Cognitive behavior therapy for late-life generalized anxiety disorder delivered by lay and expert providers has lasting benefits.

OBJECTIVE: Peaceful Living, a cognitive-behavioral treatment (CBT) for late-life generalized anxiety disorder (GAD), produced positive outcomes in GAD severity, anxiety, depression, insomnia, and mental health quality of life relative to usual care with treatment delivered by either bachelor-level lay providers (BLPs) or PhD-level expert providers (PLPs). We examined long-term maintenance of gains during 12 months following CBT for patients in this trial who received the intervention delivered by BLPs and PLPs and completed post-treatment assessments. METHODS: Participants were 112 older adults (mean age, 66.83 years) with GAD recruited from primary care who received CBT from BLPs (n = 52) or PLPs (n = 60) and completed post-treatment assessments. Assessments were given at post-treatment and at 6- and 12-month follow-up. Primary outcomes assessed long-term maintenance of gains in worry (Generalized Anxiety Disorder Severity Scale) and anxiety (State-Trait Anxiety Inventory, Structured Interview Guide for the Hamilton Anxiety Scale). Secondary outcomes assessed depression (Patient Health Questionnaire), mental health quality of life (Medical Outcomes Study Short Form - mental wellness scale), and sleep (Insomnia Severity Index). RESULTS: At 6- and 12-month follow-ups, post-treatment reductions in GAD severity, anxiety, depression, and improvements in mental health quality of life and sleep were maintained for patients in both groups. No differences were found, based on provider group. CONCLUSION: Treatment of late-life anxiety delivered by nonexpert lay providers working under supervision of licensed providers has lasting benefits. These findings support the potential of new models of care for older adults that may expand reach of mental health services. Copyright © 2016 John Wiley & Sons, Ltd.

Building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression.

INTRODUCTION: Evidence-based interventions are often poorly translated into primary care settings due to inadequate integration into organizational cultures and clinical workflows. Study designs that blend evaluation of effectiveness and implementation may enhance uptake of interventions into primary care settings. Community-Based Participatory Research (CBPR) models are useful for developing partnerships between research teams and primary care clinical partners to test blended study designs. METHODS: We conducted a formative evaluation of partnership building between a health services research team and a primary care community in US Veterans Affairs Health System to conduct a randomized effectiveness trial of an intervention embedded in routine primary care. The formative evaluation used qualitative data drawn from research/clinical partnership meetings. Data were coded and analysed using qualitative framework analysis. RESULTS: The CBPR model guided development of a research/clinical partnership based on a facilitation team consisting of 'external facilitators' (research team), 'internal facilitators' (primary care leadership) and a 'clinical advisory committee' drawn from the primary care community. Qualitative themes focused on: how the intervention components ('evidence') aligned with local clinical cultures, barriers and facilitators to acceptance and adoption of the intervention processes within the context of clinical workflows and identified 'facilitators' of intervention uptake and sustainability. CONCLUSION: A CBPR model can guide the development of research/clinical partnerships. Partnerships can identify barriers and craft modifications to intervention procedures that promote integration and into primary care workflows. Formative research/clinical partnerships are critical for designing and testing interventions focused on implementation and sustainability of new evidence within routine primary care.

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.

Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial.

BACKGROUND: Depression and diabetes cause significant burden for patients and the healthcare system and, when co-occurring, result in poorer self-care behaviors and worse glycemic control than for either condition alone. However, the clinical management of these comorbid conditions is complicated by a host of patient, provider, and system-level barriers that are especially problematic for patients in rural locations. Patient-centered medical homes provide an opportunity to integrate mental and physical health care to address the multifaceted needs of complex comorbid conditions. Presently, there is a need to not only develop robust clinical interventions for complex medically ill patients but also to find feasible ways to embed these interventions into the frontlines of existing primary care practices. METHODS/DESIGN: This randomized controlled trial uses a hybrid effectiveness-implementation design to evaluate the Healthy Outcomes through Patient Empowerment (HOPE) intervention, which seeks to simultaneously address diabetes and depression for rural veterans in Southeast Texas. A total of 242 Veterans with uncontrolled diabetes and comorbid symptoms of depression will be recruited and randomized to either the HOPE intervention or to a usual-care arm. Participants will be evaluated on a host of diabetes and depression-related measures at baseline and 6- and 12-month follow-up. The trial has two primary goals: 1) to examine the effectiveness of the intervention on both physical (diabetes) and emotional health (depression) outcomes and 2) to simultaneously pilot test a multifaceted implementation strategy designed to increase fidelity and utilization of the intervention by coaches interfacing within the primary care setting. DISCUSSION: This ongoing blended effectiveness-implementation design holds the potential to advance the science and practice of caring for complex medically ill patients within the constraints of a busy patient-centered medical home. TRIAL REGISTRATION: Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression: NCT01572389.

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.

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.