Guided self-help for generalized anxiety disorder in older adults

Anxiety among older adults during the COVID-19 pandemic

A growing body of research examines the COVID-19 pandemic's effects on well-being. Only few studies focus on older adults or explore the predictors of COVID-19-related anxiety. Intolerance of uncertainty (IU) and some behaviors (e.g., avoidance, procrastination) are linked to anxiety among older adults and could both be relevant to consider in a pandemic context. This study measured the occurrence and anxiety levels among older adults and verified the possible role of IU and behaviors in predicting anxiety symptoms, impairment and distress related to COVID-19 health standards. It also examined the indirect effect of IU on symptoms, impairment and distress through behaviors. Participants aged 60 and over (N = 356) were recruited and administered questionnaires. Anxiety levels and symptom impairment were high and appeared to have increased since the beginning of the pandemic. IU and behavioral manifestations of anxiety were associated with higher anxiety symptoms, impairment and distress related to COVID-19 health standards. The indirect effects of IU on the tendency to worry and COVID-19-related anxiety through behavioral manifestations of anxiety were confirmed. This study provides knowledge on the relationship between COVID-19 and anxiety in older adults and identifies predictors relevant to this population.

The Impact of Cognitive-Behavioral Interventions on Sleep Disturbance in Depressed and Anxious Community-dwelling Older Adults: A Systematic Review

INTRODUCTION

Depression and anxiety are prevalent mental health conditions in older adulthood. Despite sleep disturbance being a common comorbidity in late-life depression and anxiety, it is often discounted as a target for treatment. The current review aims to establish whether cognitive-behavioral therapy (CBT) is effective in treating concomitant sleep disturbance in depressed and anxious older adults and to review evidence supporting whether CBT interventions targeting anxiety and depression, or concurrent sleep disturbance, have the greatest effectiveness in this client group.

METHOD

A systematic database search was conducted to identify primary research papers evaluating the effectiveness of CBT interventions, recruiting older adults with symptoms of depression and/or anxiety, and employing a validated measure of sleep disturbance. The identified papers were included in a narrative synthesis of the literature.

RESULTS

Eleven identified studies consistently support reductions in sleep disturbance in elderly participants with depression and anxiety in response to CBT. Most CBT interventions in the review included techniques specifically targeting sleep, and only one study directly compared CBT for insomnia (CBT-I) with a CBT-I intervention also targeting depressive symptoms, limiting the ability of the review to comment on whether interventions targeting sleep disturbance or mental health symptoms have superior effectiveness.

CONCLUSION

The extant research indicates that CBT interventions are effective in ameliorating sleep disturbance in late-life depression and anxiety. Future high-quality research is required to substantiate this finding and to compare the effectiveness of CBT-I and CBT for depression and anxiety in this group to inform clinical practice.

Effectiveness and Acceptability of Low-intensity Psychological Interventions on the Well-being of Older Adults: A Systematic Review

Objectives: Growth in the older adult population and healthcare inequities mean there is a global need to increase access to early intervention in mental healthcare for older adults. This systematic review synthesized the evidence for the efficacy and acceptability of low-intensity psychological interventions (self-help, psychoeducation, bibliotherapy, internet cognitive-behavioral therapy: iCBT) for older adults with mild-to-moderate mental health problems.Methods: Ovid, EBSCOhost and ProQuest were searched for articles describing low-intensity psychological interventions. Pre and post outcome measures and a mean age of at least 50 (age range ≥40) were required for inclusion.Results: 26 articles (23 studies) described various interventions. Most studies were good quality and reported improvements in participant's mental health scores post intervention. Participants were more likely to be female, aged 60-70 and to be highly educated. Eight studies reported obtaining participant satisfaction ratings. Three studies included participants from rural areas.Conclusions: Low-intensity psychological interventions can be effective for older adults with mild-to-moderate mental health problems, but generalizability is constrained.Clinical Implications: Guided iCBT and bibliotherapy may be beneficial for adults in their 60s and 70s experiencing mild-to-moderate levels of depression. CBT may also be beneficial for reducing symptoms of mild-to-moderate anxiety. Providing the option of low-intensity psychological intervention, particularly iCBT, may help increase engagement with treatment.

Self-help guided by trained lay providers for generalized anxiety disorder in older adults: study protocol for a randomized controlled trial

Background

Only a small proportion of older patients with generalized anxiety disorder (GAD) seek professional help. Difficulties in accessing treatment may contribute to this problem. Guided self-help based on the principles of cognitive-behavioral therapy (GSH-CBT) is one way of promoting access to psychological treatment. Moreover, because the therapist’s role in GSH-CBT is limited to supporting the patient, this role could be assumed by trained and supervised lay providers (LPs) instead of licensed providers. The main goal of this study is to evaluate the efficacy of GSH-CBT guided by LPs for primary threshold or subthreshold GAD in older adults.

Methods

We will conduct a multisite randomized controlled trial comparing an experimental group receiving GSH-CBT guided by LPs (n = 45) to a wait-list control group (n = 45). Treatment will last 15 weeks and will be based on a participant’s manual. Weekly telephone sessions with LPs (30 min maximum) will be limited to providing support. Data will be obtained through clinician evaluations and self-assessment questionnaires. Primary outcomes will be the tendency to worry and severity of GAD symptoms. Secondary outcomes will be anxiety symptoms, sleep difficulties, functional deficit, diagnosis of GAD, and cognitive difficulties. For the experimental group, measurements will take place at pre- and post-treatment and at 6 and 12 months post-treatment. For the control group, three evaluations are planned: two pre-treatment evaluations (before and after the waiting period) and after receiving treatment (post-treatment). The efficacy of GSH-CBT will be established by comparing the change in the two groups on the primary outcomes.

Discussion

This project will provide evidence on the efficacy of a novel approach to treat GAD in older adults. If effective, it could be implemented on a larger scale and provide many older adults with much needed mental health treatment through an expanded workforce.

Trial registration

The trial was registered at ClinicalTrials.gov, number NCT03768544, on December 7, 2018.

Modelling changes in anxiety and depression during low-intensity cognitive behavioural therapy: An application of growth mixture models

OBJECTIVES

Research largely supports the clinical effectiveness of low-intensity cognitive behavioural therapy (LICBT) for mild-to-moderate anxiety and depression, delivered by psychological well-being practitioners (PWPs). Knowledge regarding the predictors of treatment response, however, is relatively limited. The primary aim of this study was to model the heterogeneity in longitudinal changes in anxiety and depression throughout LICBT provided by PWPs in Northern Ireland (NI), and to explore associations between pre-treatment variables and differences in treatment response.

METHODS

Growth mixture modelling (GMM) techniques were employed to examine changes in psychological status in clients (N = 253) over the first six sessions of treatment, to identify divergent early response trajectories. A series of pre-treatment variables were used to predict class membership using chi-square tests and binary logistic regression models.

RESULTS

There was one class representing improvement and one representing no improvement for both anxiety and depression. Class membership was predictive of treatment outcome. Pre-treatment variables associated with less improvement included unemployment, risk of suicide, neglect of self or others, using medication, receiving previous or concurrent treatments, a longer duration of difficulties, and comorbidities.

CONCLUSIONS

Findings indicate most of the sample populated an 'improvers' class for both depression and anxiety. Pre-treatment variables identified as predictive of poor treatment response may need to be considered by practitioners in potential triage referral decision policies, supporting cost-effective and efficient services. Further research around predictors of clinical outcome is recommended.

PRACTITIONER POINTS

Most of the sample belonged to an 'improvers' class. Several pre-treatment variables predicted poor treatment response (unemployment, suicide risk, neglect, medication, previous or concurrent treatments, longer duration of difficulties, and comorbidities). Few studies have utilized GMM to determine predictors of outcome following LICBT Regarding pre-treatment variables, the possibility of self-report bias cannot be excluded. The time period was relatively short, although represented the optimum number of sessions recommended for LICBT. The lack of a control group and random allocation were the main limitations.

Information-Seeking about Anxiety and Perceptions about Technology to Teach Coping Skills in Older Veterans

OBJECTIVE

We sought to learn where older veterans seek information about anxiety and coping. Due to increasing use of technology in health care, we also explored benefits and barriers of using technology to teach coping skills.

METHODS

Twenty veterans (mean age = 69.5 years, SD = 7.3) participated in semi-structured interviews in which we inquired about where they seek information about anxiety. We explored quantitative and qualitative differences for veterans with high versus low anxiety. In follow-up focus groups, we examined opinions about learning coping skills using technology.

RESULTS

Though veterans primarily named health care professionals as sources of information about anxiety, online searches and reading books were frequently mentioned. Reported benefits of using technology were convenience and standardized instruction of coping skills. Barriers included lack of interaction and frustration with technology usability.

CONCLUSION

Older veterans use multiple sources, heavily rely on interpersonal sources (e.g., professionals, friends), and employ varied search strategies regarding how to cope with anxiety. Using technology to teach coping skills was generally acceptable to older veterans.

CLINICAL IMPLICATIONS

Health care professionals could guide patients towards credible online and book sources. Providing instruction about using technology may help older adults use technology to learn coping skills.

Anxiety Disorders in Late Life

Anxiety disorders in later life are some of the most significant mental health problems affecting older adults. Prevalence estimates of anxiety disorders in late life vary considerably based on multiple methodological issues. Current diagnostic criteria may not adequately capture the nature and experience of anxiety in older people, particularly those in ethnic and racial minority groups. This article reviews late-life anxiety disorders. Pharmacologic and psychotherapy approaches to treat late-life anxiety are reviewed, including a summary of current innovations in clinical care across settings, treatment models, and treatment delivery.

Development of a video-delivered relaxation treatment of late-life anxiety for veterans

BACKGROUND

Behavioral treatments reduce anxiety, yet many older adults may not have access to these efficacious treatments. To address this need, we developed and evaluated the feasibility and acceptability of a video-delivered anxiety treatment for older Veterans. This treatment program, BREATHE (Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment), combines psychoeducation, diaphragmatic breathing, and progressive muscle relaxation training with engagement in activities.

METHODS

A mixed methods concurrent study design was used to examine the clarity of the treatment videos. We conducted semi-structured interviews with 20 Veterans (M age = 69.5, SD = 7.3 years; 55% White, Non-Hispanic) and collected ratings of video clarity.

RESULTS

Quantitative ratings revealed that 100% of participants generally or definitely could follow breathing and relaxation video instructions. Qualitative findings, however, demonstrated more variability in the extent to which each video segment was clear. Participants identified both immediate benefits and motivation challenges associated with a video-delivered treatment. Participants suggested that some patients may need encouragement, whereas others need face-to-face therapy.

CONCLUSIONS

Quantitative ratings of video clarity and qualitative findings highlight the feasibility of a video-delivered treatment for older Veterans with anxiety. Our findings demonstrate the importance of ensuring patients can follow instructions provided in self-directed treatments and the role that an iterative testing process has in addressing these issues. Next steps include testing the treatment videos with older Veterans with anxiety disorders.