Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults

Abstract

OBJECTIVE Generalized anxiety disorder is common among older adults and leads to diminished health and cognitive functioning. Although antidepressant medications are efficacious, many elderly individuals require augmentation treatment. Furthermore, little is known about maintenance strategies for older people. The authors examined whether sequenced treatment combining pharmacotherapy and cognitive-behavioral therapy (CBT) boosts response and prevents relapse in older adults with generalized anxiety disorder. METHOD Participants were individuals at least 60 years of age with generalized anxiety disorder (N=73) who were recruited from outpatient clinics at three sites. Participants received 12 weeks of open-label escitalopram and were then randomly assigned to one of four conditions: 16 weeks of escitalopram (10-20 mg/day) plus modular CBT, followed by 28 weeks of maintenance escitalopram; escitalopram alone, followed by maintenance escitalopram; escitalopram plus CBT, followed by pill placebo; and escitalopram alone, followed by placebo. RESULTS Escitalopram augmented with CBT increased response rates on the Penn State Worry Questionnaire but not on the Hamilton Anxiety Rating Scale compared with escitalopram alone. Both escitalopram and CBT prevented relapse compared with placebo. CONCLUSIONS This study demonstrates effective strategies for treatment of generalized anxiety disorder in older adults. The sequence of antidepressant medication augmented with CBT leads to worry reduction in the short-term. Continued medication prevents relapse, but for many individuals, CBT would allow sustained remission without requiring long-term pharmacotherapy.

Trial registration: ClinicalTrials.gov NCT00601965.

Figure 1. CONSORT Diagram for a Trial of Escitalopram Augmented With Cognitive-Behavioral Therapy (CBT) Among Older Adults With Generalized Anxiety Disorder

Figure 2. Raw Means at Baseline and Predicted Mean Hamilton Anxiety Rating Scale and Penn State Worry Questionnaire Scores in a Trial of Escitalopram Augmented With Cognitive-Behavioral Therapy (CBT) for Older Adults With Generalized Anxiety Disorder (N=73)

Figure 3. Kaplan-Meier Survival Curve for Relapse in Older Adults With Generalized Anxiety Disorder Who Received Maintenance Escitalopram, Cognitive-Behavioral Therapy (CBT), Both, or Pill Placebo (N=70)