Medication plus talk therapy for anxiety in seniors

A study of older adults has found that combining antidepressant medication with a type of psychotherapy called cognitive behavioral therapy (CBT) appears to be very effective as a treatment for anxiety. Together, they also seem to keep older adults anxiety-free for longer periods of time than either medication or CBT alone.

Researchers from Washington University School of Medicine in St. Louis, the University of California, San Diego, and the University of Pittsburgh studied 73 patients who were at least 60 years of age and who suffered from generalized anxiety disorder, a common problem estimated to affect about one in 20 seniors.

Their study is published online in The American Journal of Psychiatry.

In the past, the standard therapy for anxiety has involved drugs called benzodiazepines, a form of tranquilizer, but those drugs are not ideal for seniors.

“Benzodiazepines are particularly risky in older adults because they can contribute to falls and to cognitive impairment,” said Eric J. Lenze, MD, professor of psychiatry at Washington University. “So we have been focusing on alternative strategies for improving anxiety disorders in older adults, and we’ve had some success both with the antidepressant drug escitalopram and with cognitive behavioral therapy.”

But neither the antidepressant drug, sold commercially as Lexapro®, nor CBT has been completely successful in older adults. So this study tested them in combination.

“Our theory is that generalized anxiety disorder has two components,” explained Lenze, a geriatric psychiatrist. “One is a generally high stress level that might be managed with antidepressant medication, but the other is excessive worry. Some people are pathological worriers, and we thought that might be helped by cognitive behavioral therapy.”

All patients began the study by taking escitalopram for three months. From there, they were randomly assigned to one of two groups. The first simply stayed on the drug for another 16 weeks. The second group took the drug and also received 16 weeks of CBT.

During CBT, patients learned about the nature of worry and worked on relaxation techniques such as deep, slow breathing and progressive muscle relaxation. They also were taught problem-solving skills.

The researchers found that the participants’ anxiety levels improved with the antidepressant medication but that the individuals who also had the 16 weeks of CBT improved significantly more in a standard measure of worry pathology.

“In my opinion, CBT with anxious, older adults should include more ‘B’ than ‘C,’ that is more behavioral strategies and less cognitive restructuring,” said first author Julie Loebach Wetherell, PhD, staff psychologist at the Veterans Administration San Diego Healthcare System and professor of psychiatry at the University of California, San Diego. “The good news is that anxiety can be treated effectively in older people, and that’s important because it’s a common, debilitating condition that older people too often suffer in silence. The other important finding is that combining CBT and medication as therapy seems to allow older people to remain well, often even if they eventually stop taking the medication in the weeks or months after their anxiety subsides.”

After 16 weeks on medication, or medication plus CBT, the groups were randomly divided again. The subjects either remained on the antidepressant drug for another 28 weeks, or they slowly were weaned off the medication and were given an inactive placebo for the remainder of the study. Finally, after 56 weeks, the researchers compared patient outcomes.

“Those individuals who had both the drug and cognitive behavioral therapy also had a lower relapse rate, and if they did relapse, it happened later,” Lenze said.

He said the findings demonstrate that older adults with anxiety have treatment options for getting well and staying well. He cautioned, however, that not all older adults benefit from cognitive behavioral therapy.

“Antidepressant medication and cognitive behavioral therapy appear to work well in combination, but if an older adult has begun to develop dementia related to Alzheimer’s disease or some other illness, it appears even small amounts of cognitive impairment from those disorders can interfere with the benefits this combination of therapies provides,” he said.

Lenze and Wetherell now are collaborating on a new study testing whether an intervention that’s similar to meditation, called mindfulness-based stress reduction, can help improve worry symptoms and cognitive function, such as memory. That study is underway in St. Louis and in San Diego.

Funding for this research comes from the National Institute of Mental Health (NIMH) and the National Institute on Aging (NIA) of the National Institutes of Health (NIH). Wetherell and Lenze have received research support from Forest Laboratories (makers of Lexapro®), and Lenze also has received grant and/or research support from Johnson and Johnson, Lundbeck and Roche and has served as a consultant to Fox Learning Systems. None of the other authors reports any financial relationships with commercial interests. NIH grant numbers: MH-080151 and R01 070547 and an F31 Fellowship Award from NIA.

Wetherell JL, Petkus AJ, White KS, Nguyen H, Kornblith S, Adreescu C, Zisook S, Lenze EJ. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. The American Journal of Psychiatry, AJP in Advance, published online May 2013. doi: 10.1176/appi.ajp.2013.12081104

Washington University School of Medicine’s 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked sixth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.