Blended Acceptance and Commitment Therapy Versus Face-to-face Cognitive Behavioral Therapy for Older Adults With Anxiety Symptoms in Primary Care: Pragmatic Single-blind Cluster Randomized Trial.

BACKGROUND: Anxiety symptoms in older adults are prevalent and disabling but often go untreated. Most trials on psychological interventions for anxiety in later life have examined the effectiveness of face-to-face cognitive behavioral therapy (CBT). To bridge the current treatment gap, other treatment approaches and delivery formats should also be evaluated. OBJECTIVE: This study is the first to examine the effectiveness of a brief blended acceptance and commitment therapy (ACT) intervention for older adults with anxiety symptoms, compared with a face-to-face CBT intervention. METHODS: Adults aged between 55-75 years (n=314) with mild to moderately severe anxiety symptoms were recruited from general practices and cluster randomized to either blended ACT or face-to-face CBT. Assessments were performed at baseline (T0), posttreatment (T1), and at 6- and 12-month follow-ups (T2 and T3, respectively). The primary outcome was anxiety symptom severity (Generalized Anxiety Disorder-7). Secondary outcomes were positive mental health, depression symptom severity, functional impairment, presence of Diagnostic and Statistical Manual of Mental Disorders V anxiety disorders, and treatment satisfaction. RESULTS: Conditions did not differ significantly regarding changes in anxiety symptom severity during the study period (T0-T1: B=.18, P=.73; T1-T2: B=-.63, P=.26; T1-T3: B=-.33, P=.59). Large reductions in anxiety symptom severity (Cohen d≥0.96) were found in both conditions post treatment, and these were maintained at the 12-month follow-up. The rates of clinically significant changes in anxiety symptoms were also not different for the blended ACT group and CBT group (χ21=0.2, P=.68). Regarding secondary outcomes, long-term effects on positive mental health were significantly stronger in the blended ACT group (B=.27, P=.03, Cohen d=0.29), and treatment satisfaction was significantly higher for blended ACT than CBT (B=3.19, P<.001, Cohen d=0.78). No other differences between the conditions were observed in the secondary outcomes. CONCLUSIONS: The results show that blended ACT is a valuable treatment alternative to CBT for anxiety in later life. TRIAL REGISTRATION: Netherlands Trial Register TRIAL NL6131 (NTR6270); https://www.trialregister.nl/trial/6131.

Virtual reality-based cognitive behavioural therapy for patients with generalized social anxiety disorder: a pilot study.

BACKGROUND: Patients with generalized social anxiety disorder (SAD) avoid various social situations and can be reluctant to engage in in vivo exposure therapy. Highly personalized practising can be required before patients are ready to perform in vivo exposure. Virtual reality-based therapy could be beneficial for this group. AIMS: To assess the feasibility and potential effect of virtual reality-based cognitive behavioural therapy (VR-CBT) for patients with severe generalized SAD. METHODS: Fifteen patients with generalized SAD attended up to 16 VR-CBT sessions. Questionnaires on clinical and functional outcomes, and diary assessments on social activity, social anxiety and paranoia were completed at baseline, post-treatment and at 6-months follow-up. RESULTS: Two patients dropped out of treatment. Improvements in social anxiety and quality of life were found at post-treatment. At follow-up, depressive symptoms had decreased, and the effect on social anxiety was maintained. With respect to diary assessments, social anxiety in company and paranoia were significantly reduced by post-treatment. These improvements were maintained at follow-up. No increase was observed in social activity. CONCLUSIONS: This uncontrolled pilot study demonstrates the feasibility and treatment potential of VR-CBT in a difficult-to-treat group of patients with generalized SAD. Results suggest that VR-CBT may be effective in reducing anxiety as well as depression, and can increase quality of life.

Cost-effectiveness and cost-utility of an Acceptance and Commitment Therapy intervention vs. a Cognitive Behavioral Therapy intervention for older adults with anxiety symptoms: A randomized controlled trial.

BACKGROUND: A previous randomized controlled trial in older adults with anxiety symptoms found no differences between a brief blended Acceptance and Commitment Therapy (ACT) intervention and brief face-to-face Cognitive Behavior Therapy (CBT) regarding anxiety symptom severity at posttreatment and 12-month follow-up. A health-economic evaluation comparing these interventions has not yet been conducted. OBJECTIVE: This study examined the one-year cost-effectiveness and cost-utility of blended ACT compared to face-to-face CBT for older adults with anxiety symptoms. METHODS: The economic evaluation was embedded in a randomized controlled trial comparing blended ACT to CBT in 314 older adults with mild to moderately severe anxiety symptoms. Data were collected at baseline and 3, 6 and 12 months post baseline. For the cost-effectiveness analysis, treatment response was defined as a reliable improvement in anxiety symptom severity (measured with the Generalized Anxiety Disorder-7) between baseline and 12-month follow-up. To assess cost-utility, quality-adjusted life years (QALYs) were computed using EuroQol-5 Dimensions-5 Levels-5 utility scores. Analyses took the societal perspective, including both healthcare costs and productivity costs. Incremental cost-effectiveness ratios were calculated using 2500 bootstraps of seemingly unrelated regression equations of costs and effects. Sensitivity analyses were performed to assess the robustness of the findings. RESULTS: Differences between the blended ACT group and CBT group in treatment response and QALYs were statistically insignificant and clinically irrelevant. The ACT intervention was associated with an average per-participant cost reduction of €466 ($593) compared to CBT, which resulted from lower productivity costs in the blended ACT group. From a healthcare perspective, the ACT intervention was associated with higher costs (by €71 ($90)) than CBT. CONCLUSIONS: The results do not indicate that from a health-economic perspective blended ACT should be preferred over CBT in the treatment of older adults with anxiety symptoms. The findings support a model of shared decision making, where clinicians and patients collaboratively decide on the preferred intervention, based on ethical-medical, practical and personal considerations. TRIAL REGISTRATION: Netherlands Trial Register: TRIAL NL6131 (NTR6270); https://www.trialregister.nl/trial/6131.

Prevalence of anxiety disorders and subthreshold anxiety throughout later life: Systematic review and meta-analysis.

This systematic review and meta-analysis compared prevalence rates for subthreshold anxiety and anxiety disorders in adults aged 55+ and examined if these rates were associated with age. A systematic search and screening procedure resulted in 46 included articles. First, prevalence rates for subthreshold anxiety and anxiety disorders were statistically compared. Subthreshold panic, generalized anxiety and specific phobia were significantly more prevalent than the corresponding clinical disorders. In general, subthreshold anxiety appeared to be at least similarly prevalent to anxiety disorders, although firm conclusions are precluded due to the small number of samples that could be included in the analyses and the large heterogeneity between the reported prevalence rates. Second, using subgroup analyses, pooled prevalence rates for four age groups of older adults (55-64, 65-74, 75-84, 85+) were compared. For specific phobia, the 75-84 and 85+ groups had significantly lower prevalence rates than the 55-64 and 65-74 groups. Posttraumatic stress disorder was significantly more prevalent in the 55-64 group than in the other age groups, and lowest in the 85+ group. No other significant differences between age groups were found. The association between later life subthreshold anxiety and age could not be examined due to a lack of reported information. The main limitation of this study is the small number of samples in the analyses, which limits their power and generalizability. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An Internet-based Acceptance and Commitment Therapy intervention for older adults with anxiety complaints: study protocol for a cluster randomized controlled trial.

BACKGROUND: Anxiety is among the most prevalent and disabling mental health problems in older adults. Few older adults with mild to moderately severe anxiety symptoms receive adequate interventions, putting them at risk for developing anxiety disorders, depression, and various somatic problems. Effective, low-threshold interventions should be developed. Blended care, in which a web-based intervention is combined with a limited amount of face-to-face contacts with a mental healthcare counselor at the general practice, is a promising option. The online self-help intervention "Living to the Full"-an Acceptance and Commitment Therapy (ACT) intervention-has been proven to reduce depression and anxiety in several patient groups, but has not yet been investigated in older adults. The aim of this study is to evaluate the (cost-)effectiveness of a blended form of "Living to the Full" in reducing anxiety symptoms in adults aged 55 to 75 years. Furthermore, moderators and mediators of the treatment effect are investigated. METHODS/DESIGN: The (cost-)effectiveness of the ACT intervention will be investigated in a cluster single-blind randomized controlled trial (RCT). The blended intervention will be compared to treatment-as-usual. Thirty-six mental health counselors working at general practices in the Netherlands will be randomized to deliver blended care or treatment as usual. A total of 240 participants (aged 55-75 years) with mild to moderately severe anxiety complaints (defined as a total score of 5-15 on the GAD-7) will be recruited. There are four measurements consisting of online questionnaires (primary outcome: GAD-7) and a telephone interview: before the start of the intervention; directly following the intervention (14 weeks after baseline); and six and twelve months after baseline. Possible mediator variables will be assessed multiple times basis during the intervention. DISCUSSION: This RCT will evaluate the effectiveness of a blended ACT intervention for older adults with anxiety symptoms. If the intervention is shown to be effective, it will be implemented, thereby improving the accessibility and quality of preventive interventions for older adults with anxiety problems. TRIAL REGISTRATION: Netherlands Trial Register, NTR6270 . Registered on 21 March 2017.