Telephone-Delivered Cognitive Behavioral Therapy may be Associated with Greater Symptom Reduction than Telephone-Delivered Nondirective Therapy in Older Rural-Residing Adults with Generalized Anxiety Disorder

Resident Focus - Volume 11, Issue 7

Reference: JAMA Psychiatry 2015 Oct; 72(10):1012 (level 2 [mid-level] evidence)

Generalized anxiety disorder (GAD) is common among adults of all ages and is known to impair daily function for about 3% of people aged 65 years and older. Given the prevalence and morbidity of this disorder, it is reasonable that we continue to seek out new strategies to reach and treat affected patients. Limitations to access to in-office cognitive behavioral therapy (CBT) include long waiting lists, lack of transportation, and limited numbers of qualified local therapists. Out-of-office, telephone-delivered interventions allow for an alternative for increased patient access, especially for the elderly, physically and mentally disabled, and those with low socioeconomic status or living in rural areas. Telephone interventions may also give the patient a sense of anonymity and security which is important in a world where mental illness often carries a stigma. Evaluation of which types of these alternative outreach interventions will be of most benefit is essential. For instance, for adults aged ≥ 60 years with GAD living in rural areas, does telephone-delivered cognitive behavioral therapy (CBT-T) improve outcomes more than telephone-delivered nondirective supportive therapy (NST-T)?

141 adults aged ≥ 60 years with GAD living in a rural setting were randomized to receive either CBT-T or NST-T for an average of 10 weekly 50-minute sessions and were followed for 4 months. CBT-T sessions involved anxiety recognition skills, relaxation techniques, cognitive restructuring, use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention. NST-T sessions involved the patient sharing feelings openly without direct intervention recommendations by the therapist. The participants were 82% female and 91% white (equally matched between study arms). Participants completed various interview-based and self-reported numerically-based scales and questionnaires pre- and post-randomization.

The study had some notable limitations, including baseline differences between randomized groups and an overall low adherence rate. In the CBT-T group, fewer patients had comorbid depression than in the NST-T group (33% of patients compared to 44% in the NST-T group, no p value reported). The adherence rate of the CBT-T group was low (74% completed at least 9 of the required sessions), while 82% of the patients in the NST-T group completed 10 required sessions. Ultimately, 91% of participants were included in the primary analyses.

The first primary outcome of worry symptoms was assessed by the abbreviated Penn State Worry Questionnaire (scale from 0 to 40, with clinically meaningful improvement assessed as decrease of at least 5.5 points). Both groups had meaningful reduction in scores from baseline, but greater improvement was seen in participants receiving CBT-T compared to NST-T (clinically meaningful improvement in 72.4% vs. 42.9%, p = 0.001, NNT 4). The second primary outcome was anxiety symptoms as measured by the Hamilton Anxiety Rating Scale (scale from 0 to 56, threshold for clinically meaningful improvement not reported). Both CBT-T and NST-T were associated with a statistically significant reduction in scores, but with no difference between groups (P = 0.24). Compared to NST-T, CBT-T demonstrated a greater reduction in GAD symptoms (P = 0.005) and depressive symptoms (P = 0.02).

CBT has been established as an effective treatment for anxiety disorders, and these results are consistent with previous studies in the field. This study provides new evidence that telephone-delivered CBT is effective in the rural-residing elderly population and provides one solution to overcome many of the barriers to accessing mental health services.

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