The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam

Prevalence and predictors of anxiety disorder courses in the Canadian Armed Forces

Few studies have examined the longitudinal courses of anxiety disorders in military members. This study examined the prevalence and predictors of courses of any anxiety disorder in members and veterans of the Canadian Armed Forces, including no lifetime, remitted, new onset, and persistent/recurrent anxiety disorder. The 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey is a 16-year follow-up of n = 2941 participants from the Canadian Community Health Survey: Canadian Forces Supplement in 2002. Diagnoses of any DSM-IV anxiety disorder (i.e., generalized anxiety, social anxiety, and/or panic disorder) in 2002 and 2018 were used to create four anxiety course groups. A large proportion of the sample (36.3 %; new onset = 24.6 %, remitting = 6.9 %, and persistent/recurrent = 4.8 %) met criteria for an anxiety disorder during one or both time points. Factors at baseline and/or between 2002 and 2018, including income, education, military rank, comorbidity of PTSD or depression, deployment history, and traumatic events, were positively associated with most anxiety courses relative to no anxiety in analyses. Targeted interventions are needed to help mitigate anxiety disorders among this population. Social support and active coping were protective factors for most anxiety courses and may need to be incorporated into targeted interventions.

Childhood abuse/neglect and temporal patterns in late-life anxiety

OBJECTIVES

Anxiety has been associated with childhood abuse/neglect, but this relationship and its mechanisms are poorly documented in older adults. This study examined the association between childhood abuse/neglect and late-life anxiety temporal patterns (i.e. absence, remission, incidence, persistence), testing for mediators.

METHODS

Data were derived for 724 French-speaking community-living older adults participating in the Étude sur la santé des ainés - Services study with available information at baseline and 4-year follow-up. Past-month anxiety was based on a cutoff score ≥5 on a French translation of the 7-item Generalized Anxiety Disorder at interviews. Questions on childhood abuse/neglect (e.g. psycho-emotional, physical, sexual) were administered. Adjusted multinomial regression analyses and mediation bootstrapping models were used. Tested mediators included traumatic events (excluding childhood abuse/neglect), daily hassles, psychological resilience, and cortisol activity.

RESULTS

The absence, remission, incidence and persistence of anxiety was found in 45.3%, 25.3%, 8.7% and 20.7% of the sample, respectively. Participants with incident and persistent late-life anxiety experienced more childhood abuse/neglect. Participants with persistent anxiety also reported lower psychological resilience. The association between childhood abuse/neglect with anxiety incidence was mediated by daily hassles, while its association with anxiety persistence was mediated by daily hassles and psychological resilience.

CONCLUSION

Past childhood abuse/neglect was associated with late-life anxiety incidence and persistence, with psychological resilience and daily hassles potentially explaining this relationship. Further research should focus on ascertaining the clinical applications of psychosocial and biological profiles in informing the prevention and personalized treatment of anxiety in older adults.

Relationships Between Aging Attitudes and Successful Aging Outcomes in Middle-age and Older Women

OBJECTIVES

This study aimed to explore the relationships between aging attitudes and the outcomes of successful aging, including whether aging attitudinal types moderate psychological adjustment in the context of medical and mental health diagnoses.

METHODS

In total, 409 community-dwelling women aged 40-79 years in Australia completed the Reactions to Aging Questionnaire (RAQ), Geriatric Depression Scale, Center of Epidemiological Studies Depression Scale, and Geriatric Anxiety Inventory. Information about medical and mental health diagnoses were collected.

RESULTS

Overall, aging attitudes and all three RAQ subscales were negatively correlated with scores on measures of depression and anxiety, and number of medical diagnoses. Attitudinal types toward aging were found to moderate the relationship between the number of mental health diagnoses and scores on the psychological measures of depression but not anxiety. Unique RAQ domain-specific relationships were found with the number of mental health diagnoses.

CONCLUSIONS

The findings support the link between aging attitudes and psychological outcomes, the potential clinical value of RAQ attitudinal typologies classification as well as a multidimensional conceptualization of aging attitudes.

CLINICAL IMPLICATIONS

The findings reinforce the need for efforts to reduce ageism on a societal level, as well as informing clinical decision-making with older clients.

Effect of Job Stressors on Presenteeism among Aging Workers: A Longitudinal Moderated Mediation Model

Objectives: With the rapid global increase in the age of workforces, companies are increasingly concerned with improving the working conditions of older workers. Anxiety is an important psychological variable in sociological studies but has attracted less attention in studies of occupational health and management. In this study, we explored the mediating effect of anxiety on the relationship between job stressors and presenteeism, and the moderating effect of pessimism. Methods: We collected longitudinal data from 892 respondents who participated in the 2008 and 2012 waves of the Health and Retirement Study in the United States. We tested the proposed moderated mediation model using structural equation modeling. Results: Job stressors were positively related to anxiety and presenteeism. Anxiety was positively related to presenteeism and mediated the relationship between job stressors and presenteeism. Pessimism had a statistically significant negative effect on the relationship between anxiety and presenteeism. Conclusions: These results make theoretical and practical contributions to the literature on the influencing mechanisms of presenteeism. The use of longitudinal data ensured that the research conclusions were reliable; we suggest ways to improve the productivity of aging workers.

Course trajectories of anxiety disorders: Results from a 6-year follow-up in a general population study

OBJECTIVE

Little is known about the course of anxiety disorders in the general population. This study provides insights into the course of anxiety disorders in the general population taking into account transition to residual symptoms and to other diagnostic categories.

METHODS

Using data from three waves of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2; n = 6646), subjects with anxiety disorders (T_0;n = 243) were divided into three mutually exclusive course trajectories according to their diagnostic status at 3-year (T₁) and 6-year (T₂) follow-up: remission group (no disorder at T₂), intermittent course group (no disorder at T₁ and disorder at T₂) and chronic course group (disorder at all measurements). Transition to residual symptoms or other psychopathology were studied. In addition, predictors of course trajectories were assessed.

RESULTS

During 6-year follow-up, 77.8% of subjects achieved remission, 14.0% followed an intermittent course and 8.2% a chronic course. Of those in remission, residual anxiety symptoms remained in 46.6%, while 7.9% developed another disorder between T₀ and T₂. Compared with the remitting group, a chronic course was predicted by not living with a partner, multiple negative life events, neuroticism, lower mental functioning, severity of anxiety symptoms, use of mental health care and medication use.

LIMITATIONS

The intermittent and chronic course groups were small, limiting statistical power. As a result, certain predictors may not have reached significance.

CONCLUSIONS

In the general population at 6-year follow-up, 77.8% of subjects with anxiety disorders achieved remission. Because of transition to residual symptoms or another diagnostic category, only 52.4% of those subjects had a true favourable outcome.

Association Between Anxiety and Cognitive Decline Over 12 Years in a Population-Based Cohort

BACKGROUND

Findings on the associations between anxiety and cognitive decline are mixed and often confounded.

OBJECTIVE

We studied whether anxiety symptoms were associated with the risk of cognitive decline after adequate adjustment of confounding factors.

METHODS

Our study consists of 2,551 community-dwelling older adults recruited between the ages of 60-64 years and followed up for 12 years in the PATH Through Life cohort study. Anxiety symptoms were measured using the Goldberg Anxiety Scale (GAS; range 0-9). General cognitive function, episodic memory, working memory, verbal intelligence, processing speed, and psychomotor speed were measured. Multilevel analyses were carried out to investigate the association between anxiety symptoms and cognitive decline over 12 years, taking into account confounding variables.

RESULTS

We did not find a significant association between baseline anxiety symptoms and cognitive decline over 12 years. Although some associations between anxiety symptoms with psychomotor speed (β= -0.04, 99% CI: -0.08, 0.00) and processing speed (β= -0.27, 99% CI: -0.48, -0.07) were found, these were attenuated after adjusting for depression. We also did not find an association between cumulative anxiety and decline in cognitive performance.

CONCLUSION

In this sample of cognitively healthy men and women aged 60 years and above, anxiety symptoms were not associated with the risk of cognitive decline. Long follow-up study time, appropriate selection of confounding factors, and estimating the effect of cumulative anxiety are important to establish the association between anxiety and cognitive symptoms.

Predictors of persistence of anxiety disorders across the lifespan: a systematic review

Despite the substantial disease burden of anxiety disorders, physicians have a poor understanding of factors that predict their typical persistent course. This systematic review of predictors of persistent anxiety disorders covered 48 studies with 29 690 patients diagnosed with an anxiety disorder that were published in PubMed, PsycINFO, and Web of Science between Jan 1, 1980 (introduction of DSM-III), and Dec 1, 2019. We also compared predictors between children, adolescents, adults, and older adults (ie, ≥55 years). A persistent course was primarily predicted by clinical and psychological characteristics, including having panic attacks, co-occurring personality disorders, treatment seeking, poor clinical status after treatment, higher severity and longer duration of avoidance behaviour, low extraversion, higher anxiety sensitivity, and higher behavioural inhibition. Unlike disorder onset, sociodemographic characteristics did not predict persistence. Our results outline a profile of patients with specific clinical and psychological characteristics who are particularly vulnerable to anxiety disorder persistence. Clinically, these patients probably deserve additional or more intensive treatment to prevent development of chronicity.

Anxiety in Late-Life Depression: Determinants of the Course of Anxiety and Complete Remission

OBJECTIVE

Studies on the course of depression often ignore comorbid anxiety disorders or anxiety symptoms. We explored predictors of complete remission (no depression nor anxiety diagnoses at follow-up) and of the course of comorbid anxiety symptoms. We additionally tested the hypothesis that the course of anxiety disorders and symptoms in depressed patients is explained by negative life-events in the presence of high neuroticism or a low sense of mastery.

METHODS

An observational study of 270 patients (≥60 years) diagnosed with major depressive disorder and 2-year follow-up data, who participated in the Netherlands Study of Depression in Older persons (NESDO). Sociodemographic, somatic, psychiatric, and treatment variables were first explored as possible predictors. A multiple logistic regression analysis was used to examine their predictive value concerning complete remission. Subsequently, negative life-events, personality and their interaction were tested as potential predictors. Linear Mixed Models were used to assess whether the personality traits modified the effect of early and recent life-events, and time and their interactions on the course of the anxiety symptoms.

RESULTS

A total of 135 of 270 patients achieved complete remission. Depressed patients with a comorbid anxiety disorder at baseline less often achieved complete remission: 38 of 103 (37.0%) versus 97 of 167 (58.1%). The severity of depressive and anxiety symptomatology, the presence of a comorbid anxiety disorder, and a poorer physical health at baseline predicted nonremission. In line with our hypothesis, a less favorable course of self-reported anxiety symptoms was associated with more recent negative life-events, but only among patients with a high level of neuroticism or a low level of mastery.

CONCLUSION

Comorbid anxiety in depression as a negative impact on complete remission at 2-year follow-up. The course of anxiety severity seems dependent on the interaction of personality traits and life-events.

Temporal patterns of anxiety disorders and cortisol activity in older adults

INTRODUCTION

Studies focusing on anxiety temporal patterns and cortisol activity in older adults are scarce. The objectives of this study were to examine in older adults the relationship between anxiety temporal patterns and cortisol activity and ascertain the presence of sex differences.

METHODS

Data were retrieved from the Étude sur la santé des ainés - Services study in Quebec and included N = 762 community living adults aged ≥ 65 years having participated in interviews at baseline (T₁) and at 4 years follow-up (T₂). A standardized questionnaire, based on DSM-5 criteria, was used to ascertain in the past 6 months the presence of anxiety (absence, remission, incidence, persistence). Cortisol activity during the interview and cortisol concentration on a regular day (at T₂) were the dependent variables. Adjusted multivariable linear regression models, stratified by sex, were used.

RESULTS

Results showed higher cortisol activity during the interview in participants with anxiety in remission (Beta: 2.59; 95% CI: 0.62 , 4.57), specifically in males, and lower activity in participants with persistent anxiety (Beta: -3.97; 95% CI: -7.05, -0.88). Cortisol concentration on a regular day was higher in males reporting incident anxiety (Beta: 8.07; 95% CI: 2.39 , 13.76).

LIMITATIONS

The convenience sample with losses to follow-up may have led to a potential selection bias.

CONCLUSION

Anxiety temporal patterns were associated with cortisol activity profiles in older adults with sex being a significant moderator. Future studies are recommended to ascertain the longitudinal changes in cortisol activity and anxiety temporal patterns, which may further inform personalized treatment of anxiety.

Anxiety symptom levels are persistent in older adults with a mental disorder: A 33-month follow-up study

OBJECTIVE

Anxiety symptoms are common in old age and have been suggested as risk factors for development of cognitive impairment and mortality. The objective of the present study was to investigate whether anxiety symptoms among older adults with a mental health diagnosis are persistent, and severity of anxiety predicts cognitive decline and mortality.

METHODS

We collected data from 201 patients referred to specialist mental health service in a department of geriatric psychiatry. Of these, 150 were reexamined after 33 months, while 51 patients died before follow-up. Mean age (SD) at baseline among the patients that were reexamined was 73.4 (7.3) years, and 67% were women. The Geriatric Anxiety Inventory (GAI) was used to measure anxiety symptoms at baseline and follow-up. We investigated whether higher GAI scores at baseline were associated with persistence of anxiety. Associations with cognitive decline or mortality were also explored. The associations were estimated by use of trajectory analysis and regression models.

RESULTS

Seventy-four percentages had the same level of anxiety symptoms, and 29% had a high level of anxiety at baseline and follow-up. GAI score at baseline was not associated with cognitive decline or mortality at 33-month follow-up.

CONCLUSION

In a longitudinal study of anxiety symptoms among older adults in specialist mental health services, we demonstrate persistent high or low levels of anxiety symptoms. Anxiety trajectories over time were not predicted by patient characteristics. Also the level of anxiety cannot be used as predictor for future cognitive decline or mortality in a clinical population.

Anxiety and anhedonia in depression: Associations with neuroticism and cognitive control

BACKGROUND

Despite the fact that higher levels of anxiety and anhedonia in Major Depressive Disorder (MDD) are linked to poorer treatment outcomes, mechanisms contributing to these clinical presentations remain unclear. Neuroticism, impaired cognitive control, and blunted reward learning may be critical processes involved in MDD and may help to explain symptoms of anxiety and anhedonia.

METHODS

Using baseline data from patients with early-onset MDD (N = 296) in the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) trial, we conducted a path analysis to model relationships between neuroticism, cognitive control, and reward learning to levels of anxiety and anhedonia.

RESULTS

Neuroticism was positively associated with both anhedonia (standardized coefficient = 0.26, p < .001) and anxiety (standardized coefficient = 0.40, p < .001). Cognitive control was negatively associated with anxiety (standardized coefficient = -0.18, p < .05). Reward learning was not significantly associated with either anxiety or anhedonia.

LIMITATIONS

Extraneous variables not included in the model may have even more influence in explaining symptoms of anxiety and anhedonia. Restricted range in these variables may have attenuated some of the hypothesized relationships. Most important, because this was a cross-sectional analysis in a currently depressed sample, we cannot draw any causal conclusions without experimental and longitudinal data.

CONCLUSIONS

These cross-sectional findings suggest that neuroticism may contribute to anxiety and anhedonia in patients with early onset and either chronic or recurrent MDD, while enhanced cognitive control may protect against anxiety.

Prevalence of Anxiety Symptoms and Their Association With Loss Experience in a Large Cohort Sample of the Oldest-Old. Results of the AgeCoDe/AgeQualiDe Study

Background: Anxiety in adults is a common mental health problem. However, studies on anxiety in the oldest-old are lacking. We sought to identify the age- and gender-specific prevalence of anxiety symptoms in a large sample of general practice patients. Furthermore, we investigated relevant associations of anxiety specifically with respect to recent experience of loss. Methods: Based on the German Study on Ageing, Cognition and Dementia in general practice patients, a sample of 897 patients aged 82 years and older was assessed. Anxiety was assessed using the short form of the Geriatric Anxiety Inventory (GAI-SF). For the assessment of loss, patients were asked whether there were cases of death in their closer social environment since the last assessment. Descriptive and logistic regression analyses were run. Results: Of the oldest-old individuals (aged 82+ years, mean age: 86.8), 14.5% (95% CI 12.4-16.8) suffered from anxiety symptoms. Highest prevalence rates were found for 82- to 85-year-old women (17.2%, 95% CI 12.6-22.1) and for 86- to 90-year-old patients (both sexes) in general (15.9%, 95% CI 12.6-19.2). Older individuals who experienced cases of death in their close social environment within the last 18 months had almost twice the odds [odds ratio (OR) 1.91, 95% confidence interval (CI) 1.15-3.17] of reporting anxiety compared to those without a recent loss. As expected, depression and impaired cognitive status were associated with the presence of anxiety symptoms. No relation was found between social network, gender, age, frailty, or physical illness and anxiety in regression analysis. Conclusions: This study provides for the first time age- and gender-specific prevalence rates of anxiety symptoms and associated risk factors among a large population-based sample of oldest-old primary care attenders. Anxiety is highly prevalent in individuals aged 82 years and older. Depression, impaired cognitive status, and recent experience of loss are associated with late-life anxiety. Our findings support the idea that recent experience of loss should be taken seriously in the context of clinical practice with respect to diagnosing and treating anxiety in old age.

Predictors of Pharmacotherapy Response in Generalized Anxiety Disorder: A Systematic Review

BACKGROUND

Pharmacotherapy for generalized anxiety disorder (GAD) may be effective in reducing symptoms in the majority of patients. The study of moderators and predictors of treatment response may help clinicians both to select appropriate interventions to maximize the probability of response and to inform the general prognosis.

METHODS

A systematic literature search of electronic databases, selected authors, and reference lists was used to identify articles that reported trials of drug monotherapy in GAD. Data on predictors and moderators were extracted. Quality of evidence was determined by the presence of a priori hypotheses, number of variables investigated, adequate quality of the measurement, and use of interaction-effects testing.

RESULTS

From the 98 articles meeting inclusion criteria, 24 reported a total of 22 factors associated with treatment response. The reported results were heterogeneous, ranging over sociodemographic, clinical, comorbidity, genetic, and functional-imaging studies. Major depressive symptoms were found to moderate treatment outcome in favor of antidepressants versus benzodiazepines. Neuroticism, previous treatment, genetic polymorphisms (including serotonin receptor gene 2A), and functional activation of the anterior cingulate cortex and amygdala were identified as potential predictors of treatment response.

CONCLUSIONS

Correlates of poor emotion regulation predicted poor treatment response, but subclinical depression was the only variable capable of informing treatment selection in this review. Future research should focus on further exploring the value of depression as a moderator and on a narrower list of potential genetic, brain-imaging, and temperament predictors of response to pharmacotherapy in GAD.

Worry and cognitive control predict course trajectories of anxiety in older adults with late-life depression

BACKGROUND

Many older adults with depressive disorder manifest anxious distress. This longitudinal study examines the predictive value of worry as a maladaptive cognitive emotion regulation strategy, and resources necessary for successful emotion regulation (i.e., cognitive control and resting heart rate variability [HRV]) for the course of anxiety symptoms in depressed older adults. Moreover, it examines whether these emotion regulation variables moderate the impact of negative life events on severity of anxiety symptoms.

METHODS

Data of 378 depressed older adults (CIDI) between 60 and 93 years (of whom 144 [41%] had a comorbid anxiety disorder) from the Netherlands Study of Depression in Older Adults (NESDO) were used. Latent Growth Mixture Modeling was used to identify different course trajectories of six-months BAI scores. Univariable and multivariable longitudinal associations of worry, cognitive control and HRV with symptom course trajectories were assessed.

RESULTS

We identified a course trajectory with low and improving symptoms (57.9%), a course trajectory with moderate and persistent symptoms (33.5%), and a course trajectory with severe and persistent anxiety symptoms (8.6%). Higher levels of worry and lower levels of cognitive control predicted persistent and severe levels of anxiety symptoms independent of presence of anxiety disorder. However, worry, cognitive control and HRV did not moderate the impact of negative life events on anxiety severity.

CONCLUSIONS

Worry may be an important and malleable risk factor for persistence of anxiety symptoms in depressed older adults. Given the high prevalence of anxious depression in older adults, modifying worry may constitute a viable venue for alleviating anxiety levels.

Sedative-Hypnotic Use Among Older Adults Participating in Anxiety Research

Older adults are prescribed sedative-hypnotic medications at higher rates than younger adults. These are not recommended for older adults due to risk of sedation, cognitive impairment, and falls. Severe generalized anxiety disorder (GAD) is a possibly appropriate use of these medications in older people, but little is available on use of sedative-hypnotic medications among older adults with GAD. This study examined the frequency and predictors of sedative-hypnotic medication use among older adults screening positive for anxiety. 25.88% ( n = 125) of participants reported taking sedative-hypnotics over the past 3 months; 16.36% ( n = 79) reported taking benzodiazepines, and 12.22% ( n = 59) reported taking hypnotic sleep medications. Depressive symptoms were more strongly associated with sedative-hypnotic use than insomnia or worry. Major depressive disorder and posttraumatic stress disorder, but not GAD, predicted sedative-hypnotic use. Other medications and treatments are more appropriate and efficacious for depression, anxiety, and insomnia in this population.

Anxiety symptoms in Korean elderly individuals: a two-year longitudinal community study

BACKGROUND

Although late-life anxiety occurs frequently and is associated with higher morbidity, few longitudinal studies have been concerned with the evaluation thereof. We investigated the prevalence, incidence, and persistence of anxiety and related factors over a two-year period in community-dwelling Korean elderly individuals.

METHODS

A total of 1,204 Korean elderly individuals were evaluated at baseline, and 909 were followed up two years later. The community version of the Geriatric Mental State Schedule was used to estimate anxiety at both baseline and follow-up interviews. We defined "prevalence" as the rate of anxiety symptoms (for both anxiety cases and sub-threshold anxiety) at baseline; "incidence" as the rate of anxiety symptoms at follow-up in those without baseline anxiety symptoms; and "persistence" as the rate of anxiety symptoms at follow-up in those with baseline anxiety symptoms. Associations between various covariates and anxiety status were examined using multivariate logistic regression models.

RESULTS

The prevalence, incidence, and persistence of anxiety symptoms were 38.1%, 29.3%, and 41.1%, respectively. Prevalent anxiety symptoms were associated independently with female, rented housing, more stressful life event and medical illness, physical inactivity, depression, insomnia, and lower cognitive function. Incident anxiety symptoms were predicted by older age, female gender, depression, and insomnia; persistent anxiety symptoms were predicted by older age, more medical illness, and baseline depression.

CONCLUSIONS

Since depression was associated with prevalent, incident, and persistent anxiety symptoms, effective detection and management thereof is important in older adults to reduce anxiety. Furthermore, preventive collaborative care should be considered, particularly for older, female, insomniac patients.

Investigation of diazepam efficacy on anxiety-like behavior in hemiparkinsonian rats

There is growing recognition that anxiety disorders have a greater impact on quality of life in Parkinson's disease than motor symptoms. Yet, little is known about the pathophysiology underlying this non-motor symptom in Parkinson's disease which poses a considerable barrier in developing effective treatment strategies. Here, we administered diazepam to hemiparkinsonian and non-parkinsonian rats and assessed its efficacy in three anxiety behavioral tests. At present, no information about this exists in preclinical research with sparse data in the clinical literature. Moreover, diazepam is an acute anxiolytic which makes this drug a suitable research tool to unmask differences in anxiety-like behavior. Using the unilateral, medial forebrain bundle 6-hydroxydopamine rat model of Parkinson's disease, we noted that hemiparkinsonian rats had more baseline anxiety-like behavior with 60% of them exhibiting high anxiety (HA) behavior in the elevated plus maze. In contrast, 41% of sham-lesioned rats and 8% of naïve rats exhibited HA behavior. Next, we employed the elevated plus maze and noted that diazepam (1.5mg/kg) was anxiolytic in low anxiety (LA) sham-lesioned (p=0.006) and HA sham-lesioned rats (p=0.016). Interestingly, diazepam was anxiolytic for LA hemiparkinsonian rats (p=0.017), but not for HA hemiparkinsonian rats (p=0.174) despite both groups having similar motor impairment and parkinsonian phenotype. Overall, diazepam administration unmasked differences in anxiolytic efficacy between HA hemiparkinsonian rats, LA hemiparkinsonian rats and non-parkinsonian rats. Our data suggests that neuro-circuits involved in anxiety-like behavior may differ within these groups and posits that diazepam may have reduced efficacy in certain individuals with PD anxiety disorders.

New research on anxiety disorders in the elderly and an update on evidence-based treatments

Anxiety disorders are frequently encountered in the elderly, but they are largely undetected and untreated. Epidemiological studies indicate a prevalence ranging from 1.2 to 15 %. With the exception of generalized anxiety disorder and agoraphobia, which can often start in late life, most anxiety disorders in older patients are chronic and have their onset earlier in life. Anxiety disorders are an often unrecognized cause of distress, disability, and mortality risk in older adults, and they have been associated with cardiovascular disease, stroke, and cognitive decline. The mechanisms of anxiety in older adults differ from that in younger adults due to age-related neuropathology, as well as the loss and isolation so prominent in late life. Our review intends to provide a comprehensive summary of the most recent research done in the field of anxiety disorders in the elderly. Recent findings in clinical research, neuroimaging, neuroendocrinology, and neuropsychology are covered. An update on treatment options is discussed, including pharmacological and non-pharmacological alternatives.

The natural course of anxiety disorders in the elderly: a systematic review of longitudinal trials

BACKGROUND

The anxiety disorders are a prevalent mental health problem in older age with a considerable impact on quality of life. Until recently there have been few longitudinal studies on anxiety in this age group, consequently most of the evidence to date has been cross-sectional in nature.

METHODS

We undertook a literature search of Medline, PsycINFO, the Cochrane trials database and the TRIP medical database to identify longitudinal studies which would help elucidate natural history and prognosis of anxiety disorders in the elderly.

RESULTS

We identified 12 papers of 10 longitudinal studies in our Review. This represented 34,691 older age participants with 5,199 with anxiety disorders including anxious depression and 3,532 individuals with depression without anxiety. Relapse rates of anxiety disorders are high over 6 year follow-up with considerable migration to mixed anxiety-depression and pure depressive mood episodes. Mixed anxiety-depression appears to be a poorer prognostic state than pure anxiety or pure depression with higher relapse rates across studies. In community settings treatment rates are low with 7-44% of the anxious elderly treated on antidepressant medications.

CONCLUSIONS

To our knowledge this is the first Systematic Review of longitudinal trials of anxiety disorders in older people. Major longitudinal studies of the anxious elderly are establishing the high risk of relapse and persistence alongside the progression to depression and anxiety depression states. There remains considerable under-treatment in community studies. Specialist assessment and treatment and major public health awareness of the challenges of anxiety disorders in the elderly are required.

The regional distribution of anxiety disorders: implications for the Global Burden of Disease Study, 2010

Anxiety disorders are increasingly acknowledged as a global health issue however an accurate picture of prevalence across populations is lacking. Empirical data are incomplete and inconsistent so alternate means of estimating prevalence are required to inform estimates for the new Global Burden of Disease Study 2010. We used a Bayesian meta-regression approach which included empirical epidemiological data, expert prior information, study covariates and population characteristics. Reported are global and regional point prevalence for anxiety disorders in 2010. Point prevalence of anxiety disorders differed by up to three-fold across world regions, ranging between 2.1% (1.8-2.5%) in East Asia and 6.1% (5.1-7.4%) in North Africa/Middle East. Anxiety was more common in Latin America; high income regions; and regions with a history of recent conflict. There was considerable uncertainty around estimates, particularly for regions where no data were available. Future research is required to examine whether variations in regional distributions of anxiety disorders are substantive differences or an artefact of cultural or methodological differences. This is a particular imperative where anxiety is consistently reported to be less common, and where it appears to be elevated, but uncertainty prevents the reporting of conclusive estimates.

A longitudinal examination of anxiety disorders and physical health conditions in a nationally representative sample of U.S. older adults

BACKGROUND

There has been growing interest in the relation between anxiety disorders and physical conditions in the general adult population. However, little is known about the nature of this association in older adults. Understanding the complex relationship between these disorders can help to inform prevention and treatment strategies unique to this rapidly growing segment of the population.

METHODS

A total of 10,409 U.S. adults aged 55+ participated in Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Lifetime and past-year DSM-IV anxiety, mood, and substance use disorders, and lifetime personality disorders, were assessed in both waves. Participants self-reported on whether they had been diagnosed by a healthcare professional with a broad range of physical health conditions; this study focuses on cardiovascular disease, gastrointestinal disease, and arthritis. Multivariable logistic regressions adjusted for sociodemographics, comorbid mental disorders, and number of physical health conditions assessed: (1) the relation between past-year physical conditions at Wave 1 and incident past-year anxiety disorders at Wave 2 and; (2) the relation between individual lifetime anxiety disorders at Wave 1 and incident physical conditions at Wave 2. A second set of adjusted multinomial logistic regressions examined Wave 1 sociodemographic and physical and mental health risk factors associated with incident physical condition alone, anxiety disorder alone, and comorbid anxiety and physical condition at Wave 2.

RESULTS

Past-year arthritis at Wave 1 was significantly associated with increased odds of incident generalized anxiety disorder at Wave 2. Further, any lifetime anxiety disorder and posttraumatic stress disorder at Wave 1 were significantly associated with increased odds of incident gastrointestinal disease at Wave 2. Differential sociodemographic and physical and mental health predictors were significantly associated with increased odds of incident comorbid anxiety disorder and physical conditions.

CONCLUSION

Results of the current study elucidate the longitudinal bidirectional relationships between anxiety disorders and physical health conditions in a large, nationally representative sample of older adults. These results have important implications for identifying at risk older adults, which will not only impact this growing segment of the population directly, but will also potentially lessen burden on the healthcare system as a whole.

Prevalence and predictors of persistent versus remitting mood, anxiety, and substance disorders in a national sample of older adults

OBJECTIVES

Relatively little is known about whether mental disorders other than depression remit versus persist in later life, especially within nationally representative samples. Our objectives were to examine the prevalence of persistent mood, anxiety, and substance disorders in older adults and to explore a range of physical and mental health predictors of disorder chronicity.

METHODS

This study involved a 3-year follow-up design using Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Participants included 1,994 adults aged 55 years and older who had a past-year mental disorder at Wave 1 and who completed Wave 2. The primary outcome was the prevalence of persistent mood, anxiety, and substance disorders at Wave 2. Potential predictors of persistence included sociodemographic variables, physical health (chronic health conditions and physical health-related quality of life), and mental health (childhood adversity, suicide attempts, mental health-related quality of life, comorbid mental disorders, personality disorders, and lifetime treatment-seeking).

RESULTS

With the exception of nicotine dependence, the prevalence of persistent mood, anxiety, and substance disorders ranged from 13% to 33%. Only younger age predicted substance disorder chronicity. Significant predictors of persistent mood and anxiety disorders included physical and mental health comorbidity, physical health- and mental health-related quality of life, suicide attempts, comorbid personality disorders, and treatment-seeking.

CONCLUSIONS

At least two-thirds of mental disorders in these older adults were not persistent. Sociodemographic variables had little influence on chronicity, whereas a number of markers of mental disorder severity and complexity predicted persistent mood and anxiety disorders. The findings have important treatment and prevention implications.

Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: a comparison with younger patients

BACKGROUND

Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive-behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults.

METHODS

A total of 172 patients with PDA (DSM-IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18-60 years) and older (≥ 60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions.

RESULTS

Attrition rates were 2/31 (6%) for the over-60s and 31/141 (22%) for the under-60s group (χ(2) = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate-to-large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age-related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P-values < .001). Apart from a superior reduction of agoraphobic avoidance in the 60+ participants (β = -0.30, P = .037), chronological age was not related to outcome, while in the older patients higher chronological age, late-onset type and short DOI were linked to superior improvement of agoraphobic avoidance.

CONCLUSIONS

CBT appears feasible for 60+ PDA-patients, yielding outcomes that are similar and sometimes even superior to those obtained in younger patients.

Global epidemiology of mental disorders: what are we missing?

Background

Population-based studies provide the understanding of health-need required for effective public health policy and service-planning. Mental disorders are an important but, until recently, neglected agenda in global health. This paper reviews the coverage and limitations in global epidemiological data for mental disorders and suggests strategies to strengthen the data.

Methods

Systematic reviews were conducted for population-based epidemiological studies in mental disorders to inform new estimates for the global burden of disease study. Estimates of population coverage were calculated, adjusted for study parameters (age, gender and sampling frames) to quantify regional coverage.

Results

Of the 77,000 data sources identified, fewer than 1% could be used for deriving national estimates of prevalence, incidence, remission, and mortality in mental disorders. The two major limitations were (1) highly variable regional coverage, and (2) important methodological issues that prevented synthesis across studies, including the use of varying case definitions, the selection of samples not allowing generalization, lack of standardized indicators, and incomplete reporting. North America and Australasia had the most complete prevalence data for mental disorders while coverage was highly variable across Europe, Latin America, and Asia Pacific, and poor in other regions of Asia and Africa. Nationally-representative data for incidence, remission, and mortality were sparse across most of the world.

Discussion

Recent calls to action for global mental health were predicated on the high prevalence and disability of mental disorders. However, the global picture of disorders is inadequate for planning. Global data coverage is not commensurate with other important health problems, and for most of the world's population, mental disorders are invisible and remain a low priority.

Pharmacologic treatment of anxiety disorders in Parkinson disease

OBJECTIVE

Neither best practices nor an evidence base for the pharmacologic treatment of anxiety in Parkinson disease (PD) has been established. This study investigated pharmacologic treatment of anxiety disorders in idiopathic PD and the associated clinical features.

DESIGN

Cross-sectional.

SETTING

Three community-based movement disorder neurology practices.

PARTICIPANTS

250 subjects with PD.

MEASUREMENTS

Anxiety disorder diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Current medications were provided by the treating neurologists at the time of interview.

RESULTS

Among subjects with anxiety disorders only, 53% were untreated with medications. When anxious subjects with comorbid depressive disorders were included, 70.8% were on medications effective for treatment of anxiety. Subjects with anxiety and comorbid depressive disorders were more likely to be treated for their psychiatric disturbances than subjects with anxiety disorders alone (odds ratio: 8.33), as were subjects with comorbid motor fluctuations (odds ratio: 3.65). There were no differences in the types of anti-anxiety medications used in regard to the presence of depression or motor fluctuations.

CONCLUSIONS

These findings suggest that over half of nondepressed PD patients with clinically significant anxiety are untreated with medication. A better understanding of the role of clinical features associated with anxiety in PD, such as depression and motor fluctuations, may improve the recognition and treatment of anxiety disorders in this population.

Longitudinal relationship of depressive and anxiety symptoms with dyslipidemia and abdominal obesity

OBJECTIVE

Previous research indicates that patients with severe symptoms of depression or anxiety are prone toward the development of dyslipidemia and abdominal obesity. We sought to study these associations longitudinally.

METHODS

Among 2126 Netherlands Study of Depression and Anxiety participants, we studied whether severity of depressive (Inventory of Depressive Symptoms) or anxiety (Beck Anxiety Inventory) symptoms at baseline was associated with changes in lipids (i.e., total, high-density lipoprotein [HDL] or low-density lipoprotein cholesterol, and triglycerides) or waist circumference during a 2-year follow-up period. We also examined whether changes in severity of symptoms were associated with changes in lipid or waist circumference levels over these 2 years. Multivariate linear regression analyses were adjusted for age, sex, education, and tobacco consumption.

RESULTS

Baseline symptoms of depression or anxiety predicted a decrease in HDL cholesterol (adjusted β = -.062 [p = .003] and β = -.050 [p = .02], respectively) and an increase in waist circumference (adjusted β = .060 [p = .01] and β = .053 [p = .02], respectively) for 2 years. Reduction of symptoms of depression or anxiety over time did not coincide with an amelioration of lipid or waist circumference values.

CONCLUSIONS

People with initially severe symptoms of depression or anxiety showed a subsequent decrease in HDL cholesterol levels and an increase in abdominal obesity over time, independent of a potential reduction in symptom severity in this period. Therefore, such people are at elongated and increasing risk for dyslipidemia and obesity, predisposing them to cardiovascular disease.

The association of African Americans' perceptions of neighborhood crime and drugs with mental illness

BACKGROUND

Many African Americans are socioeconomically disadvantaged and live in neighborhoods containing chronic sources of stress. Although environmental stressors can contribute to the development of mental illness, there is a paucity of national studies examining the association of neighborhood crime and drug problems with psychiatric disorders. This study aims to determine if higher levels of perceived neighborhood problems are associated with greater prevalence of 12-month and lifetime psychiatric disorders among African Americans.

METHODS

To do so, we used cross-sectional data from the National Survey of American Life, which interviewed a nationally representative sample of 3,570 African Americans.

RESULTS

Of these African Americans, nearly 20 and 40% reported that crime and drug use are problems in their neighborhoods, respectively. Respondents reporting high levels of perceived neighborhood crime or drug problems are 1.5-2.9 times more likely to have a 12-month psychiatric disorder and 1.4-2.1 times more likely to have a lifetime psychiatric disorder compared to the other respondents. After accounting for sociodemographics and chronic disease, neighborhood crime remains associated with 12-month mood, 12-month substance use, and lifetime substance use disorders, whereas neighborhood drug problems remain significantly associated with 12-month and lifetime anxiety and substance use disorders.

CONCLUSIONS

Among African Americans perceived neighborhood problems are widespread and positively associated with psychiatric disorders. Consideration of neighborhood context is important to more comprehensively understand mental illness and its treatment in this population.

Mental healthcare need and service utilization in older adults living in public housing

OBJECTIVES

Anxiety and depression in socioeconomically disadvantaged older adults frequently go unrecognized and untreated. This study aims to characterize mental illness and its treatment in older adult public housing residents who have many risk factors for anxiety and depression.

DESIGN

Cross-sectional study.

SETTING

Public housing high-rises in Rochester, New York.

PARTICIPANTS

One hundred ninety residents aged 60 years and older.

MEASUREMENTS

Anxiety and depression were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, GAD-7, and Patient Health Questionnaire. We obtained information on mental healthcare from medication review and self-report.

RESULTS

Participants had a median age of 66 years, 58% were women, 80% were black, and 92% lived alone. Many participants (31%) were in need of mental healthcare: 21% had syndromal and 11% had subsyndromal anxiety or depression. Mental healthcare need was associated with younger age; intact cognitive functioning; impairments in instrumental activities of daily living (IADL); more medical illness; decreased mobility; smaller social network size; more severe life events; and increased utilization of medical, human, and informal services. Of those with mental healthcare need, most were not receiving it. Compared with residents receiving mental healthcare, residents with untreated need were more likely to be men and have less IADL impairment, medical illness, severe life events, onsite social worker use, and human services utilization.

CONCLUSIONS

Mental illness was common and largely untreated in public housing residents. Increasing collaboration between medical, mental, and human services is needed to improve identification, treatment, and ultimately prevention of late-life mental illness in this community setting.

Anxiety disorders in older people

This article reviews the research into anxiety disorders in adults aged 65 years and older that has been published over the past ten years. The topics covered include: the construct of anxiety and its disorders in this age group; epidemiology, including prevalence, incidence, course, outlook, and risk factors; assessment scales; co-morbidity and differential diagnosis (depression, dementia, physical illness); and management, both pharmacological and non-pharmacological. There has been a significant improvement in our understanding of these disorders in older adults over this period, but evidence to support their treatment and prevention is still quite sparse.

A lifespan view of anxiety disorders

Neurodevelopmental changes over the lifespan, from childhood through adulthood into old age, have important implications for the onset, presentation, course, and treatment of anxiety disorders. This article presents data on anxiety disorders as they appear in older adults, as compared with earlier in life. In this article, we focus on aging-related changes in the epidemiology, presentation, and treatment of anxiety disorders. Also, this article describes some of the gaps and limitations in our understanding and suggests research directions that may elucidate the mechanisms of anxiety disorder development later in life. Finally we describe optimal management of anxiety disorders across the lifespan, in "eight simple steps" for practitioners.

A Twin Study of Lifetime Generalized Anxiety Disorder (GAD) in Older Adults: Genetic and Environmental Influences Shared by Neuroticism and GAD

The nature of Generalized Anxiety Disorder (GAD) and worry across the lifespan remains incompletely understood. We investigated genetic and environmental influences on GAD and the proportion of genetic and environmental variation in GAD that is shared with neuroticism in older adult twins. Participants included 1618 monozygotic and 2291 same-sexed dizygotic twin pairs from the Swedish Twin Registry aged 55 to 74. Participants provided personality information in 1973 and also participated in a telephone screening between 1998 and 2002 that included an assessment for lifetime GAD. Univariate biometric models indicated that both GAD and neuroticism were moderately heritable (.27 and .47, respectively), while the balance of variation reflected environmental factors unique to the individual. Bivariate analyses indicated that approximately one third of the genetic influences on GAD were in common with genetic influences on neuroticism, while individual specific environmental influences were virtually unshared between GAD and neuroticism. Analyses of sex effects suggested that men and women differed in the frequency of lifetime GAD and level of neuroticism; however, no sex differences for genetic and environmental influences for either trait were identified.

Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults

OBJECTIVE

The primary objectives of this study were to examine the likelihood of anxiety disorders among respondents with common physical health conditions and to explore the associations between this comorbidity and older adults' perceived mental and physical health.

METHOD

The sample consisted of older adults from the Canadian Community Health Survey 1.2 (n=12,792). Trained lay interviewers assessed psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Physical health conditions were based on self-reported diagnoses by health professionals. Multiple logistic regressions examined whether suffering from a physical health condition increased the odds of any assessed anxiety disorder (panic, agoraphobia, social phobia and posttraumatic stress disorder). Multiple linear regressions examined associations between self-rated health and comorbid physical health conditions and anxiety.

RESULTS

After adjusting for confounding variables, the presence of chronically painful conditions (i.e., arthritis, back pain and migraine) and of other commonly occurring diseases (i.e., allergies, cataracts and gastrointestinal, lung and heart disease) were positively associated with anxiety. The comorbidity of anxiety with allergies, cataracts, arthritis and lung disease resulted in poorer self-rated physical and/or mental health after adjusting for confounding variables.

CONCLUSION

Health problems in older adults are associated with increased odds of anxiety, and this comorbidity is associated with poorer self-reported health than medical problems or anxiety alone. These findings have important clinical implications for health professionals.

Anxiety, mood, and substance use disorders in United States African-American public housing residents

BACKGROUND

African-Americans experience considerable mental healthcare disparities in the United States, but little is known about sensitive subgroups within this population. To better understand healthcare disparities within African-Americans communities, we characterized anxiety, mood, and substance use disorder prevalence and associated service utilization among public and non-public housing residents.

METHODS

We used data from a nationally representative sample of African-Americans recruited as part of the National Survey of American Life.

RESULTS

In public housing residents, the 12-month prevalence of anxiety disorders was 1.8 times higher than in non-public housing residents (P = 0.002), mood disorders was 1.4 times higher (P = 0.189), and substance use disorders was 2.2 times higher (P = 0.031). Public housing remained associated with mental illness after controlling for sociodemographics and chronic illness. Public and non-public housing residents did not differ significantly in mental healthcare utilization, but utilization was low with 16-30% of public housing residents with a 12-month disorder receiving mental health assistance.

CONCLUSIONS

A relatively high proportion of African-American public housing residents suffered from psychiatric disorders, and few received mental healthcare assistance, indicating that further work is needed to enhance utilization.

Anxiety disorders and comorbid depression in community dwelling older adults

Anxiety disorder is a common psychiatric problem during late-life, and frequently co-occurs with depression. High comorbidity between anxiety and depression may partly be explained by the definition of the disorders and the assessment of both disorders with one instrument at the same time. The current study investigates the relation of current and past depression with anxiety disorders in the Rotterdam Study, a large population-based cohort study of older adults in the Netherlands (n study population = 5565). DSM-IV anxiety disorder was ascertained with the Munich version of the Composite International Diagnostic Interview. DSM-IV depression was diagnosed with the Schedules for Clinical Assessment of Neuropsychiatry (SCAN) on a different day. Past depression was assessed from general practitioners' records, self-report, and a prior SCAN interview. Of the 457 persons with an anxiety disorder, 11.6% had a comorbid major depression, and another 6.3% had other depressive syndromes. However, 49.3% of persons with an anxiety disorder experienced or had in the past experienced a depressive episode. Our study suggests that comorbid depression in older adults with anxiety disorders may be less prevalent than previously suggested. However, the relation of current anxiety disorders with past depression is substantial.

Anxiety and its correlates among older adults accessing aging services

OBJECTIVES

To assess the characteristics of anxiety in aging services network (ASN) clients.

METHODS

Interviews were conducted as part of an academic-community partnership for studying the mental health needs of community-dwelling older adults. Participants consisted of ASN clients in Monroe County, NY, that were aged 60 years and older and received an in-home assessment for care management services. The Goldberg Anxiety Scale screened for anxiety symptoms, and instruments covering the domains of associated mental health, physical health and disability, social support, negative life events, and other areas relevant to delivery of aging services were administered.

RESULTS

Of 378 subjects enrolled, 27% had clinically significant levels of anxiety. In bivariate analyses anxiety was associated with having a current major depressive episode (MDE), five or more medical conditions, pain, younger age, less income, and negative life events. After controlling for MDE in multivariate analyses, medical conditions, pain, negative life events, and younger age were significant correlates of anxiety in ASN clients.

CONCLUSIONS

Anxiety was common among ASN clients who received in-home care management services. These anxious clients suffered from a combination of mental, medical, and social issues that suggests the need for multidisciplinary care. Because aging services providers work with their clients to ameliorate conditions that are highly correlated with anxiety, the ASN represents a promising venue for detecting, managing, and preventing anxiety among older adults.

Mental distress and service utilization among help-seeking, community-dwelling older adults

BACKGROUND

This study aimed to characterize healthcare and human services utilization among mentally distressed and non-distressed clients receiving in-home care management assessment by aging services provider network (ASPN) agencies in the U.S.A.

METHODS

A two-hour research interview was administered to 378 English-speaking ASPN clients aged 60+ years in Monroe County, NY. A modified Cornell Services Index measured service utilization for the 90 days prior to the ASPN assessment. Clients with clinically significant anxiety or depressive symptoms were considered distressed.

RESULTS

ASPN clients utilized a mean of 2.93 healthcare and 1.54 human services. The 42% of subjects who were distressed accessed more healthcare services (e.g. mental health, intensive medical services) and had more outpatient visits and days hospitalized than the non-distressed group. Contrary to expectations, distressed clients did not receive more human services. Among those who were distressed, over half had discussed their mental health with a medical professional in the past year, and half were currently taking a medication for their emotional state. A far smaller proportion had seen a mental health professional.

CONCLUSIONS

In the U.S.A., aging services providers serve a population with high medical illness burden and medical service utilization. Many clients also suffer from anxiety and depression, which they often have discussed with a medical professional and for which they are receiving medications. Few, however, have seen a mental health specialist preceding intake by the ASPN agency. Optimal care for this vulnerable, service intensive group would integrate primary medical and mental healthcare with delivery of community-based social services for older adults.

A randomized controlled study of paroxetine and cognitive-behavioural therapy for late-life panic disorder

OBJECTIVE

To examine the effectiveness of paroxetine and cognitive-behavioural therapy (CBT) in elderly patients suffering from panic disorder with or without agoraphobia (PD(A)).

METHOD

Forty-nine patients aged 60+ years with confirmed PD(A) were randomly assigned to 40 mg paroxetine, individual CBT, or to a 14-week waiting list. Outcomes, with avoidance behaviour and agoraphobic cognitions being the primary measures, were assessed at baseline and at weeks 8, 14 (conclusion CBT/waiting list), and at week 26 (treated patients only) and analysed using mixed models.

RESULTS

All outcome measures showed that the patients having received CBT and those treated with paroxetine had significantly better improvement compared with those in the waiting-list condition. With one patient (1/20, 5%) in the CBT and three (3/14, 17.6%) in the paroxetine condition dropping out, attrition rates were low.

CONCLUSION

Patients with late-life panic disorder respond well to both paroxetine and CBT. Although promising, the outcomes warrant replication in larger study groups.

Long-term effectiveness and prediction of treatment outcome in cognitive behavioral therapy and sertraline for late-life anxiety disorders

BACKGROUND

Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders.

METHODS

Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established.

RESULTS

Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants.

CONCLUSIONS

Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Prevention of depression and anxiety in later life: design of a randomized controlled trial for the clinical and economic evaluation of a life-review intervention

BACKGROUND

Depressive and anxiety symptoms in older adults could develop into significant health problems with detrimental effects on quality of life and a possibly poor prognosis. Therefore, there is a need for preventive interventions which are at once effective, acceptable and economic affordable.

METHODS AND DESIGN

This paper describes the design of a study evaluating "The stories we live by", a preventive life-review group intervention, which was recently developed for adults of 55 years and over with depressive and anxiety symptoms. Both clinical and economic effectiveness will be evaluated in a pragmatic randomized controlled trial. The participants in the intervention condition will receive the 8-session preventive intervention. The participants in the control condition will have access to usual care. Clinical end-terms are depressive and anxiety symptoms, current major depressive episode, quality of life and positive mental health post-treatment (3 months after baseline) and at follow-ups (6 and 12 months after baseline). Additional goals of this study are to identify groups for whom the intervention is particularly effective and to identify the therapeutic pathways that are vital in inducing clinical change. This will be done by analyzing if treatment response is moderated by demographics, personality, past major depressive episodes, important life events and chronically disease, and mediated by reminiscence functions, perceived control, automatic positive thoughts and meaning in life. Finally the cost-effectiveness of the intervention relative to care as usual will be assessed by computing incremental costs per case of depression and anxiety avoided (cost-effectiveness) and per quality adjusted life year (QALY) (cost utility).

DISCUSSION

It is expected that both the life-review intervention and its evaluation will contribute to the existing body of knowledge in several ways. First, the intervention is unique in linking life-review with narrative therapy and in its focus on specific, positive memories. Second, the evaluation is likely to answer questions regarding the acceptability and cost-effectiveness of life-review that have not been addressed thoroughly until now. Positive results of this study will make available a new evidence-based intervention to improve public health among people of 55 years and over.

TRIAL REGISTRATION

Nederlands Trial Register TC = 1860.

Benzodiazepine and antidepressant use in elderly patients with anxiety disorders: a survey of 796 outpatients in Japan

Since the literature on benzodiazepine use in elderly patients with anxiety disorders is limited, a large cross-sectional review of psychotropic prescriptions in 796 patients with neurotic disorders (ICD-10) (age range=11-91 years) was conducted across 30 sites in Japan. Use of benzodiazepine-derivative anxiolytics was approximately 70% in all decades without a group difference. The proportion of subjects who received prescriptions for benzodiazepine-derivative anxiolytics in the absence of antidepressants was higher in older age groups (e.g., 27.7% and 43.2% in the third and sixth decades, respectively). On the other hand, antidepressants were less frequently prescribed in older age groups (e.g., 59.8% and 41.5% in the third and sixth decades, respectively). The very high use of anxiolytics in the elderly, especially in the absence of concomitant antidepressant use, is a cause for concern since they are not a preferred long-term treatment strategy given their adverse effects in the elderly.

Anxiety in middle adulthood: effects of age and time on the 14-year course of panic disorder, social phobia and generalized anxiety disorder

BACKGROUND

Much about the long-term course of anxiety disorders is unknown. The present study utilizes a naturalistic, longitudinal, short-interval follow-up design to elucidate the course of anxiety disorders over 14 years in a largely middle-aged adult sample recruited from out-patient psychiatry and primary care facilities.

METHOD

The sample consisted of 453 participants with a diagnosis of panic disorder (PD), social phobia (SP) and/or generalized anxiety disorder (GAD). Anxiety symptom ratings were tracked using weekly psychiatric status ratings (PSRs). Controlling for demographic and clinical variables, the course of PD, GAD and SP were examined using longitudinal growth models, with the most severe PSR at each follow-up point as the main outcome variable.

RESULTS

PSRs significantly decreased in severity over time in each of the three disorders. In the interaction effects models, age x time had a significant effect on course for PD and GAD, but not for SP, in that older age was associated with lower PSRs over time.

CONCLUSIONS

The present findings suggest that the severity of anxiety disorders declines over time, although this decline is modest and depends on the specific disorder being assessed. Older individuals with PD and GAD have a better prognosis than their younger counterparts, as their course is characterized by a steeper decline in severity. The present findings provide important information about the course of anxiety disorders in mid-life.

Associations of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample

OBJECTIVE

To determine whether obesity is associated with a variety of psychiatric outcomes after taking into account physical health conditions.

METHODS

Data came from the public use dataset of the Canadian Community Health Survey Cycle 1.2 (age 15 years and older, N=36,984). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric diagnoses of major depressive disorder, mania, panic attacks, panic disorder, social phobia, agoraphobia, alcohol dependence, and drug dependence were examined, as was suicidal behavior (ideation or attempts). Multiple logistic regression was utilized to examine the association between obesity (defined as body mass index >or=30) and mental health outcomes. Covariates in the regressions included sociodemographic factors and a measure of physical illness burden (the Charlson Comorbidity Index).

RESULTS

In adjusted models, obesity was positively related to several lifetime psychiatric disorders (depression, mania, panic attacks, social phobia, agoraphobia without panic disorder), any lifetime mood or anxiety disorder, suicidal ideation, and suicide attempts [adjusted odds ratio (AOR) range: 1.22-1.58]. Obesity was similarly positively associated with past-year depression, mania, panic attacks, social phobia, any anxiety disorder, and suicidal ideation (AOR range: 1.24-1.52), and negatively associated with past-year drug dependence (AOR=0.53, 95% CI 0.31-0.89). Most of these associations were found to be specific to women, while some were also present in men.

CONCLUSION

Independent of physical health conditions, obesity was associated with psychiatric disorders and suicidal behavior in the Canadian population. Possible mechanisms and clinical implications of these findings are considered.

Seizures in the elderly: impact on mental status, mood, and sleep

Comorbidities of epilepsy have not been well explored in the elderly. Herein, we examined mental status, mood, and sleep in elderly patients with epilepsy, compared with age- and gender-matched community controls without epilepsy from the Einstein Aging Study. Testing included a mental status test, the Blessed Information Memory and Concentration (BIMC) test; Prime-MD Patient Health Questionnaire (PHQ) Depression and Anxiety Modules; and Medical Outcomes Study Sleep Scale. Persons with epilepsy (n=31) had higher mean BIMC scores than controls (n=31, BIMC 6.3 vs.1.2, P<0.0001). Mean PHQ Depression scores were higher for cases than controls, indicating more depressive symptoms (4.2 vs 0.8, P=0.006); six cases (18%) and no controls met screening criteria for depression. Mean PHQ Anxiety scores were also higher for cases than controls (3.7 vs 0.0, P=0.001). Cases had poorer sleep scores in the categories of somnolence (P=0.009) and shortness of breath/headache (P=0.021). Thus, comorbidities of epilepsy in this elderly population included decreased mental status, a higher prevalence of depression and anxiety, and poorer sleep health when compared with agemates without epilepsy. Mental status impairment was not related to antiepileptic medication or mood disturbance. Further investigation will explore these associations prospectively.

Meta-analysis comparing different behavioral treatments for late-life anxiety

OBJECTIVE

To evaluate the efficacy of different types of behavioral treatments for geriatric anxiety (cognitive behavior therapy [CBT] alone, CBT with relaxation training [RT], and RT alone).

METHOD

The authors compared effect sizes from 19 trials. Analyses were based on uncontrolled outcomes (comparing posttreatment and pretreatment scores) and effects relative to control conditions on both anxiety and depressive symptoms.

RESULTS

Treatments for older adults with anxiety symptoms were, on average, more effective than active control conditions. Effect sizes were comparable to those reported elsewhere for CBT for anxiety in the general population or for pharmacotherapy in anxious older adults. CBT (alone or augmented with RT) does not seem to add anything beyond RT alone, although a direct comparison is challenging given differences in control conditions. Effects on depressive symptoms were smaller, with no differences among treatment types.

CONCLUSION

Results suggest that behavioral treatments are effective for older adults with anxiety disorders and symptoms. Results must be interpreted with caution given the limitations of the literature, including differing sample characteristics and control conditions across studies.