Maria E.A. Armento

The Pittsburgh Sleep Quality Index in older primary care patients with generalized anxiety disorder: psychometrics and outcomes following cognitive behavioral therapy.

The Pittsburgh Sleep Quality Index (PSQI) is a widely used, comprehensive self-report measure of sleep quality and impairment, which has demonstrated good psychometric properties within various populations, including older adults. However, the psychometric properties of the PSQI and its component scores have not been evaluated for older adults with generalized anxiety disorder (GAD). Additionally, changes in PSQI global or component scores have not been reported following cognitive-behavioral treatment (CBT) of late-life GAD. This study examined (1) the psychometric properties of the PSQI within a sample of 216 elderly primary care patients age 60 or older with GAD who were referred for treatment of worry and/or anxiety; as well as (2) response to CBT, relative to usual care, for 134 patients with principal or coprincipal GAD. The PSQI demonstrated good internal consistency reliability and adequate evidence of construct validity. Those receiving CBT experienced greater reductions in PSQI global scores at post-treatment, relative to those receiving usual care. Further, PSQI global and component scores pertaining to sleep quality and difficulties falling asleep (i.e., sleep latency and sleep disturbances) demonstrated response to treatment over a 12-month follow-up period. Overall, results highlight the usefulness of the PSQI global and component scores for use in older adults with GAD.

Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design

BackgroundDespite the availability of evidence-based psychotherapies for depression and anxiety, they are underused in non-mental health specialty settings such as primary care. Hybrid effectiveness-implementation designs have the potential to evaluate clinical and implementation outcomes of evidence-based psychotherapies to improve their translation into routine clinical care practices.MethodsThis protocol article discusses the study methodology and implementation strategies employed in an ongoing, hybrid, type 2 randomized controlled trial with two primary aims: (1) to determine whether a brief, manualized cognitive behavioral therapy administered by Veterans Affairs Primary Care Mental Health Integration program clinicians is effective in treating depression and anxiety in a sample of medically ill (chronic cardiopulmonary diseases) primary care patients and (2) to examine the acceptability, feasibility, and preliminary outcomes of a focused implementation strategy on improving adoption and fidelity of brief cognitive behavioral therapy at two Primary Care-Mental Health Integration clinics. The study uses a hybrid type 2 effectiveness/implementation design to simultaneously test clinical effectiveness and to collect pilot data on a multifaceted implementation strategy that includes an online training program, audit and feedback of session content, and internal and external facilitation. Additionally, the study engages the participation of an advisory council consisting of stakeholders from Primary Care-Mental Health Integration, as well as regional and national mental health leaders within the Veterans Administration. It targets recruitment of 320 participants randomized to brief cognitive behavioral therapy (n = 200) or usual care (n = 120). Both effectiveness and implementation outcomes are being assessed using mixed methods, including quantitative evaluation (e.g., intent-to-treat analyses across multiple time points) and qualitative methods (e.g., focus interviews and surveys from patients and providers). Patient-effectiveness outcomes include measures of depression, anxiety, and physical health functioning using blinded independent evaluators. Implementation outcomes include patient engagement and adherence and clinician brief cognitive behavioral therapy adoption and fidelity.ConclusionsHybrid designs are needed to advance clinical effectiveness and implementation knowledge to improve healthcare practices. The current article describes the rationale and challenges associated with the use of a hybrid design for the study of brief cognitive behavioral therapy in primary care. Although trade-offs exist between scientific control and external validity, hybrid designs are part of an emerging approach that has the potential to rapidly advance both science and practice.Trial registrationNCT01149772 athttp://www.clinicaltrials.gov/ct2/show/NCT01149772

Cognitive Behavioral Therapy for Depression and Anxiety in Parkinson's Disease: A Clinical Review

Parkinsons disease (PD) is the second most common neurodegenerative disorder. It is generally defined by its progressive motor features; but increased attention is being paid to its non-motor neuropsychiatric symptoms, which profoundly impact quality of life for patients and caregivers. Anxiety and depression are particularly problematic and are the strongest predictors of quality of life in PD. Recent research has focused on non-pharmacological approaches to treating depression and anxiety in patients with PD. Cognitive-behavioral therapy (CBT) is a potentially efficacious non-pharmacological treatment for mood and anxiety symptoms associated with PD. Accordingly, this review examines empirical studies of CBT-based treatments for depression and anxiety symptoms in PD. Medical Subject Headings were used in searches of PsychInfo and PubMed of English-language articles published in peer-reviewed journals, resulting in the identification of 10 articles. Four additional articles were identified from the references of these articles and upon the suggestions of experts, for 15 articles in all. Results of individual studies varied significantly; however, the randomized controlled trials showed encouraging results and support the need for further investigation of the utility of CBT for depressed and anxious patients with PD. CBT is potentially a useful treatment for patients with PD and comorbid depression and/or anxiety, but more systematic research will be necessary to measure its effects.

Behavioral health coaching for rural-living older adults with diabetes and depression: an open pilot of the HOPE Study

BackgroundPatients with diabetes are at increased risk for depression, compounding the burden of disease. When comorbid with diabetes, depression leads to poorer health outcomes and often complicates diabetes self-management. Unfortunately, treatment options for these complex patients are limited and comprehensive services are rarely available for patients in rural settings.MethodsA small open trial was conducted to test the acceptability, feasibility and preliminary outcomes of a telephone-delivered coaching intervention for rural-dwelling older adults with uncontrolled diabetes and comorbid, clinically significant depressive symptoms. A total of eight older adults were enrolled in Healthy Outcomes through Patient Empowerment (HOPE), a 10-session (12-week), telephone-based coaching intervention. Primary study constructs included measures of diabetes control (Hemoglobin [Hb] A1c), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and diabetes-related distress (Problem Areas in Diabetes Scale [PAID]). Assessments were conducted at baseline, post-intervention, and 6-month follow-up. Acceptability and feasibility were evaluated using patient surveys, focused exit interviews, and session attendance data.ResultsClinically significant improvements were realized post-intervention and at 6-month follow-up for outcomes related to diabetes and depression. Effect sizes using Cohens d were determined post-intervention and at 6-month follow-up, respectively, for HbA1c (d=0.36; d=0.28), PHQ-9 (d=1.48; d=1.67, and PAID (d=1.50; d=1.06) scores. Among study participants, HbA1c improved from baseline by a mean (M) of 1.13 (SD=1.70) post-intervention and M=0.84 (SD=1.62) at 6 months. Depression scores, measured by the PHQ-9, improved from baseline by M=5.14 (SD=2.27) post-intervention and M=7.03 (SD=4.43) at 6-month follow-up. PAID scores also improved by M=17.68 (SD=10.7) post-intervention and M=20.42 (SD=20.66) from baseline to 6-month follow-up. Case examples are provided for additional context and to more fully articulate salient intervention concepts.ConclusionAlthough preliminary, data from this small open trial suggest that HOPE holds the potential to improve both physical (diabetes) and emotional (diabetes distress, depression) health outcomes and that changes can be maintained over a 6-month time period. As envisioned by the authors, HOPE may function as an extension of traditional primary care for rural-dwelling older adults with multiple comorbidities. A future randomized clinical trial will test HOPE’s broader effectiveness with rural-dwelling older adults.Trial registrationNCT01274715

Calmer Life: A Culturally Tailored Intervention for Anxiety in Underserved Older Adults

OBJECTIVES To evaluate the feasibility of the Calmer Life and Enhanced Community Care interventions delivered by community and expert providers and test their preliminary effectiveness on worry, generalized anxiety disorder (GAD) severity, anxiety, depression, sleep, health-related quality of life, and satisfaction. DESIGN Small randomized trial, with measurements at baseline and 3 months. SETTING Underserved, low-income, mostly minority communities in Houston, TX. PARTICIPANTS Forty underserved adults 50 years and older, with significant worry and principal or coprincipal GAD or anxiety disorder not otherwise specified. INTERVENTION Combination of person-centered, flexible skills training to reduce worry; resource counseling to target unmet basic needs; and facilitation of communication with primary care providers developed through a community-academic partnership with social service and faith-based organizations. Religion/spirituality may be incorporated. MEASUREMENTS PRIMARY OUTCOMES worry (Penn State Worry Questionnaire-Abbreviated), GAD severity (GAD-7), anxiety (Geriatric Anxiety Inventory-Short Form). SECONDARY OUTCOMES depression (Patient Health Questionnaire-8 and Geriatric Depression Scale-Short Form), sleep (Insomnia Severity Index), health-related quality of life (12-item Medical Outcomes Study Short Form), satisfaction (Client Satisfaction Questionnaire and exit interviews). RESULTS Provider training was valid; mean ratings for community providers were well above average, with none less than adequate. Reach was excellent. Participants receiving the Calmer Life intervention had greater improvement in GAD severity and depression than those receiving Enhanced Community Care. Satisfaction with both treatments was equivalent. CONCLUSIONS A larger comparative-effectiveness trial needs to examine outcomes following the Calmer Life intervention relative to standard community-based care and to evaluate more fully issues of implementation potential.

Telephone-Delivered Cognitive-Behavioral Therapy for Older, Rural Veterans with Depression and Anxiety in Home-Based Primary Care

ABSTRACT Objectives: Rural, homebound older adults are at increased risk for anxiety and depression and have limited access to mental health services. These individuals face many barriers to receiving evidence-based mental health treatment and would benefit from interventions that increase access to and efficiency of care. The aim of this study was to evaluate use of a telephone-delivered, modular, cognitive behavioral therapy (CBT) intervention for both late-life depression and anxiety delivered to rural, homebound Veterans. Methods: Three cases are presented to illustrate the flexible adaptation of the intervention for use among older Veterans enrolled in home-based primary care, with varying symptom presentations and functional limitations. The Veterans received 7 to 9 sessions of the CBT intervention, with ordering of skill modules based on symptom presentation and determined collaboratively between patient and therapist. Results: The three Veterans showed improvement in depression and/or anxiety symptoms following treatment and provided positive feedback regarding their experiences in this program. Conclusions: These results suggest that telephone-delivered CBT is acceptable to older adults and can be tailored to individual patient needs. Clinical Implications: Clinicians should consider telephone-delivered CBT as an alternate mode of therapy to increase access to mental health care for rural, homebound individuals with depression and anxiety.

Santa Clara Strength of Religious Faith Questionnaire: psychometric analysis in older adults.

Objectives: To assist researchers and clinicians considering using the Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ) with older-adult samples, the current study analyzed the psychometrics of SCSRFQ scores in two older-adult samples. Method: Adults of age 55 or older who had formerly participated in studies of cognitive-behavioral therapy for anxiety and/or depression were recruited to complete questionnaires. In Study 1 (N = 66), the authors assessed the relations between the SCSRFQ and other measures of religiousness/spirituality, mental health, and demographic variables, using bivariate correlations and nonparametric tests. In Study 2 (N = 223), the authors also conducted confirmatory and exploratory factor analyses of the SCSRFQ, as well as an item response theory analysis. Results: The SCSRFQ was moderately to highly positively correlated with all measures of religiousness/spirituality. Relations with mental health were weak and differed across samples. Ethnic minorities scored higher than White participants on the SCSRFQ, but only in Study 2. Factor analyses showed that a single-factor model fit the SCSRFQ best. According to item response theory analysis, SCSRFQ items discriminated well between participants with low-to-moderate levels of the construct but provided little information at higher levels. Conclusion: Although the SCSRFQ scores had adequate psychometric characteristics, the measures usefulness may be limited in samples of older adults.

Predictors of Outcomes for Older Adults Participating in Calmer Life, a Culturally Tailored Intervention for Anxiety

ABSTRACT Objective: Determine predictors of reduced worry and anxiety for older adults participating in the pilot phase of Calmer Life, a modular, personalized cognitive-behavioral treatment for worry. Methods: Underserved adults (N = 54) over age 50 participated. Therapists were either experts (Ph.D. or Master’s) or nonexpert providers (case managers, community health workers, and bachelor’s level). Participants completed the Penn State Worry Questionnaire—Abbreviated (PSWQ-A) and the Geriatric Anxiety Inventory—Short Form (GAI-SF) before treatment and at 3 months. Results: Demographic and clinical variables were individually entered into separate regression equations, controlling for pretreatment scores, to determine their associations with post-treatment 1) PSWQ-A and 2) GAI-SF scores. Only younger age and African American race were significant (p < .05) univariate predictors of higher post-treatment PSWQ-A scores. African American race was also a significant predictor of higher post-treatment GAI-SF scores. Conclusions: African American participants had higher post-treatment PSWQ-A and GAI-SF scores than White and Hispanic participants. Younger age was also associated with more severe PSWQ-A post-treatment scores. Clinical Implications: Younger participants may experience additional stressors (e.g., caregiving, working) compared with older participants. Smaller decreases in anxiety in African Americans point to the need for continued focus and additional modification of interventions.