Treating Late-life Anxiety in Primary Care: Current Status and Future Directions Melinda Stanley, Ph.D. Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine Houston Center for Quality of Care and Utilization Studies, MEDVAMC
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Treating Late-life Anxiety in Primary Care: Current Status and Future Directions Melinda Stanley, Ph.D. Menninger Department of Psychiatry and Behavioral.
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Treating Late-life Anxiety in Primary Care: Current Status and Future Directions
Melinda Stanley, Ph.D.
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
Houston Center for Quality of Care and Utilization Studies, MEDVAMC
Community Prevalence of Anxiety Disorders in Later Life
Stanley MA, et al. J Consult Clin Psychol. 2003; Stanley MA, et al. Behav Ther. 1996; Wetherell JL, et al. J Consult Clin Psychol. 2003; Mohlman J, et al. Am J Geriatr Psychiatry. 2003; Mohlman et al., Behav Res Ther 2005.
165 excluded No GAD, cognitive impairment 11 non-study clinical training cases
148 included (99% of target!) Approx. 6 per month 95% self-referred
Sample Characteristics (n = 148)
Demographics 78% women Mean age = 67 years (SD = 5.8) Mean education = 16 years (SD = 3.0) 17% African American; 9% Hispanic 50% using psychotropic medication
Coexistent psychiatric diagnosis 69% at least 1 45% Depression (MDD, Dysthymia, NOS) 26% Specific Phobia 14% Social Phobia
Treatment Progress (1/07)
CBT UC
Randomized 70 64
ITT 61 57
Completed 42 37
Overall attrition = 27%[9% before randomization; 12% before post-treatment;
6% during follow-up]Higher attrition in UC (26%) vs. CBT (13%)
ITT Analysis: PSWQ change scores
0
1
2
3
4
5
6
7
8
9
3-months 6-months
CBT
UC
3-month d = .64 (.001); 6-month d = .73 (.001)
ITT Analysis: SIGH-A change scores
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
3-months 6-months
CBT
UC
3-month d = .28 (ns); 6-month d = .46 (.02)
ITT Analysis: GADSS change scores
0
0.5
1
1.5
2
2.5
3-months 6-months
CBT
UC
3-month d = .35 (.06); 6-month d = .35 (.06)
Summary & Limitations
CBT is moderately effective relative to UC Effect sizes equivalent to other collaborative care
studies (.28 - .73 vs. .23 - .57) Increasing effects over time
Low attrition in CBT (13%) Translational value limited
Homogeneous, non-representative sample Limited generalizability of treatment to real-world care
(expert providers, long sessions, no attention to patient preference)
Future Directions: Peaceful Living Project
Increase emphasis on effectiveness and collaborative care models Examine effectiveness of CBT delivered by
non-expert providers Enhance communication and collaboration
with primary care via use of EMR Modify CBT to increase flexibility and enhance
translational value/sustainability Implement intervention in more diverse
medical setting (BCM, MEDVAMC)
Peaceful Living Team
Academic investigators
Mark Kunik, M.D. Nancy Wilson, M.A.,
L.M.S.W. Jeff Cully, Ph.D. Louise Quijano, Ph.D.,
L.C.S.W. Michael Kallen, Ph.D.,
M.P.H.
Primary care investigators
Michael Crouch, M.D. (BCM)
Victor Narcisse, M.D. (BCM)
Stinson Tillerson, M.D. (MEDVAMC)
Peaceful Living: CBT Modifications
Modular treatment Integrate telephone-based service
delivery Incorporate patient preference Briefer sessions and simplified procedures BA module to target coexistent