Jeffrey A. Cully

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.

COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial.

BACKGROUND Chronic obstructive pulmonary disease (COPD) affects 14 to 20 million Americans and is associated with increased prevalence of affective disorders, contributing significantly to disability. This study compared cognitive behavioral therapy (CBT) group treatment for anxiety and depression with COPD education for COPD patients with moderate-to-severe anxiety and/or depressive symptoms. METHOD A randomized controlled trial (RCT) was conducted between 11 July 2002 and 30 April 2005 at the Michael E. DeBakey VA Medical Center, Houston, TX. Participants were 238 patients treated for COPD the year before, with forced expiratory value in 1 second (FEV)1/forced vital capacity (FVC)<70% and FEV1<70% predicted, and symptoms of moderate anxiety and/or moderate depression, who were being treated by a primary care provider or pulmonologist. Participants attended eight sessions of CBT or COPD education. Assessments were at baseline, at 4 and 8 weeks, and 4, 8 and 12 months. Primary outcomes were disease-specific and generic quality of life (QoL) [Chronic Respiratory Questionnaire (CRQ) and Medical Outcomes Survey Short Form-36 (SF-36) respectively]. Secondary outcomes were anxiety [Beck Anxiety Inventory (BAI)], depressive symptoms [Beck Depression Inventory-II (BDI-II)], 6-minute walk distance (6MWD) and use of health services. RESULTS Both treatments significantly improved QoL, anxiety and depression (p<0.005) over 8 weeks; the rate of change did not differ between groups. Improvements were maintained with no significant change during follow-up. Ratios of post- to pretreatment use of health services were equal to 1 for both groups. CONCLUSIONS CBT group treatment and COPD education can achieve sustainable improvements in QoL for COPD patients experiencing moderate-to-severe symptoms of depression or anxiety.

Older Adults’ Preferences For Religion/Spirituality In Treatment For Anxiety And Depression

Objectives: To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors. Method: Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearmans rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling. Results: Most participants (77–83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important. Conclusion: For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.

Healthy IDEAS: A Depression Intervention Delivered by Community-Based Case Managers Serving Older Adults

This study evaluated an evidence-based intervention for depression delivered by case managers in three community-based service agencies to high-risk, diverse older adults. Case managers were trained to provide screening and assessment, education, referral and linkage, and behavioral activation. Outcomes addressed depression, general health status, social and physical activation, and mental health services use at baseline and 6 months. Participants (n = 94) were predominantly women (79%) and Hispanic (44%), with a mean age of 72 years. Mean Geriatric Depression Scale—15 scores differed significantly between baseline and 6 months (9.0 versus 5.5). At 6 months, significantly more participants knew how to get help for depression (68% versus 93%), reported that increasing activity helped them feel better (72% versus 89%), and reported reduced pain (16% versus 45 %). The authors conclude that nonspecialty providers can be trained to successfully implement an evidence-based self-management intervention for depression with frail, high-risk, and diverse older adults.

Prevalence of dementia among veterans affairs medical care system users

Objectives: In an aging population, the number of veterans diagnosed with dementia is likely to increase. Knowledge of existing dementia prevalence will be beneficial in planning for future patient care needs. Our objectives were to assess the prevalence of the dementia diagnosis among those treated at Veterans Affairs (VA) medical centers and determine how it varies across race and Veterans Integrated Service Network (VISN). Materials and Methods: Data were collected on all veterans seen within the VA medical system from 1997 through the first half of 2001. Only veterans aged 65 and over were included in the study. Veterans were included if they had one of the following dementia ICD-9 codes: 290.XX, 291.2, 294.XX, 331.XX, 046.1, or 046.3. Results: The overall prevalence of dementia was 7.3%. The prevalence of dementia was similar among white patients and patients of other races, except African-American patients, in whom it was 50% higher. Across VISNs, the prevalence of dementia ranged from 5.8 to 9.4%. Alzheimer’s disease was the most frequently diagnosed type of dementia within the VA, and inpatient service utilization and outpatient psychiatry visits by individuals with dementia were high relative to other VA patients. Discussion: The overall prevalence identified is consistent with that reported in the literature, as is the elevated prevalence in African-Americans versus whites. The data on prevalence by VISN may identify regional variation in either the types of dementia present or the diagnostic criteria used. The dementia diagnosis is clearly associated with substantial service use.

Predictors of depressive symptoms in older veterans with heart failure

Objectives: This study collected data on demographic factors, heart failure physical limitations, perception of heart failure intrusiveness, coping mechanisms, locus of control, self-efficacy and social support for 104 older veterans with heart failure (HF) to determine the factors’ relative importance in predicting depressive symptoms. Method: Participants were veterans at least 60 years of age with HF who were screened for depression and anxiety with the Geriatric Depression Scale and Geriatric Anxiety Inventory, respectively, so that the final sample consisted of equal numbers with and without significant levels of anxiety and depression. Other measures included the Kansas City Cardiomyopathy Questionnaire, Heart Failure Illness Intrusiveness Rating Scale, Brief-COPE, Multidimensional Health Locus of Control Scale, Chronic Disease Self-Efficacy and Multidimensional Scale of Perceived Social Support. Results: Correlational analyses indicated that depressive symptoms were significantly associated with physical limitations from HF, HF perceptions of intrusiveness, maladaptive coping, attributing locus of control to chance and HF self-efficacy. Including these variables in one regression equation predicting depressive symptoms indicated that perceptions of intrusiveness from HF and attributing locus of control to chance were the only variables to predict depressive symptoms independent of the influence of other significant bivariate predictors. Conclusion: Even if physical limitations, maladaptive coping and self-efficacy are held constant, decreasing perceptions of HF intrusiveness and locus of control to chance reduce depressive symptoms. These two cognitive/perceptual factors may play a salient role in treatment of depression among older HF patients.

Integration of religion into cognitive-behavioral therapy for geriatric anxiety and depression.

Religion is important to most older adults, and research generally finds a positive relationship between religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of religion into CBT may increase its acceptability and effectiveness in this population. This article reviews studies that have examined the effects of integrating religion into CBT for depression and anxiety. These studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment when CBT incorporates religion, although effects are equivalent at follow-up. The authors present recommendations for integrating religious beliefs and behaviors into CBT based on empirical literature concerning which aspects of religion affect mental health. A case example is also included that describes the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider the integration of religion into psychotherapy for older adults with depression or anxiety and that studies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of depression and anxiety in older adults. (Journal of Psychiatric Practice 2009;15:103–112).

The Relationship Between Use of CBT Skills and Depression Treatment Outcome: A Theoretical and Methodological Review of the Literature

Cognitive and behavioral therapies emphasize the importance of skill acquisition and use, and these skills are proposed to mediate treatment outcomes. Despite its theoretical importance, research on skill use as a mechanism of change in CBT and its measurement is still in its infancy. A search of online databases was conducted to identify and review the literature testing the meditational effect of CBT skills on treating depression in adults. Additionally, we reviewed the various methods to assess a patients use of CBT skills. We identified 13 studies examining the frequency of CBT skill use and 11 studies examining the quality of CBT skill use. While the literature provides preliminary evidence for the mediational role of CBT skill use frequency and quality on depression treatment outcomes, methodological limitations in much of the existing literature prevent firm conclusions about the role of skills use on treatment outcomes.

Changes in Psychotherapy Utilization Among Veterans With Depression, Anxiety, and PTSD

OBJECTIVE Large-scale health care systems such as the Veterans Health Administration (VHA) have recently invested heavily in the expansion of psychotherapy services. This study examined longitudinal changes in use of psychotherapy at the VHA during a period of substantial programmatic change targeting increased availability and quality of mental health care. METHODS This retrospective cohort study used data from the VHA National Patient Care Database outpatient treatment files to identify patients with a new-onset diagnosis of depression, anxiety, or posttraumatic stress disorder during fiscal years (FYs) 2004 (N=424,428), 2007 (N=494,318), and 2010 (N=583,733). Use of psychotherapy during the 12 months after diagnosis was assessed. RESULTS The proportion of patients receiving any psychotherapy increased across the three study time points (FY 2004, 21%; FY 2007, 22%; and FY 2010, 27%). Amount of psychotherapy also increased such that with time a growing proportion of patients received eight or more psychotherapy sessions. The median time between diagnosis and start of psychotherapy decreased from 56 to 47 days from FY 2004 to FY 2010. Consistent with VHA expansion efforts, more substantial increases in psychotherapy reach, amount, and timeliness occurred between FY 2007 and 2010 than between FY 2004 and FY 2007. CONCLUSIONS These findings highlight recent increases in the use of VHA psychotherapy and correspond to substantial efforts to improve access to mental health services. Despite these advances, most newly diagnosed patients received no psychotherapy or a low-intensity amount of psychotherapy. Additional efforts to promote veteran engagement in needed mental health services appear warranted.

LAY PROVIDERS CAN DELIVER EFFECTIVE COGNITIVE BEHAVIOR THERAPY FOR OLDER ADULTS WITH GENERALIZED ANXIETY DISORDER: A RANDOMIZED TRIAL

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.