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.

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.

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.

Anxiety disorders, physical illnesses, and health care utilization in older male veterans with Parkinson disease and comorbid depression.

This study examined the rates of anxiety and depressive disorders, physical illnesses, and health service use in male patients 55 years or older with a diagnosis of Parkinson disease who were seen at least twice at the 10 medical centers in the Veterans Affairs Healthcare Network of the South Central region of the United States. Of the 273 male patients diagnosed between October 1, 1997, and September 30, 2009, 62 (22.7%) had a depressive disorder. The overall prevalence of anxiety disorders was 12.8%; patients with comorbid depression had a 5-fold greater prevalence of anxiety disorders than those without depression (35.5% vs 6.2%, P<.0001). Patients with comorbid depression also had increased prevalence of all physical illnesses examined and more outpatient clinic and mental health visits. Patients with Parkinson disease and comorbid depression are more likely to have anxiety disorders and several physical illnesses, to be using antipsychotic and dementia medicines, and to have increased health service utilization than those without depression.

Enabling lay providers to conduct CBT for older adults: key steps for expanding treatment capacity.

The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.

Cognitive-behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants.

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

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.

Characteristics of generalized anxiety disorder in patients with dementia.

BACKGROUND: Overlap of cognitive and anxiety symptoms (i.e., difficulty concentrating, fatigue, restlessness) contributes to inconsistent, complicated assessment of generalized anxiety disorder (GAD) in persons with dementia. METHODS: Anxious dementia patients completed a psychiatric interview, the Penn State Worry Questionnaire-Abbreviated, and the Rating for Anxiety in Dementia scale. Analyses to describe the 43 patients with and without GAD included the Wilcoxon Mann-Whitney two-sample test, Fisher's exact test. Predictors of GAD diagnosis were identified using logistic regression. RESULTS: Those with GAD were more likely to be male, have less severe dementia and endorsed more worry, and anxiety compared to patients without GAD. Gender, muscle tension and fatigue differentiated those with GAD from those without GAD. CONCLUSIONS: Although this study is limited by a small sample, it describes clinical characteristics of GAD in dementia, highlighting the importance of muscle tension and fatigue in recognizing GAD in persons with dementia.

Obsessions and worry beliefs in an inpatient OCD population.

Dysfunctional beliefs in obsessive-compulsive disorder (OCD) and worry are thought to contribute to vulnerability and maintenance of pathological anxiety. In this study, five belief domains concerning responsibility/threat estimation, perfectionism, intolerance of uncertainty, importance/control of thoughts and thought-action fusion were examined to see whether they differentially predicted worry and obsession severity in patients with severe OCD. Correlational analysis revealed that perfectionism and intolerance of uncertainty were associated with worry, whereas beliefs in the importance and control of thoughts and thought-action fusion were associated with obsession severity when obsession severity and worry, respectively, were controlled. In regression analyses, thought-action fusion and intolerance of uncertainty predicted OCD severity. The relation between dysfunctional beliefs and specific subtypes of OCD symptoms was also examined. Specific relationships were identified, including perfectionism with ordering, obsessions with control/importance of thoughts and checking and washing with threat estimation.