Christina M. Gilliam

Stepped care versus standard cognitive–behavioral therapy for obsessive–compulsive disorder: A preliminary study of efficacy and costs

Background: Exposure and response prevention (ERP) for obsessive–compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low‐intensity, low‐cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention. Methods: Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low‐intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist‐administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist‐administered ERP with no lower‐intensity lead‐in. Results: The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third‐party payers than did standard ERP, with large effect sizes. Conclusions: These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long‐term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings. Depression and Anxiety 0:1–10, 2011.  © 2011 Wiley‐Liss, Inc.

Group cognitive-behavioral therapy for hoarding disorder: An open trial

Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment.

Assessment of Anxiety in Older Home Care Recipients

PURPOSE This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services. DESIGN AND METHODS Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD). RESULTS Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified). IMPLICATIONS These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.

Impairments in Life Quality among Clients in Geriatric Home Care: Associations with Depressive and Anxiety Symptoms

The aim of this study was to determine the independent contributions of depressive and anxiety symptoms to quality of life among older adults who were receiving services through a home care program.

Stepped Care for Obsessive-Compulsive Disorder: An Open Trial

This study evaluated the effectiveness and treatment costs associated with a stepped care protocol of exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). In the current open trial, patients (N=14) began with self-directed EX/RP and minimal therapist guidance over the course of six weeks (Step 1). During this phase of treatment, no therapist-directed exposures were conducted. Those who did not respond optimally to Step 1 went on to Step 2, which consisted of 15 sessions of twice-weekly therapist-directed exposures. Results of this study show promise for stepped care utilizing EX/RP for some patients with OCD, with a response rate of 88% and a 60% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score among treatment completers. Significant improvements were found in Y-BOCS from pre to post-treatment for both Step 1 and Step 2 completers. Forty-five percent of participants (n=5) responded following completion of Step 1, resulting in reduced cost of treatment among these participants. All participants who responded to Step 1 maintained acute gains during the brief follow-up period. Limitations include a small sample size and high attrition rate.

Psychometric Properties of a Structured Diagnostic Interview for DSM-5 Anxiety, Mood, and Obsessive-Compulsive and Related Disorders:

Three hundred sixty-two adult patients were administered the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND). Of these, 121 provided interrater reliability data, and 115 provided test–retest reliability data. Participants also completed a battery of self-report measures that assess symptoms of anxiety, mood, and obsessive-compulsive and related disorders. Interrater reliability of DIAMOND anxiety, mood, and obsessive-compulsive and related diagnoses ranged from very good to excellent. Test–retest reliability of DIAMOND diagnoses ranged from good to excellent. Convergent validity was established by significant between-group comparisons on applicable self-report measures for nearly all diagnoses. The results of the present study indicate that the DIAMOND is a promising semistructured diagnostic interview for DSM-5 disorders.

Extending Cognitive-Behavioral Therapy for Late-Life Anxiety to Home Care: Program Development and Case Examples.

Data suggesting that cognitive-behavioral therapy (CBT) is efficacious for late-life anxiety are accumulating; however, effectiveness has not been well established. Incorporating CBT for anxiety into home care is needed to facilitate access to evidenced-based treatment for a growing population of community-dwelling, functionally impaired elderly people. In this article, the authors describe the development of a home-based CBT program for late-life anxiety, outlining their experience partnering with a community care management organization. They also describe the CBT protocol and present data form two participants who completed the treatment. The two case examples illustrate multiple barriers to achieving successful treatment outcomes with this population. Future research needs to determine the extent to which adaptations are necessary to optimize the success of CBT for anxiety in a home care setting.

Changes in saving cognitions mediate hoarding symptom change in cognitive-behavioral therapy for hoarding disorder

Cognitive-behavioral therapy (CBT) is an empirically-supported treatment for hoarding disorder (HD). However, meta-analytic studies suggest that CBT is only modestly effective, and a significant number of individuals with HD remain symptomatic following treatment. To inform the development of more effective and targeted treatments, it will be important to clarify the mechanisms of treatment response in CBT for HD. To this end, the current study examined whether change in maladaptive saving beliefs mediated symptom change in CBT for HD. Sixty-two patients with primary HD completed measures of maladaptive saving cognitions and hoarding severity at pre-, mid-, and post-CBT. Results showed that change in saving cognitions mediated change in all three domains of HD symptoms (i.e., acquiring, difficulty discarding, and excessive clutter), suggesting that cognitive change may be a mechanism of treatment response in CBT. The findings indicate that cognitive change may have an impact on treatment outcomes, and are discussed in terms of cognitive-behavioral theory of HD and potential ways in which to enhance belief change in treatment.

Metacognitive Beliefs in Late-Life Generalized Anxiety Disorder

The aim of this study was to determine the association between metacognitive beliefs, trait worry, and generalized anxiety disorder (GAD) among older adults. Sixty-six home health care clients aged 65 and older completed the Metacognitions Questionnaire-30 (MCQ-30) along with measures of worry and GAD severity Effect size estimates of differences on the MCQ-30 subscales between those diagnosed with and without GAD ranged from medium to large. The Positive Beliefs subscale was the strongest predictor of trait worry. However, negative beliefs about worry (specifically beliefs in the uncontrollability and dangers of worrying) predicted GAD symptom severity when also controlling for trait worry, and partially mediated the relationship between trait worry and GAD symptom severity. These findings suggest that theories positing a role for metacognitive beliefs in the etiology and maintenance of GAD may extend to older adults.