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Articles   |    
Antidepressant Medication Augmented With Cognitive-Behavioral Therapy for Generalized Anxiety Disorder in Older Adults
Julie Loebach Wetherell, Ph.D.; Andrew J. Petkus, M.A.; Kamila S. White, Ph.D.; Hoang Nguyen, M.D.; Sander Kornblith, Ph.D.; Carmen Andreescu, M.D.; Sidney Zisook, M.D.; Eric J. Lenze, M.D.
Am J Psychiatry 2013;170:782-789. doi:10.1176/appi.ajp.2013.12081104
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Dr. Wetherell has received research support from Forest Laboratories. Dr. Lenze has received grant/research support from Forest Laboratories, Johnson and Johnson, Lundbeck, and Roche and has served as a consultant to Fox Learning Systems. All other authors report no financial relationships with commercial interests.

Supported by NIMH grants MH-080151 (to Dr. Wetherell) and R01 070547 (to Dr. Lenze) and an F31 Fellowship Award by the National Institute on Aging (to Dr. Petkus).

Clinicaltrials.gov registry number, NCT00601965.

From the Veterans Administration San Diego Healthcare System, San Diego; University of California, San Diego; San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology; University of Missouri, St. Louis; Western Psychiatric Institute and Clinic, Pittsburgh; and Washington University, St. Louis.

Address correspondence to Dr. Wetherell (jwetherell@ucsd.edu).

Copyright © 2013 by the American Psychiatric Association

Received August 23, 2012; Revised November 24, 2012; Accepted January 07, 2013.


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.

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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)
Anchor for Jump
TABLE 1.Demographic and Clinical Characteristics at Study Entry Across the Four Study Conditions in a Trial of Escitalopram Augmented With Cognitive-Behavioral Therapy (CBT) for Older Adults With Generalized Anxiety Disorder
Table Footer Note

b Significant difference between groups (χ2=9.85, df=3, p=0.02).



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