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Original Investigation |

Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder A Randomized Clinical Trial

Gretchen A. Brenes, PhD1; Suzanne C. Danhauer, PhD2; Mary F. Lyles, MD3; Patricia E. Hogan, MS4; Michael E. Miller, PhD4
[+] Author Affiliations
1Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
2Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
3Department of Geriatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
4Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina
JAMA Psychiatry. 2015;72(10):1012-1020. doi:10.1001/jamapsychiatry.2015.1154.
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Importance  Generalized anxiety disorder (GAD) is common in older adults; however, access to treatment may be limited, particularly in rural areas.

Objective  To examine the effects of telephone-delivered cognitive behavioral therapy (CBT) compared with telephone-delivered nondirective supportive therapy (NST) in rural older adults with GAD.

Design, Setting, and Participants  Randomized clinical trial in the participants’ homes of 141 adults aged 60 years and older with a principal or coprincipal diagnosis of GAD who were recruited between January 27, 2011, and October 22, 2013.

Interventions  Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping.

Main Outcomes and Measures  Primary outcomes included interviewer-rated anxiety severity (Hamilton Anxiety Rating Scale) and self-reported worry severity (Penn State Worry Questionnaire–Abbreviated) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Mood-specific secondary outcomes included self-reported GAD symptoms (GAD Scale 7 Item) measured at baseline and 4 months’ follow-up and depressive symptoms (Beck Depression Inventory) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Among the 141 participants, 70 were randomized to receive CBT and 71 to receive NST.

Results  At 4 months’ follow-up, there was a significantly greater decline in worry severity among participants in the telephone-delivered CBT group (difference in improvement, −4.07; 95% CI, −6.26 to −1.87; P = .004) but no significant differences in general anxiety symptoms (difference in improvement, −1.52; 95% CI, −4.07 to 1.03; P = .24). At 4 months’ follow-up, there was a significantly greater decline in GAD symptoms (difference in improvement, −2.36; 95% CI, −4.00 to −0.72; P = .005) and depressive symptoms (difference in improvement, −3.23; 95% CI, −5.97 to −0.50; P = .02) among participants in the telephone-delivered CBT group.

Conclusions and Relevance  In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD.

Trial Registration  clinicaltrials.gov Identifier: NCT01259596.

Figures in this Article

Figures

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Figure 1.
CONSORT Flow Diagram

aSome participants had multiple reasons for ineligibility.

bTelephone-delivered cognitive behavioral therapy (CBT-T) could be completed with between 9 and 11 sessions. Telephone-delivered nondirective supportive therapy (NST-T) required 10 sessions to be complete.

cPrespecified primary analysis used all participants with any follow-up data at 2 or 4 months’ follow-up. Those excluded from the prespecified primary analysis did not have any follow-up information. Sensitivity analyses using multiple imputation also were performed to include all participants.

dThere were 10 total participants missing either the Penn State Worry Questionnaire–Abbreviated (PSWQ-A) or Hamilton Anxiety Rating Scale (HAMA): 2 with the following health problems, 2 indicated they did not have the time, 4 completed the PSWQ-A but not HAMA, and 2 with unknown or other reasons (6 of these participants withdrew consent after providing month 2 data).

eTwo participants cited self or family health problems, 1 participant cited that he or she did not like randomized therapy, and 1 participant had an unknown reason.

fOne participant cited health problems and withdrew consent after providing 2-months’ follow-up data.

gTwo participants cited personal or family health problems and 2 had unknown reasons (2 participants withdrew consent after providing 2-month follow-up data).

hTwo participants cited health problems.

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Figure 2.
Treatment Effects on Primary Outcomes
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Figure 3.
Treatment Effects on Secondary Outcomes
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Supporting cognitive behavioral therapy by assigned tasks.
Posted on October 28, 2015
Andrzej Brodziak
Institute of Occupational Medicine and Environmental Health, Sosnowiec, Poland
Conflict of Interest: None Declared
Brenes et al. proved, that it is a possibly to deliver the Cognitive Behavioral Therapy to older adults by telephone and that this kind of therapy is more effective then so called Nondirective Supportive Therapy [1]. The participants randomized to CBT-T received 9 – 11 weekly 50-minute telephone therapy sessions, performed by two graduate social workers and one postdoctoral clinical psychologist [1]. The detailed description of this randomized clinical trial enable to realize the effort necessary for the experimental delivery of CBT sessions. The trial was done however to suggest the application of CB-T as a possible, routine procedure.
Erike A. Lenze, in the accompanying editorial, clearly justifies the need and usefulness of psychotherapies delivered to older people, discussing the possible solutions for actual “geriatric mental health crisis”[2]. He writes “we need geriatric mental health treatment packages in modern technology to extend their reach while retaining effectiveness”. He remarks however that CB-T “is just as time-intensive as in-person therapy” and continues, stating “Doing the demographic math, it seems that we must move toward more nonconsumable (ie., computerized) interventions to fill the gap between consumer need and provider availability”[2].
We gathered recently our experiences in the realm of the evaluation of risk factors of cognitive impairments and trials of its modification among the participants of so called University of Third Age. This allows us to suggest a partial solution for the problem of excessive time and personal participation, needed for application of Cognitive Behavioral Therapy.
The process of the initial diagnosis and subsequent therapy should be structuralized. The causes of anxiety, depression and any sub-optimal well-being can be systematized according to the most frequent adverse life happenings. Such negative life trajectories should be linked to the possible counteracting advices, and next - should be transferred to patients by the recommendation of tasks augmenting the understanding of the existing problems, increasing resilience and other elements of CBT like “cognitive restructuring, coping, problem solving, worry control, behavioral activation, exposure” [3]. These tasks could consist, for example on the recommendation of a lecture of very particular novel, on taking particular a social action or realizing a well-defined trip.
It is already proved that reading, adjusted literary fiction improves not only the understanding of personal situations but usually enhances the overall empathic attitude [3]. Eg. the short story, tuned to the feelings evoked by a daughter, who abandoned a mother was written by Alice Munro [5].

References
1. Brenes GA, Danhauer SC, Lyles MF, Hogan PE, Miller ME. Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015; 72(10):1012-1020

2. Lenze EJ. Solving the Geriatric Mental Health Crisis in the 21st Century. JAMA Psychiatry. 2015 Aug 5. doi: 10.1001/jamapsychiatry.2015.1306. [Epub ahead of print]

3. Janssen BM, Van Regenmortel T., Abma TA. Identifying sources of strength: resilience from the perspective of older people receiving long-term community care. Eur J Ageing. 2011; 8(3): 145–156.

4. Kidd DC, Castano E. Reading literary fiction improves theory of mind. Science.
2013 ;342(6156):377-80.

5. Munro A.: Silence – short story printed in the volume “Runaway”, Vintage Books, 2013



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