Effectiveness of the implementation of guidelines for anxiety disorders in specialized mental health care

OBJECTIVE

To examine the effect of implementing anxiety disorders guidelines on guideline adherence and patient outcomes in specialized mental health care.

METHOD

A treatment setting in which guidelines were implemented (intervention condition) was compared with one in which guidelines were only disseminated (control condition).

RESULTS

Of 61.7% of 81 intervention-condition patients received treatment according to the guidelines vs. 40.6% of 69 control-condition patients (P = 0.01). At 1-year follow-up, intervention-condition patients showed a greater decrease in anxiety symptoms (d = 0.48, P < 0.05); higher percentages of response (52.6% vs. 33.8%; P = 0.025) and remission (33.3% vs.16.9%; P = 0.026); and a greater decrease in the rate of phobic avoidance (d = 0.34, P < 0.05). At 2-year follow-up, control-condition patients had experienced a longer period of treatment, which had eroded most of these differences, except for phobic avoidance.

CONCLUSION

Systematic guideline implementation results in earlier gains and shorter treatment times.

[Treatment of anxiety disorders in the elderly]

AIM

To collect empirical evidence concerning the effectiveness of the treatment of anxiety disorders in the elderly.

METHOD

Meta-analysis and randomised controlled trials.

RESULTS

Meta-analysis showed that cognitive behavioural therapy (CBT) was more successful than waiting-list control or active control as a treatment for older persons with anxiety disorders. In a direct comparison of the treatment of older persons with panic disorder (PD) both CBT an paroxetine were found to be more effective than waiting-list control. CBT was more successful in reducing avoidance behaviours in older persons with PD. Older persons with reported fewer and less severe agoraphobic cognitions than younger patients, but there was no difference between the severity of agoraphobic avoidance in older patients with PD and younger patients with PD.

CONCLUSION

There is sufficient empirical evidence to support the effectiveness of CBT in the treatment of older persons with anxiety disorders. In assessing the severity of PD in the elderly, one should carefully consider the severity of avoidance behaviours. Because no difference was found between the effectiveness of CBT and paroxetine for the treatment of PD in the elderly and because was more effective in reducing avoidance behaviours in older patients with PD than in younger patients with pd, there seems to be a slight preference for CBT in the case of older patients with PD. Older age is not associated with a poorer outcome of treatment with CBT.

[The efficacy of the systems training for emotional predictability and problem solving (STEPPS) in the treatment of borderline personality disorder. A randomized controlled trial]

BACKGROUND

The types of treatment for borderline personality disorder devised over the last few decades are often difficult to implement in therapy centres. stepps is a group treatment for this disorder which is easy to implement.

AIM

To compare the efficacy of stepps supported by limited individual treatment with 'treatment as usual' (tau).

METHOD

79 patients with bpd were randomly assigned to stepps or to tau. Measurements were taken before and after the intervention and at one-year follow-up. Outcome measures were: borderline and general psychiatric symptomatology, suicide attempts, quality of life and use of care services. results stepps led to a larger reduction in symptoms than did tau, the difference being still significant at follow-up. 70% of patients treated with stepps showed improvement compared to 47% of patients treated with tau. In both treatment groups the percentage of patients who recovered was small. There was no difference in the number of suicide attempts in each group. stepps led to a greater improvement in quality of life than did tau, particularly at follow-up. Care service use seemed about equal.

CONCLUSION

The efficacy of treatment for bpd can be improved by the introduction of stepps, which is relatively simple to implement.

[Treatment of obsessive-compulsive disorder in older patients - case studies]

Five patients aged 64 to 74 years with obsessive-compulsive disorder were treated successfully, one with cognitive behavioural therapy and four with a combination of antidepressants and cognitive behavioural therapy. The current multidisciplinary guidelines on anxiety treatment, which cover the age-range 18 to 65 years, are a good starting point for the treatment of obsessive compulsive disorder in older patients.

Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine

OBJECTIVE

Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behaviour therapy (CBT) have both proven to be effective in the treatment of obsessive compulsive disorder (OCD). It is generally recommended that adequate but unsuccessful SSRI treatment is supplemented with CBT, although only one empirical study was conducted to verify this recommendation. The present study examined the effects of supplemental CBT to continued fluoxetine treatment in OCD patients non-responding to fluoxetine alone.

METHOD

After 12 weeks of fluoxetine, 14 of 56 out-patients had a reduction rate less than 25% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and were classified as non-responders. They subsequently received 12 sessions CBT additional to the continued fluoxetine treatment.

RESULTS

The mean symptom reduction as rated by the Y-BOCS, for the patients who completed both treatment phases, was 8.5% in the first phase and 41% in the second phase.

CONCLUSION

Supplemental CBT for OCD patients, after initial, unsuccessful fluoxetine treatment is shown to be effective.