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Am J Psychiatry 2013;170:A14-A14. doi:10.1176/appi.ajp.2012.1707issue
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Copyright © 2013 by the American Psychiatric Association

 
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CBT’s benefit lasted even after antidepressant treatment was stopped (Wetherell et al., p.782)

Clinical Guidance: Antidepressant + CBT for Generalized Anxiety in Older Adults 

Cognitive-behavioral therapy (CBT) added to ongoing antidepressant therapy reduces pathological worrying (figure) and the likelihood of relapse in older patients with generalized anxiety disorder, even if antidepressant treatment is stopped after augmentation. Escitalopram did more than CBT to prevent relapse in the trial by Wetherell et al. (p. 782), but among patients switched from escitalopram to placebo during maintenance treatment, the subsequent relapse rate was 25% for those who had received CBT and 64% for those who had not. CBT could be an option for older patients who prefer to discontinue antidepressants or an alternative to augmentation with antipsychotic medications, which Barlow and Comer note in an editorial (p. 707) are increasingly used in treating anxiety disorders.

Frequent contacts and an expectation of efficacy appear to have therapeutic effects that contribute to high response rates in clinical trials of new antidepressants, especially in patients receiving placebo. Rutherford and Roose (p. 723) evaluated factors in the failure of clinical trials to show differences between placebo and medication. Rater bias and regression to the mean in symptom ratings might be ameliorated by such mechanisms as ongoing rater training and centralized raters. Placebo response has not been linked to any specific patient characteristic but is less likely in patients with greater depressive severity.

Clinical Guidance: Behavioral Treatment of Insomnia in Bipolar Disorder 

Adopting a consistent sleep schedule throughout the week is the first step in behavioral treatment of insomnia for bipolar patients. It has the added benefit of helping to regulate the patient’s daily life, which in itself is an established treatment for bipolar disorder. Many patients’ insomnia responds to simple stimulus control, i.e., limiting time in bed to sleep and sex. In treating 15 patients with bipolar disorder, Kaplan and Harvey (p. 716) found that increased manic symptoms did not result from either stimulus control or restriction of sleep time to the amount documented in sleep diaries.

Clinical Guidance: CBT vs. Psychodynamic Therapy for Social Anxiety Disorder 

Both cognitive behavioral therapy (CBT) and targeted psychodynamic therapy improve symptoms of social anxiety disorder in large proportions of patients. In the comparison by Leichsenring et al. (p. 759), 25 treatment sessions produced response rates of 60% for CBT, 52% for supportive-expressive psychodynamic therapy, and 15% for a waiting list control condition. CBT is more likely to produce remission, but the response rate for psychodynamic therapy is comparable to rates for pharmacotherapy and group CBT. Milrod (p. 703) notes in her editorial that therapists should be vigilant for signs of separation anxiety and rage during termination, as these dynamics are frequent in social anxiety disorder patients.

Clinical Guidance: Late-Onset Agoraphobia 

Agoraphobia in the elderly may be overlooked because it often occurs in conjunction with depression and is usually not associated with panic attacks. The longitudinal study of a population sample by Ritchie et al. (CME, p. 790) revealed surprisingly high rates of agoraphobia in 1,968 adults age 65 or older: a 10% baseline prevalence and new cases in an additional 11% over the next 4 years. New-onset agoraphobia in the elderly is not more common in women but is associated with poor visuospatial memory, trait anxiety, and younger age, in addition to depression.

CBT’s benefit lasted even after antidepressant treatment was stopped (Wetherell et al., p.782)

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