What are the optimal treatment courses for geriatric anxiety, and how do we find out?

The prevalence, reporting, and treatment of anxiety among older adults in nursing homes and other residential aged care facilities

BACKGROUND

Little is known about anxiety in aged care populations, despite its increase in this frail population. This study investigated the prevalence, recording, and treatment rate of anxiety disorders among aged care residents.

METHODS

A cross-sectional, observational design was used to assess 180 elderly residents from 12 aged care facilities in Melbourne, Australia. Participants were assessed for threshold and subthreshold anxiety disorders and comorbid depression using the MINI for DSM-5. Medical files were also reviewed to determine whether there was any indication that anxiety had previously been detected, and what treatment those with a threshold/subthreshold diagnosis were receiving.

RESULTS

Overall prevalence of threshold and subthreshold anxiety disorders was 19.4% and 11.7%, respectively. Generalized anxiety disorder was the most common threshold disorder and agoraphobia was the most prevalent subthreshold anxiety disorder. While less than half of those with a threshold or subthreshold anxiety disorder had an indication of anxiety in their file, the majority received psychotropic medication. Cognitive impairment was not significantly associated with the prevalence or treatment of anxiety.

CONCLUSIONS

The prevalence of threshold and subthreshold anxiety in aged care settings is high, but remains under-reported by staff and GPs. Facility staff and GPs should ensure they are aware of how anxiety presents in elderly residents and routinely screen for this common mental health issue. This cohort had poor access to psychological treatments for their condition.

Secondary Outcomes From the Child/Adolescent Anxiety Multimodal Study: Implications for Clinical Practice

BACKGROUND

Controlled evaluations comparing medication, cognitive-behavioral therapy (CBT), and their combination in the treatment of youth anxiety have predominantly focused on global ratings by independent evaluators. Such ratings are resource-intensive, may be of limited generalizability, and do not directly inform our understanding of treatment responses from the perspective of treated families. We examined outcomes from the perspective of treated youth and parents in the Child/Adolescent Anxiety Multimodal Study (CAMS).

METHODS

Participants (N=488; ages 7-17 years) who had a primary diagnosis of separation, social, and/or generalized anxiety disorder were randomly assigned to a treatment condition in the CAMS trial. Linear mixed-effects and ANCOVA models examined parent- and youth-reported anxiety symptoms, impact of anxiety, broader internalizing and externalizing psychopathology, depressive symptoms, and family burden throughout the 12-week acute treatment phase and 6-month follow-up.

RESULTS

At week 12, combination treatment showed superiority over placebo, sertraline, and CBT with regard to parent-reported youth anxiety symptoms, and sertraline and CBT as monotherapies showed superiority over placebo with regard to parent-reported youth anxiety. Combination therapy and sertraline also showed week 12 superiority over placebo with regard to parent-reported internalizing psychopathology, and superiority over placebo and CBT with regard to parent-reported impact of anxiety, family burden, and youth depressive symptoms. By week 36, parent reports of many youth outcomes were comparable across active conditions. Youth measures tracked parent measures on many outcomes.

CONCLUSIONS

Findings were drawn on brief, readily available questionnaires that in conjunction with clinician measures can inform patient-centered care and collaborative decision-making.Trial Registry Name: Child and Adolescent Anxiety Disorders (CAMS)Registry identification number: NCT00052078Registry URL: https://www.clinicaltrials.gov/ct2/show/NCT00052078.

Future Directions in the Use of Telemental Health to Improve the Accessibility and Quality of Children's Mental Health Services

OBJECTIVES

This concluding commentary offers a brief overview of progress to date in providing telemental health services to children, and then offers a critical vision for future research needed to provide the rigorous empirical foundation for telemental health to be considered a well-established format for the delivery of children's mental health services.

METHODS

We review how recent years have witnessed advances in the science and practice of children's telemental health, and the articles in this special series collectively offered a critical step forward in the establishment of a guiding literature to provide informed direction for child providers incorporating remote technologies to extend their practices.

RESULTS

Researchers must be cautious not to develop a "horse race" mentality and a misguided search for a decisive "winner" regarding the ultimate effectiveness of child telemental health versus traditional clinic-based treatments. Instead, research efforts are needed to examine key mediators and moderators of telemental health treatment response. The question should not be simply whether telemental health strategies are supported, but rather when, under what circumstances, and for whom telemental health formats may be most indicated. Barriers to the continued evolution of children's telemental health are discussed, and we consider issues of telemental health reimbursement and matters of cross-state professional jurisdiction.

CONCLUSIONS

Continued efforts are needed in order to fully actualize the potential of children's telemental health to optimize the quality and transform the accessibility of mental health services for all children, regardless of income or geography.

Moderators of intensive CBT for adolescent panic disorder: the of fear and avoidance

BACKGROUND

Research supports the efficacy of intensive cognitive behavioral therapy (CBT) for the treatment of adolescent panic disorder with or without agoraphobia (PDA). However, little is known about the conditions under which intensive treatment is most effective. The current investigation examined the moderating roles of baseline fear and avoidance in the intensive treatment of adolescent PDA.

METHODS

Adolescents with PDA (ages 11-17; N = 54) were randomized to either an intensive CBT treatment (n = 37) or a waitlist control condition (n = 17). PDA diagnosis, symptom severity, and number of feared and avoided situations were assessed at baseline and 6-week post-treatment/post-waitlist. Hierarchical regression analyses examined the relative contributions of treatment condition, number of baseline feared or avoided situations, and their interactions in the prediction of post-treatment/waitlist PDA symptoms.

RESULTS

The main effect of intensive CBT on post-treatment PDA symptoms was not uniform across participants, with larger treatment effects found among participants with lower, relative to higher, baseline levels of fear and avoidance.

CONCLUSIONS

Findings help clarify which adolescents suffering with PDA may benefit most from an intensive treatment format.

Extending parent-child interaction therapy for early childhood internalizing problems: new advances for an overlooked population

Although efficacious psychological treatments for internalizing disorders are now well established for school-aged children, until recently there have regrettably been limited empirical efforts to clarify indicated psychological intervention methods for the treatment of mood and anxiety disorders presenting in early childhood. Young children lack many of the developmental capacities required to effectively participate in established treatments for mood and anxiety problems presenting in older children, making simple downward extensions of these treatments for the management of preschool internalizing problems misguided. In recent years, a number of research groups have successfully adapted and modified parent-child interaction therapy (PCIT), originally developed to treat externalizing problems in young children, to treat various early internalizing problems with a set of neighboring protocols. As in traditional PCIT, these extensions target child symptoms by directly reshaping parent-child interaction patterns associated with the maintenance of symptoms. The present review outlines this emerging set of novel PCIT adaptations and modifications for mood and anxiety problems in young children and reviews preliminary evidence supporting their use. Specifically, we cover (a) PCIT for early separation anxiety disorder; (b) the PCIT-CALM (Coaching Approach behavior and Leading by Modeling) Program for the full range of early anxiety disorders; (c) the group Turtle Program for behavioral inhibition; and (d) the PCIT-ED (Emotional Development) Program for preschool depression. In addition, emerging PCIT-related protocols in need of empirical attention--such as the PCIT-SM (selective mutism) Program for young children with SM--are also considered. Implications of these protocols are discussed with regard to their unique potential to address the clinical needs of young children with internalizing problems. Obstacles to broad dissemination are addressed, and we consider potential solutions, including modular treatment formats and innovative applications of technology.