of life.

Older adults' preferences for religion/spirituality in treatment for anxiety and depression.

OBJECTIVES: To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors. METHOD: Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearman's rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling. RESULTS: Most participants (77-83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important. CONCLUSION: For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.

Relationship-contingent self-esteem and the ups and downs of romantic relationships.

Relationship-contingent self-esteem (RCSE) emerges from perspectives on authenticity, need fulfillment, and relationship functioning and is an unhealthy form of self-esteem that depends on one's relationship. Four studies provided evidence of convergent, discriminant, incremental, and predictive validity for RCSE. Study 1 tested associations between RCSE and several conceptually related and unrelated constructs in multiple samples. In Study 2, the authors employed an event-contingent diary procedure to examine reports of self-esteem as a function of everyday relationship events. The association between event valence and changes in self-esteem became stronger with RCSE, and this interaction remained controlling for several parallel interactions by other constructs. Study 3 employed an interval-contingent diary procedure and found support for a mediation model in which the moderating role of RCSE largely occurred through momentary emotions, which in turn predicted momentary self-esteem. Study 4 sampled couples and found that partners who were both higher in RCSE felt more committed but not more satisfied or close.

Are VA primary care providers aware of HIV testing recommendations for Veterans? Findings at an urban VA primary care clinic.

Given the prevalence of human immunodeficiency virus (HIV) in veterans and that nearly 90% of veterans have not been HIV tested, the Veterans Affairs (VA) has recommended routine HIV testing of all veterans.The objective of this study carried out at an urban VA primary care clinic was to assess provider knowledge of recent U.S. Centers for Disease Control and Prevention (CDC) and VA HIV testing recommendations and policies. Fifty-six primary care providers completed a survey. Nearly 40% of providers were unaware of the CDC recommendation to test all persons ages 13 to 64 in health care settings or the VA policy to test veterans of all ages. Over 75% of providers were unaware of the latest requirements for pre- and posttest counseling, and many were unaware of the latest consent process requirements. Educating VA providers about recent HIV testing recommendations and policies may improve the low HIV testing prevalence in the VA.

The association between self-concealment from one's partner and relationship well-being.

In two studies the authors examined whether self-concealment from one's partner is associated with lower relationship well-being. In Study 1, participants who were in a romantic relationship (N = 165) completed an online survey. Self-concealment from one's partner was associated with lower relationship satisfaction and commitment. Furthermore, results were consistent with this relationship being mediated by autonomy and relatedness needs. In Study 2, couples (N = 50) completed daily records for 14 consecutive days. Multilevel analyses indicated that daily self-concealment from one's partner was associated with daily relationship satisfaction, commitment, and conflict. Lagged analyses also showed that self-concealment from one's partner predicted lower relationship well-being on the following day. Moreover, results supported that thwarted basic needs mediated the association between daily self-concealment and relationship well-being. Finally, actor-partner interdependence model over time analyses indicated that, apart from one's own self-concealment, one's partner's self-concealment was associated negatively with one's own relationship well-being.

Factor structure and convergent validity of the inventory of interpersonal problems in an inpatient setting.

The Inventory of Interpersonal Problems (IIP32) is a self-report measure designed to be used in clinical settings to assess interpersonal difficulties. However, it has been exclusively used in either outpatient or non-clinical settings, and psychometric data concerning its use in inpatients are limited. The current study examined the factor structure and construct validity of the IIP-32, and ways to optimally use this measure with inpatients at a private hospital providing intensive treatment. The original eight-factor structure was a poor fit to the data, whereas a five-factor structure provided a somewhat better fit. Although the five factors (Nonassertive, Detached, Intrusive, Self-Sacrificing, and Socially Inhibited) demonstrated adequate internal consistency, reliability, and limited convergent validity, the IIP is ultimately useful insofar as it engages patients in collaborative self-awareness during intensive psychotherapeutically oriented treatment.

Cognitive behavioral therapy for depression and anxiety in Parkinson's disease: a clinical review.

Parkinson's disease (PD) is the second most common neurodegenerative disorder. It is generally defined by its progressive motor features; but increased attention is being paid to its non-motor neuropsychiatric symptoms, which profoundly impact quality of life for patients and caregivers. Anxiety and depression are particularly problematic and are the strongest predictors of quality of life in PD. Recent research has focused on non-pharmacological approaches to treating depression and anxiety in patients with PD. Cognitive-behavioral therapy (CBT) is a potentially efficacious non-pharmacological treatment for mood and anxiety symptoms associated with PD. Accordingly, this review examines empirical studies of CBT-based treatments for depression and anxiety symptoms in PD. Medical Subject Headings were used in searches of PsychInfo and PubMed of English-language articles published in peer-reviewed journals, resulting in the identification of 10 articles. Four additional articles were identified from the references of these articles and upon the suggestions of experts, for 15 articles in all. Results of individual studies varied significantly; however, the randomized controlled trials showed encouraging results and support the need for further investigation of the utility of CBT for depressed and anxious patients with PD. CBT is potentially a useful treatment for patients with PD and comorbid depression and/or anxiety, but more systematic research will be necessary to measure its effects.

The Pittsburgh Sleep Quality Index in older primary care patients with generalized anxiety disorder: psychometrics and outcomes following cognitive behavioral therapy.

The Pittsburgh Sleep Quality Index (PSQI) is a widely used, comprehensive self-report measure of sleep quality and impairment, which has demonstrated good psychometric properties within various populations, including older adults. However, the psychometric properties of the PSQI and its component scores have not been evaluated for older adults with generalized anxiety disorder (GAD). Additionally, changes in PSQI global or component scores have not been reported following cognitive-behavioral treatment (CBT) of late-life GAD. This study examined (1) the psychometric properties of the PSQI within a sample of 216 elderly primary care patients age 60 or older with GAD who were referred for treatment of worry and/or anxiety; as well as (2) response to CBT, relative to usual care, for 134 patients with principal or coprincipal GAD. The PSQI demonstrated good internal consistency reliability and adequate evidence of construct validity. Those receiving CBT experienced greater reductions in PSQI global scores at post-treatment, relative to those receiving usual care. Further, PSQI global and component scores pertaining to sleep quality and difficulties falling asleep (i.e., sleep latency and sleep disturbances) demonstrated response to treatment over a 12-month follow-up period. Overall, results highlight the usefulness of the PSQI global and component scores for use in older adults with GAD.