Brain-computer interface relieves chronic chemotherapy-induced peripheral neuropathy: A randomized, double-blind, placebo-controlled trial.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) includes negative sensations that remain a major chronic problem for cancer survivors. Previous research demonstrated that neurofeedback (a closed-loop brain-computer interface [BCI]) was effective at treating CIPN versus a waitlist control (WLC). The authors' a priori hypothesis was that BCI would be superior to placebo feedback (placebo control [PLC]) and to WLC in alleviating CIPN and that changes in brain activity would predict symptom report. METHODS: Randomization to one of three conditions occurred between November 2014 and November 2018. Breast cancer survivors no longer in treatment were assessed at baseline, at the end of 20 treatment sessions, and 1 month later. Auditory and visual rewards were given over 20 sessions based on each patient's ability to modify their own electroencephalographic signals. The Pain Quality Assessment Scale (PQAS) at the end of treatment was the primary outcome, and changes in electroencephalographic signals and 1-month data also were examined. RESULTS: The BCI and PLC groups reported significant symptom reduction. The BCI group demonstrated larger effect size differences from the WLC group than the PLC group (mean change score: BCI vs. WLC, -2.60 vs. 0.38; 95% confidence interval, -3.67, -1.46 [p = .000; effect size, 1.07]; PLC, -2.26; 95% confidence interval, -3.33, -1.19 [p = .001 vs. WLC; effect size, 0.9]). At 1 month, symptoms continued to improve only for the BCI group. Targeted brain changes at the end of treatment predicted symptoms at 1 month for the BCI group only. CONCLUSIONS: BCI is a promising treatment for CIPN and may have a longer lasting effect than placebo (nonspecific BCI), which is an important consideration for long-term symptom relief. Although scientifically interesting, the ability to separate real from placebo treatment may not be as important as understanding the placebo effects differently from effects of the intervention. PLAIN LANGUAGE SUMMARY: Chemotherapy-induced nerve pain (neuropathy) can be disabling for cancer survivors; however, the way symptoms are felt depends on how the brain interprets the signals from nerves in the body. We determined that the perception of neuropathy can be changed by working directly with the brain. Survivors in our trial played 20 sessions of a type of video game that was designed to change the way the brain processed sensation and movement. In this, our second trial, we again observed significant improvement in symptoms that lasted after the treatment was complete.

Efficacy of Superior Hypogastric Plexus Neurolysis for the Treatment of Cancer-Related Pelvic Pain.

OBJECTIVE: Cancer-related abdominal and pelvic pain syndromes can be debilitating and difficult to treat. The objective of this study was to evaluate the efficacy of superior hypogastric plexus blockade or neurolysis (SHPN) for the treatment of cancer-related pelvic pain. DESIGN: Retrospective study. SETTING: MD Anderson Cancer Center, Houston, Texas. METHODS: We enrolled 46 patients with cancer-related pelvic pain who underwent SHPN. A numeric rating scale (NRS) was used for pain intensity, and symptom burden was evaluated using the Edmonton Symptom Assessment System at baseline, visit 1 (within one month), and visit 2 (within one to six months). RESULTS: Forty-six patients who received SHPN showed a significant reduction in pain score from 6.9 to 5.6 at visit 1 (P = 0.01). Thirty of the 46 patients continued to complete visit 2 follow-up, and the NRS score was consistently lower at 4.5 at visit 2 (P < 0.0001), with anxiety and appetite improved significantly. There was no significant change in the morphine equivalent dose at visits 1 and 2. The efficacy of the block was not influenced by patients' age, gender, type of cancer, cancer stage, regimen of chemotherapy and/or radiation therapy, diagnostic block, approach or laterality of procedure, or type or amount of neurolytic agent. Nonsmokers with high baseline pain scores were more likely to have improved treatment outcomes from SHPN at short-term follow-up. Adverse effects with SHPN were mild and well tolerated. CONCLUSIONS: SHPN was an effective and relatively safe procedure for pain associated with pelvic malignancies. There is a need for larger prospective trials.

Compliance with Opioid Therapy: Distinguishing Clinical Characteristics and Demographics Among Patients with Cancer Pain.

Background: Because an increase of patients who misuse opioids has been identified in our cancer clinical setting through urine drug testing (UDT) and the Screener and Opioid Assessment for Patient's with Pain-Short Form (SOAPP-SF), we conducted this retrospective cohort study to identify patient characteristics that are associated with UDT that indicates noncompliance. Methods: Over a two-year period, 167 of 8,727 patients (2.4%) seen in the pain clinic and who underwent UDT were evaluated to determine compliance with prescribed opioid regimens. Descriptive clinical and demographic data were collected, and group differences based on compliance with opioid therapy were evaluated. Results: Fifty-eight percent of the patients were noncompliant with their prescribed opioid therapy. Noncompliant patients were younger than compliant patients, with a median age of 46 vs 49 years (P = 0.0408). Noncompliant patients were more likely to have higher morphine equivalent daily doses; however, the difference was not statistically significant. Patients with a history of alcohol (ETOH) (P = 0.0332), illicit drug use (P = 0.1014), and smoking (P = 0.4184) were more likely noncompliant. Univariate regression analysis showed that a history of ETOH use (P = 0.034), a history of anxiety (P = 0.027), younger age (P = 0.07), and a SOAPP-SF score of 4 or higher (P = 0.05) were associated with an abnormal UDT. Conclusions: History of ETOH use, anxiety, high SOAPP-SF score, and younger age were associated with UDT that indicates noncompliance. Given the very small percentage of UDT testing, it is quite likely that a significant number of patients who did not undergo UDT were also nonadherent with treatment recommendations.

Randomized controlled trial of neurofeedback on chemotherapy-induced peripheral neuropathy: A pilot study.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is a significant problem for cancer patients, and there are limited treatment options for this often debilitating condition. Neuromodulatory interventions could be a novel modality for patients trying to manage CIPN symptoms; however, they are not yet the standard of care. This study examined whether electroencephalogram (EEG) neurofeedback (NFB) could alleviate CIPN symptoms in survivors. METHODS: This was a randomized controlled trial with survivors assigned to an NFB group or a wait-list control (WLC) group. The NFB group underwent 20 sessions of NFB, in which visual and auditory rewards were given for voluntary changes in EEGs. The Brief Pain Inventory (BPI) worst-pain item was the primary outcome. The BPI, the Pain Quality Assessment Scale, and EEGs were collected before NFB and again after treatment. Outcomes were assessed with general linear modeling. RESULTS: Cancer survivors with CIPN (average duration of symptoms, 25.3 mo), who were mostly female and had a mean age of 62.5 years, were recruited between April 2011 and September 2014. One hundred percent of the participants starting the NFB program completed it (30 in the NFB group and 32 in the WLC group). The NFB group demonstrated greater improvement than the controls on the BPI worst-pain item (mean change score, -2.43 [95% confidence interval, -3.58 to -1.28] vs 0.09 [95% confidence interval, -0.72 to -0.90]; P =·.001; effect size, 0.83). CONCLUSIONS: NFB appears to be effective at reducing CIPN symptoms. There was evidence of neurological changes in the cortical location and in the bandwidth targeted by the intervention, and changes in EEG activity were predictive of symptom reduction. Cancer 2017;123:1989-1997. © 2017 American Cancer Society.

Disease burden and pain in obese cancer patients with chemotherapy-induced peripheral neuropathy.

PURPOSE: Chemotherapy-induced peripheral neuropathy (CIPN) and obesity are prevalent in cancer survivors and decrease quality of life; however, the impact of the co-occurrence of these conditions has garnered little attention. This study investigated differences between obese and non-obese cancer survivors with CIPN and predictors of symptom burden and pain. METHODS: Patients with CIPN were administered the MD Anderson Symptom Inventory and a modified version of pain descriptors from the McGill Pain Inventory. Independent t tests assessed group differences between obese and non-obese survivors, and linear regression analyses explored predictors of patient outcomes. RESULTS: Results indicated a significant difference in symptom severity scores for obese (M = 32.89, SD = 25.53) versus non-obese (M = 19.35, SD = 16.08) patients (t(37.86) = -2.49, p = .02). Significant differences were also found for a total number of pain descriptors endorsed by obese (M = 4.21, SD = 3.45) versus non-obese (M = 2.42, SD = 2.69) participants (t(74) = -2.53, p = .01). Obesity was a significant predictor of symptom severity and total pain descriptors endorsed. Other significant predictors included age and months since treatment. CONCLUSIONS: Cancer survivors with CIPN and co-occurring obesity may be more at risk for decreased quality of life through increased symptom severity and pain compared to non-obese survivors. This paper identified risk factors, including obesity, age, and months since treatment, that can be clinically identified for monitoring distress in CIPN patients. Future research should focus on the longitudinal relationship between obesity and CIPN, and robust interventions to address the multifaceted issues faced by cancer survivors.

Psychometric Study of the Pain Drawing.

PURPOSE: The objectives of the study were to (1) assess the extent to which interrater reliability of pain drawing location and dispersion scoring methods are similar across pain disciplines in a sample of patients with cancer treatment-induced neuropathic pain (N = 56) and (2) investigate indicators of validity of the pain drawing in this unique sample. METHODS: Patients undergoing cancer therapy completed the Brief Pain Inventory Body Map, the MD Anderson Symptom Inventory, and the McGill Pain Questionnaire. RESULTS: Intraclass correlation coefficients among medical and psychology professionals ranged from .93-.99. Correlations between pain drawing score and symptom burden severity ranged from .29-.39; correlations between pain drawing score and symptom burden interference ranged from .28-.34. Patients who endorsed pain in the hands and feet more often described their pain as electric, numb, and shooting than patients without pain in the hands and feet. They also endorsed significantly more descriptors of neuropathic pain. CONCLUSIONS: Results suggest a similar understanding among members of a multidisciplinary pain team as to the location and dispersion of pain as represented by patients' pain drawings. In addition, pain drawing scores were related to symptom burden severity and interference and descriptors of neuropathic pain in expected ways.

Examining pain, body image, and depressive symptoms in patients with lymphedema secondary to breast cancer.

OBJECTIVE: Depression and reduced quality of life are often reported in patients with upper-extremity lymphedema secondary to breast cancer treatment. Little is known about how pain and body image influence depression in patients with lymphedema. The current study examined the association of pain intensity and body integrity beliefs with depressive symptoms and the extent to which body image dissatisfaction mediated these associations. METHODS: A cross-sectional sample of patients with lymphedema secondary to breast cancer treatment completed self-report questionnaires of pain, body image, and depressive symptoms. Hierarchical regression analyses and tests of mediation were conducted to examine the associations among the variables of interest. RESULTS: Pain intensity and body integrity beliefs were positively associated with depressive symptoms. Further, body image dissatisfaction mediated the relationship between pain and depressive symptoms, indicating that higher levels of pain led to higher states of body image dissatisfaction, which, in turn, led to greater depressive symptoms. Body image dissatisfaction also mediated the relationship between body integrity beliefs and depressive symptoms, suggesting that greater body integrity beliefs led to higher dissatisfaction with one's body and subsequently to greater depressive symptoms. CONCLUSIONS: Our findings provide preliminary evidence that pain intensity and body image are important factors in understanding depressive symptoms in patients with lymphedema. Clinical implications include screening for pain and body image concerns in this population to identify patients who are in distress. Counseling interventions targeting body image dissatisfaction can also be potentially helpful for patients with lymphedema.

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.

The association of presurgery psychological symptoms with postsurgery pain among cancer patients receiving implantable devices for pain management.

PURPOSE: Psychological symptoms are a common part of the cancer pain experience, yet little is known about how these factors relate to implantable device outcomes in patients with cancer pain. The purpose of this study was to examine how psychological symptoms relate to implantable device outcomes in cancer pain management. METHODS: We retrospectively examined the medical records of 79 cancer patients, collecting information on psychological symptoms and pain, as assessed on the Edmonton Symptom Assessment System. Data were collected prior to and at three points following the implantation of either a spinal cord stimulator or an intrathecal pump. RESULTS: Pain was correlated with both anxiety, r = 0.39 (n = 74, p < 0.01), and depression, r = 0.38, (n = 75, p < 0.01), at the presurgery baseline. Results of linear mixed model (LMM) analysis indicated that neither baseline anxiety nor baseline depression main effects were significantly associated with pain at postimplant assessments, when adjusting for baseline pain, demographics, and clinical factors. However, the group-by-time interaction was significant for anxiety (beta = 0.223, p value = 0.037). The trajectory of pain scores over time differed by baseline anxiety scores, with pain scores increasing over time at a higher rate for those with a high baseline anxiety score, compared to those with low baseline anxiety scores. CONCLUSION: Presurgery psychological symptoms should be considered, along with other medical, psychosocial, and individual characteristics in multidisciplinary treatment planning. Multidisciplinary care which includes aspects of mood management or supportive psychotherapy would likely be beneficial to cancer patients presenting with high psychological symptoms.

Risk stratification of opioid misuse among patients with cancer pain using the SOAPP-SF.

BACKGROUND: Opioids are recognized as an integral part of the armamentarium in the management of cancer pain. There has been a growing awareness of the misuse of prescription opioids among cancer patients. More research is needed to detail risk factors and incidence for opioid misuse among cancer pain patients. METHODS: We reviewed 522 patient charts that were seen in our Pain Center from January 1, 2009 to June 30, 2009 for risk stratification of opioid misuse with demographic and clinical factors utilizing the Screener and Opioid Assessment for Patients with Pain-short form (SOAPP-SF). Group differences based on High (≥4) and Low (<4) SOAPP-SF scores were evaluated at initial visit, follow-up within a month and 6-9 months. RESULTS: One hundred forty-nine of the 522 (29%) patients had a SOAPP-SF score of ≥4. The mean age for patients with high SOAPP-SF score (≥4) was 50 ± 14 vs 56 ± 14 for patients with low SOAPP-SF score (<4) (P < 0.0001). The pain scores were higher for patients with high SOAPP-SF score compared with patients with low SOAPP-SF score at consult (P < 0.0001). Morphine equivalent daily dose (MEDD) was higher for patients with high SOAPP-SF score compared with patients with low SOAPP-SF score at consult (P = 0.0461). Fatigue, feeling of well-being, and poor appetite were higher among the high SOAPP-SF group at initial visit (P < 0.0001, <0.0001, <0.0149, respectively). The high SOAPP-SF score patients also had statistically significant (P < 0.05) higher anxiety and depression scores at all three time points. In the multivariate analysis, patients younger than 55 years have a higher odds of having a "high" SOAPP-SF score than patients 55 years and older {odds ratio (OR) (95% confidence interval [CI]) = 2.76 (1.58, 4.81), P = 0.0003} adjusting for employment status, disease status, treatment status, usual pain score, and morphine equivalency at consult. Patients with higher usual pain score at consult have higher odds of a "high" SOAPP-SF score (OR [95% CI] = 1.34 [1.19, 1.51], P < 0.0001) adjusting for age, employment status, disease status, treatment status, and morphine equivalency at consult. CONCLUSION: Patients classified by the SOAPP-SF in the current study as high risk tended to be younger, endorse more pain, have higher MEDD requirement, and endorse more symptoms of depression and anxiety. These findings are consistent with the literature on risk factors of opioid abuse in chronic pain patients which suggests that certain patient characteristics such as younger age, anxiety, and depression symptomatology are associated with greater risk for opioid misuse. However, a limitation of the current study is that other measures of opioid abuse were not available for validation and comparison with the SOAPP-SF.

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.

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.

Preliminary evaluation of an educational model for promoting positive team attitudes and functioning among pain medicine fellows.

OBJECTIVE: In response to the Accreditation Council for Graduate Medical Education's (ACGME) new pain medicine fellowship requirement, which emphasizes multidisciplinary training strategies aimed at providing improved clinical care for pain patients, we developed a multidisciplinary team training education model for trainees in our institution's Fellowship Program in Pain Medicine. Although the biopsychosocial model guides the delivery of care by multidisciplinary pain teams, there is a gap on how to improve team attitudes and functioning within an already extensive pain medicine curriculum. The current study aimed to fill that gap by developing and incorporating an educational model that focuses on interpersonal relationships among team members and strategies for improving team performance over time. DESIGN, SETTING, PARTICIPANTS, INTERVENTION, AND OUTCOME MEASURES: Here, we provide a brief overview of our institution's pain medicine fellowship training program highlighting how we have included a team training component into lectures, interdisciplinary case conferences, and journal club articles that focus on topics in the ACGME pain medicine curriculum. We present data from a team attitude and functioning assessment battery administered to 11 pain medicine fellows at the outset and end of their fellowship. RESULTS AND CONCLUSIONS: Mean assessment scores increased from the beginning of the fellowship to the end of the fellowship on interdisciplinary pain team knowledge, current team skills, and attitude toward health care teams. The current study demonstrated effective ways for assessing team attitudes and functioning and including this educational component into a 1-year pain medicine curriculum. Based on our results, we will continue to teach and model effective teamwork in an effort to enhance our trainees' attitudes toward working on an interdisciplinary pain team.

The roles of social support and self-efficacy in physical health's impact on depressive and anxiety symptoms in older adults.

Physical illness may precipitate psychological distress among older adults. This study examines whether social support and self-efficacy moderate the associations between physical health and depression and anxiety. Predictions were tested in 222 individuals age 60 or older presenting for help with worry. Physical health was assessed through self-report (subjective) and physical diagnoses (objective). Objective physical health did not have a significant association with depression or anxiety. Worse subjective physical health was associated with increased somatic anxiety, but not with depression or worry. The relationship between subjective physical health and depressive symptoms was moderated by self-efficacy and social support. As predicted, when self-efficacy was low, physical health had its strongest negative association with depressive symptoms such that as physical health improved, depressive symptoms also improved. However, the moderation effect was not as expected for social support; at high levels of social support, worse physical health was associated with increased depressive affect.

The utility of the Generalized Anxiety Disorder Severity Scale (GADSS) with older adults in primary care.

BACKGROUND: The Generalized Anxiety Disorder Severity Scale (GADSS) is an interview rating scale designed specifically for assessing symptom severity of generalized anxiety disorder (GAD), which has demonstrated positive psychometric data in a sample of adult primary care patients with GAD and panic disorder. However, the psychometric properties of the GADSS have not been evaluated for older adults. METHODS: This study evaluated the psychometric properties of the GADSS, administered via telephone, with a sample of older primary care patients (n=223) referred for treatment of worry and/or anxiety. RESULTS: The GADSS demonstrated adequate internal consistency, strong inter-rater reliability, adequate convergent validity, poor diagnostic accuracy, and mixed discriminant validity. CONCLUSIONS: Results provide mixed preliminary support for use of the GADSS with older adults.

A primer of ethical issues involving opioid therapy for chronic nonmalignant pain in a multidisciplinary setting.

OBJECTIVE: This forum presents a clinical vignette of orofacial pain and expounds on ethical issues related to opioid therapy in the context of multidisciplinary treatment. The purpose of this forum is to assist health care providers from different disciplines in identifying ethical issues and conflicts regarding opioid therapy encountered in multidisciplinary clinical pain practices. DESIGN: We use the case vignette and opioid therapy as a backdrop for a discussion of 1) an overview of ethics terminology; 2) a presentation of key ethics principles; 3) our conceptualization of ethical obligations of patients regarding opioid therapy; and 4) the process of developing an appropriate treatment plan within the context of the discussed ethical principles.

Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial.

CONTEXT: Cognitive behavior therapy (CBT) can be effective for late-life generalized anxiety disorder (GAD), but only pilot studies have been conducted in primary care, where older adults most often seek treatment. OBJECTIVE: To examine effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial recruiting 134 older adults (mean age, 66.9 years) from March 2004 to August 2006 in 2 primary care settings. Treatment was provided for 3 months; assessments were conducted at baseline, posttreatment (3 months), and over 12 months of follow-up, with assessments at 6, 9, 12, and 15 months. INTERVENTION: Cognitive behavior therapy (n = 70) conducted in the primary care clinics. Treatment included education and awareness, motivational interviewing, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients assigned to receive EUC (n = 64) received biweekly telephone calls to ensure patient safety and provide minimal support. MAIN OUTCOME MEASURES: Primary outcomes included worry severity (Penn State Worry Questionnaire) and GAD severity (GAD Severity Scale). Secondary outcomes included anxiety ratings (Hamilton Anxiety Rating Scale, Beck Anxiety Inventory), coexistent depressive symptoms (Beck Depression Inventory II), and physical/mental health quality of life (12-Item Short Form Health Survey). RESULTS: Cognitive behavior therapy compared with EUC significantly improved worry severity (45.6 [95% confidence interval {CI}, 43.4-47.8] vs 54.4 [95% CI, 51.4-57.3], respectively; P < .001), depressive symptoms (10.2 [95% CI, 8.5-11.9] vs 12.8 [95% CI, 10.5-15.1], P = .02), and general mental health (49.6 [95% CI, 47.4-51.8] vs 45.3 [95% CI, 42.6-47.9], P = .008). There was no difference in GAD severity in patients receiving CBT vs those receiving EUC (8.6 [95% CI, 7.7-9.5] vs 9.9 [95% CI, 8.7-11.1], P = .19). In intention-to-treat analyses, response rates defined according to worry severity were higher following CBT compared with EUC at 3 months (40.0% [28/70] vs 21.9% [14/64], P = .02). CONCLUSIONS: Compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care. However, a measure of GAD severity did not indicate greater improvement with CBT. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00308724.

Generalized anxiety disorder in older medical patients: diagnostic recognition, mental health management and service utilization.

BACKGROUND: Primary care physicians often treat older adults with Generalized Anxiety Disorder. Objective To estimate physician diagnosis and recognition of anxiety and compare health service use among older adults with GAD with two comparison samples with and without other DSM diagnoses. METHODS: Participants were 60+ patients of a multi-specialty medical organization. Administrative database and medical records were reviewed for a year. Differences in frequency of health service use were analyzed with logistic regression and between-subjects analysis of covariance. RESULTS: Physician diagnosis of GAD was 1.5% and any anxiety was 9%, and recognition of anxiety symptoms was 34% in older adults with GAD. After controlling for medical comorbidity, radiology appointments were increased in the GAD group relative to those with and without other psychiatric diagnoses, chi(2) (2, N = 225) = 4.75, p < .05. CONCLUSIONS: Most patients with anxiety do not have anxiety or symptoms documented in their medical records.

Psychometric properties of the Depression Anxiety and Stress Scale-21 in older primary care patients.

The Depression Anxiety Stress Scale (DASS) was designed to efficiently measure the core symptoms of anxiety and depression and has demonstrated positive psychometric properties in adult samples of anxiety and depression patients and student samples. Despite these findings, the psychometric properties of the DASS remain untested in older adults, for whom the identification of efficient measures of these constructs is especially important. To determine the psychometric properties of the DASS 21-item version in older adults, we analyzed data from 222 medical patients seeking treatment to manage worry. Consistent with younger samples, a three-factor structure best fit the data. Results also indicated good internal consistency, excellent convergent validity, and good discriminative validity, especially for the Depression scale. Receiver operating curve analyses indicated that the DASS-21 predicted the diagnostic presence of generalized anxiety disorder and depression as well as other commonly used measures. These data suggest that the DASS may be used with older adults in lieu of multiple scales designed to measure similar constructs, thereby reducing participant burden and facilitating assessment in settings with limited assessment resources.

Comparison of self-report measures for identifying late-life generalized anxiety in primary care.

This study evaluated the Penn State Worry Questionnaire, Penn State Worry Questionnaire-Abbreviated, and the Generalized Anxiety Disorder Questionnaire-IV for identifying generalized anxiety disorder in older medical patients. Participants were 191 of 281 patients screened for a clinical trial evaluating cognitive-behavior treatment, n = 110 with generalized anxiety disorder, 81 without. Participants completed the Penn State Worry Questionnaire and Generalized Anxiety Disorder Questionnaire-IV at pretreatment. Kappa coefficients estimated agreement with the Structured Clinical Interview for Diagnosis. Receiver operating characteristic curves compared sensitivity and specificity of self-report measures. The Penn State Worry Questionnaire (cutoff = 50) provided the strongest prediction of generalized anxiety disorder (sensitivity, 76%; specificity, 73%; 75% correctly classified; kappa = .49. Item 2 of the Generalized Anxiety Disorder Questionnaire-IV demonstrated comparable accuracy. The Penn State Worry Questionnaire, Generalized Anxiety Disorder Questionnaire-IV, and briefer versions of these measures may be useful in identifying late-life generalized anxiety disorder in medical settings.