Cognitive-Behavior Therapy for Generalized Anxiety in Late Life

Pergamon

Journal of Anxiety Disorders, Vol. 14, No. 2, pp. 191–207, 2000 Copyright  2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0887-6185/00 $–see front matter

PII S0887-6185(99)00048-1

Cognitive-Behavior Therapy for Generalized Anxiety in Late Life: An Evaluative Overview Melinda A. Stanley, Ph.D. and Diane M. Novy, Ph.D. University of Texas Health Science Center at Houston, Houston, Texas, USA

Abstract—Of the pervasive anxiety disorders diagnosed in late life, generalized anxiety disorder (GAD) is the most prevalent. In this paper, the clinical features of GAD among older adults are described, with particular attention to differences in the nature of relevant symptoms among older and younger cohorts. Outcome studies addressing the efficacy of cognitive-behavior therapy (CBT) for younger and middle-aged adults with GAD then are reviewed briefly. Next, early literature investigating the potential usefulness of cognitive-behavioral treatments among older anxious community volunteers is then reviewed and critiqued in some detail. More recent work, some of which is currently in progress, has focused on the efficacy of CBT for older adults with well-diagnosed GAD. This research also is reviewed, and directions for future research in this area are provided.  2000 Elsevier Science Ltd. All rights reserved. Keywords: Cognitive-behavior therapy; Generalized anxiety; Late life

Of the pervasive anxiety disorders diagnosed in late life, generalized anxiety disorder (GAD) is the most prevalent. In community surveys, prevalence rates for GAD among older adults range from 0.7% to 7.1%, with figures varying as a result of differential criteria for case definition, diagnostic procedures, and survey methods (Flint, 1994). Initial data from the Epidemiological Catchment Area survey, conducted in the mid-1980s, omitted consideration of GAD because it was not recognized as a distinct psychiatric syndrome at the time (American Psychiatric Association, 1980). A second wave of Epidemiological Catchment Area data, however, indicated 1-month and lifetime prevalence rates of 1.9% and 4.6%, respectively, for GAD in older adults (Blazer, George, & Hughes, 1991). These Epidemiological Catchment Area figures, although striking as they are presented, actually may be underestimates given

Requests for reprints should be sent to Melinda A. Stanley, Ph.D., University of Texas Health Sciences Center-Houston, MSI-1300 Moursund Avenue, Houston, TX 77030-3497.

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that hierarchical diagnostic criteria were used, requiring exclusion of GAD if any other diagnoses were present. Furthermore, the study focused on community-dwelling adults, thereby omitting consideration of the significant proportion of older individuals who reside in institutions and may be at significantly greater risk of experiencing psychiatric difficulties (Bland, Newman, & Orn, 1988). Even among community-dwelling older adults, prevalence rates for anxiety disorders in general are higher for those who report some level of confinement than those who are more mobile (Bruce & McNamara, 1992). These prevalence rates, combined with the pervasive and chronic nature of GAD (Rapee & Barlow, 1991), suggest that this disorder poses a major public health problem for older adults. However, current cohorts of older individuals generally are reluctant to seek mental health services, and data have suggested that only 38% of individuals with GAD in this age group reported use of outpatient mental health services in the year before the interview (Blazer et al., 1991). Instead, most mental health treatment for older adults is provided by primary care physicians (Blazer et al., 1991; McCarthy, Katz, & Foa, 1991). As such, anxiety is most often treated with medication, usually the benzodiazepines. In fact, prevalence rates for benzodiazepine use among older adults ranges from 17% to 50% (Salzman, 1991). Given potentially serious limitations of this treatment approach for older individuals (e.g., increased adverse effects including cognitive impairment, agitation, and psychomotor slowing; potentially harmful drug interactions; and the potential for dependence), development of psychosocial alternatives for the treatment of anxiety in late life is essential. In this regard, recent literature has begun to examine the effects of psychosocial treatments, most notably cognitive behavioral approaches, among older adults with anxiety symptoms or disorders. In this article, we begin with an overview of GAD in older adults, with attention to similarities and differences in the nature of the disorder across the lifespan. Next, we review briefly the components and efficacy of cognitivebehavior therapy (CBT) for GAD in younger and middle-aged adults. The empirical literature addressing the usefulness of these procedures for the treatment of late-life GAD then is reviewed, and attention is given to important future research directions in this area.

OVERVIEW OF GENERALIZED ANXIETY DISORDER IN LATE LIFE In many respects, the nature of GAD among older and younger adults is much the same. In fact, one of the first studies to examine the clinical features of late-life GAD indicated that older adults with the disorder exhibited levels of worry, anxiety, social fears, and depression similar to those of younger cohorts (Beck, Stanley, & Zebb, 1996). These findings actually should not be surprising given that at present, the same diagnostic criteria are used to establish

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the disorder across all age groups (APA, 1994). As such, GAD in older adults is characterized by pervasive, excessive worry that is difficult to control. Associated symptoms include restlessness, fatigability, difficulty concentrating, irritability, muscle tension, and sleep difficulties. It has been proposed, however, that differential diagnostic criteria uniquely tailored to the experience of anxiety in older adults may need to be considered (Blazer, 1997). In this regard, despite some significant overlap in the core symptoms of GAD in older and younger samples, there also appear to be some meaningful differences. First, worry content seems to vary across younger and older cohorts. In community surveys, for example, older adults report more worries about health and fewer concerns about work relative to younger and middleage adults who are most concerned about family and finances (Person & Borkovec, 1995; Powers, Wisocki, & Whitbourne, 1992). These differential worries appear to represent changing life circumstances, but they nevertheless may be important to consider in the diagnosis and treatment of late-life GAD. Second, general differences seem to exist in the expression or structure, or both, of affect across older and younger cohorts. For instance, Lawton, Kleban, and Dean (1993) reported that affect terms assessing guilt (e.g., ashamed, guilty, worried, blamed) were less salient in the self-reported characterization of anxiety for older adults (age 60 and over) than younger individuals (ages 18–30). Older adults also reported less anxiety overall than younger and middle-age adults. Although it is possible, as the authors suggest, that these data indicate differential meanings of affect terms, variations in the experience of anxiety across the lifespan, or both (Lawton et al., 1993), the findings may simply reflect the reluctance of older adults to discuss difficulties in psychological terms (Lasoski, 1986; McCarthy et al., 1991). Similarly, in our own work with older adults whose symptoms meet criteria for GAD, we have found that many patients prefer to describe their experiences using words such as fret or concern rather than worry or anxiety. It is not completely clear, however, that the experience of anxiety is dramatically different for older and younger adults. It also is likely that this phenomenon represents a cohort effect that may well disappear as the current baby-boom generation, with extensive socialization in the psychological domain, advances into older age. Third, older adults tend to emphasize somatic experiences of anxiety more than psychic or cognitive elements. As noted earlier, current cohorts of older individuals are reluctant to describe difficulties in psychological terms, and they are hesitant to seek social services in general (Lasoski, 1986; McCarthy et al., 1991). Additionally, given increased health problems that often accompany advancing age, older adults frequently have more physiological symptoms characteristic of anxiety (e.g., shortness of breath, chest pain, palpitations) that may or may not be associated with psychiatric or psychological difficulties. For these and other reasons, older adults with anxiety often seek treatment at primary care settings, generally anticipating a medical diagnosis

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that may explain distressing somatic symptoms. In this regard, the differential diagnosis of medical illness and anxiety is of particular concern in assessing older patients. Finally, a number of other differential diagnostic issues are particularly salient in the assessment of late-life anxiety. Although not unique to the older population, anxiety in late life frequently is accompanied by elevated levels of depressive symptoms and disorders (Alexopoulos, 1991; Flint, 1994), making differential diagnosis a difficult task. In addition, notable overlap between anxiety and sleep disturbance (Morin & Gramling, 1989), as well as some evidence of decreased cognitive performance (in particular, memory problems) associated with anxiety in late life suggest that careful attention must be given to these issues in the diagnosis of anxiety among older adults.

COGNITIVE-BEHAVIOR THERAPY FOR GENERALIZED ANXIETY DISORDER IN YOUNGER AND MIDDLE-AGED ADULTS A relatively large body of literature has developed to address the efficacy of CBT for GAD in younger and middle-age adults. Various multifaceted CBT programs have been studied, most of which include some form of relaxation training to target somatic symptoms as well as some version of cognitive therapy to address worry-related thoughts and beliefs (Brown, O’Leary, & Barlow, 1993). More recent treatment programs also have included an exposure component that derives from conceptualizations of worry as a negatively reinforcing activity that prevents distressing emotional arousal, reactivity, or both (Borkovec & Hu, 1990). In some cases, exposure is designed to provide opportunities for practicing coping skills and desensitizing anxiety (Borkovec & Costello, 1993), whereas in other cases it is conducted according to an extinction paradigm (Craske, Barlow, & O’Leary, 1992). Controlled treatment outcome studies have demonstrated fairly consistently that various packages of CBT are effective relative to wait-list control conditions, with particularly impressive results from the newer treatment programs based on new conceptualizations of GAD (Brown et al., 1993). A recent meta-analysis, in fact, suggested an overall effect size for CBT of .70, a figure that was statistically equivalent to the effect size for pharmacologic interventions (.60) (Gould, Otto, Pollack, & Yap, 1997). Results also suggested, however, that CBT generally results in maintenance of gains for periods of up to 1 year, whereas response after medication discontinuation is attenuated (Gould et al., 1997). Moreover, in some trials, CBT also has resulted in decreased use of antianxiety medications (Brown et al., 1993). These data provide strong support for the potential usefulness of CBT for the treatment of GAD in younger and middle-age adults.

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Nevertheless, studies comparing the efficacy of CBT with alternative psychosocial interventions have not provided as clear or consistent findings. In a number of early trials, few or no differences were reported in clinical trials of this sort, with various types of CBT and nondirective supportive approaches generally producing similar levels of improvement (Brown et al., 1993). In at least two more recent studies, however, there is evidence that integrated treatment packages targeting the core symptoms of GAD are superior to alternative psychosocial approaches. Butler, Fennell, Robson, and Gelder (1991), for example, demonstrated that a combined package of cognitive behavioral treatment showed superior efficacy for patients with GAD relative to a treatment protocol without cognitive interventions to target core symptoms of worry. Similarly, Borkovec and Costello (1993) demonstrated that a multifaceted CBT program including applied relaxation, cognitive therapy, and coping desensitization to target the symptoms of GAD as it currently is conceptualized was superior to both applied relaxation alone and a nondirective, supportive treatment. Given these findings, it appears that integrated treatment packages incorporating interventions designed to target specifically the core symptoms of GAD may be optimal for the treatment of this disorder. Only recently has research begun to address the potential usefulness of these interventions for the treatment of late-life GAD.

COGNITIVE-BEHAVIOR THERAPY FOR GENERALIZED ANXIETY DISORDER IN OLDER ADULTS The earliest controlled trials of cognitive behavioral interventions for anxiety in older adults examined the efficacy of various treatments among community volunteers reporting various anxiety complaints. These studies are summarized in Table 1. Results suggest the potential usefulness of CBT, in particular, relaxation training, for the reduction of both anxiety and affective symptoms among community-dwelling adults more than age 60. In some cases, CBT was superior to wait-list or nonspecific treatment control conditions (DeBerry, 1982; Keller, Croake, & Brooking, 1975; Scogin, Rickard, Keith, Wilson, & McElreath, 1992); whereas in others, improvements after CBT or relaxation were equivalent to alternative treatments (Sallis, Lichstein, Clarkson, Stalgaitis, & Campbell, 1983; Scates, Randolph, Gutsch, & Knight, 1986). In general, there were no systematic differences in the efficacy of various types of relaxation training (DeBerry, 1982; DeBerry, Davis, & Reinhard, 1989; Scogin et al., 1992), and treatment gains were maintained over brief follow-up intervals (DeBerry, 1982; Sallis et al., 1983; Scogin et al., 1992). In one instance, assessment at longer-term follow-up demonstrated maintenance of gains in trait anxiety and general psychopathologic features over a period of 1 year after CBT (Rickard, Scogin, & Keith, 1994).

33

36

32

24 completers out of 58 50 completers out of 60

Keller et al. (1975)

DeBerry (1982)

DeBerry et al. (1989)

Sallis et al. (1983)

Scates et al. (1986)

Authors

75

71

69

63–79

68

64

83

50

100

93

Mean No. Age Gender Participants (years) (% women)

Anxiety treatment vs. depression treatment vs. nonspecific control treatment Cognitive-behavior therapy vs. reminiscence therapy vs. activity group

Relaxation–meditation vs. cognitive restructuring vs. control treatment

Relaxation–meditation with homework tapes vs. relaxation–meditation without tapes vs. pseudorelaxation control

Wait list control (WLC) vs. rational emotive therapy (RET)

Design

Primary Outcome Measure

5 weeks, 1 hour, 2 times per week 3 weeks, 1 hour, 2 times per week

STAI; Life Satisfaction Index-A (LSI-A)

STAI; BDI

10 weeks, 45 STAI; Beck Depression minutes, Inventory (BDI) 2 times per week

Spielberger State-Trait Anxiety Inventory (STAI); Adult Ideas Inventory 10 weeks, 30 STAI; Zung Checklist minutes per week

4 weeks, 2 hours per week

Duration of Treatment

10 weeks, gains maintained for two treatment groups 1 month, gains maintained

10 weeks, gains maintained for two relaxation groups

None

Follow-up

No change on STAI or Unclear LSI-A duration

Anxiety and irrational beliefs decreased following RET, not WLC Decrease on STAI for two relaxation groups, not for control group No change in depression STAI-Trait improved in all 3 gorups; STAI-State improved only in relaxation group STAI and BDI both decreased in all 3 groups

Results

TABLE 1 Studies Evaluating Cognitive Behavior Therapy for Anxiety Symptoms in Older Adult Community Volunteers

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Scogin et al. 54 com(1992) pleters out of 71

68

—

Progressive relaxation (PR) vs. imaginal relaxation (IR) vs. delayed treatment (DT)

4 sessions

STAI; Symptom Checklist90 (SCL-90)

No change on STAITrait; STAI-State and SCL-90 decreased following PR and IR, not DT

1 month, gains maintained and improved on STAI-Trait and SCL-90; deterioration on STAI-State Rickard et al. (1994): 1 year, gains maintained on STAI-Trait and SCL-90; deterioration on STAI-State

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Although these treatment trials are not specific to GAD, overall the data are promising in terms of the potential benefit of cognitive behavioral treatments for this disorder. However, conclusions are limited in a number of important ways. First, selection of participants in all cases failed to include a diagnostic interview; rather, individuals generally were selected for study inclusion based on self-report of various anxiety symptoms. Although many of the symptoms reported (e.g., tension, fatigue, insomnia, subjective anxiety) are characteristic of GAD, the samples were not well defined in terms of psychiatric diagnosis. It is interesting to observe, however, that pretreatment state and trait anxiety scores in these community-based treatment trials are comparable with those of older adults with well-diagnosed GAD (Stanley, Beck, & Zebb, 1996). Nonetheless, generalizability of the findings to clinical samples with symptoms that clearly meet criteria for GAD is unclear. Second, sample sizes in most studies were quite small, with as few as eight participants per treatment condition (Scates et al., 1986). Thus, power to detect treatment differences was low in most cases. Third, treatments were quite brief, lasting only 4 to 10 weeks, and did not include multiple components to target the cognitive, physiological, and behavioral symptoms of GAD as it currently is conceptualized. Therefore, interventions were not representative of the well-developed, integrative treatments that have been demonstrated effective in clinical trials of younger adults with GAD. Fourth, follow-up evaluations were conducted after only very brief intervals (range ⫽ 1 month–10 weeks), with the exception of one study that evaluated one-half of those who completed treatment at 1-year follow-up (Rickard et al., 1994). In this regard, then, it is difficult to make firm conclusions about the durability of treatment effects. Finally, outcome evaluation generally was limited to two or three selfreport measures of anxiety and associated symptoms (e.g., depression, general psychopathologic features). Despite some serious methodologic limitations, these early trials nevertheless provide encouraging findings regarding the potential usefulness of CBT for late-life GAD. Other relevant findings also are available in the literature addressing cognitive behavioral interventions for depression in older adults. Given the particularly high rates of coexistence between anxiety and affective symptoms and disorders in late life (Alexopoulos, 1991; Flint, 1994), it is not surprising that reductions in severity of anxiety are noted after CBT for depression (Steuer et al., 1984; Thompson, Gallagher, & Breckenridge, 1987). Again, although these data do not address directly the efficacy of CBT for GAD, the findings are salient and provide promising preliminary data to support more direct investigations of cognitive behavioral interventions with patients whose symptoms meet criteria for the disorder. Of more direct relevance, one early case report suggested the potential usefulness of CBT for 10 patients, 5 of whom were diagnosed with GAD (King &

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Barrowclough, 1991). Patients ranged in age from 66 to 78, and treatment focused primarily on modifying maladaptive thoughts. Although patients with GAD were included, an emphasis in treatment was placed on panic symptoms given that panic disorder, agoraphobia, or both were present in all but one patient. In another more recent report, six patients (age 65–76) with symptoms of GAD appeared to benefit from group cognitive behavioral treatment that incorporated both relaxation training and cognitive interventions (Radley, Redston, Bates, & Pontefract, 1997). Patients had a range of additional anxiety disorders, however, and the specific focus of treatment was unclear. In both of these reports, sample sizes also were extremely small and treatment procedures were not directed specifically toward core features of GAD. Moreover, the lack of experimental control groups seriously limits the conclusions that can be made. Only recently have larger, better-controlled clinical trials begun to examine the usefulness of CBT for well-diagnosed older adults with GAD. In the first of these (Stanley, Beck, & Glassco, 1996), the efficacy of CBT was compared with nondirective, supportive psychotherapy (SP) in a sample of 48 adults, ages 55 to 81 (mean ⫽ 68 years), with GAD diagnosed according to semistructured interviews. Treatment was conducted in a small group format over a period of 14 weeks. CBT was based on programs with demonstrated efficacy in younger adults (Borkovec & Costello, 1993; Craske et al., 1992), with some modifications to meet the special needs of older patients. Specific treatment components included relaxation training, cognitive therapy, and graduated exposure practice in worry-producing situations. Supportive psychotherapy was selected as a control condition given that it has demonstrated inferior effects relative to CBT with younger patients (Borkovec & Costello, 1993), and it omits the need to withhold treatment as is necessary in a wait-list control condition. Of the 48 patients who entered the study, 2 withdrew before randomization to treatment condition. After randomization, 10 patients (22%) discontinued treatment and 5 (11%) did not attend at least 60% of sessions, resulting in a total attrition rate of 33%. Although the authors noted that similar drop-out rates have been reported in similar studies with younger adults, this figure is rather high and may reflect the reluctance of older adults to acknowledge mental health problems and receive social services. Nevertheless, for the 31 participants who completed treatment, significant improvements were noted after both CBT and SP in self-report and clinician-rated measures of worry, anxiety, and depression. Effect sizes generally were large, and treatment gains were maintained over a follow-up interval of 6 months. At follow-up, 50% of CBT patients and 77% of SP participants were classified as treatment responders based on a 20% or greater decrease in at least three of four primary outcome measures.

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In general, these data provide the first evidence from a controlled trial for the potential usefulness of CBT in reducing symptoms associated with GAD in older individuals. Equivalent improvements in the CBT and SP groups, however, are inconsistent with findings from the younger adult literature (Borkovec & Costello, 1993) and call into question the unique role of CBT in treating late-life GAD. In fact, given the omission of a no treatment control condition in the Stanley et al. (1996) study, it is impossible to conclude with any certainty that symptom reduction was the result of any specific treatment procedures. Nonetheless, it is interesting to note that differences between CBT and SP among younger individuals with GAD were based on treatments administered in an individual format; in the comparison with older adults, a group format was used for both interventions. Differences in the efficacy of these treatments administered in group and individual formats have yet to be investigated in any clinical trial focused on GAD. To expand on data from this preliminary trial, at least two other studies are ongoing to investigate further the usefulness of CBT for late-life GAD. In one of these that directly follows Stanley et al. (1996), the efficacy of CBT is being compared with a minimal contact control condition that involves weekly phone contact with patients. Individuals age 60 and over with GAD are included in this trial, with random assignment to CBT or minimal contact control for a period of 15 weeks. Cognitive behavior therapy is conducted according to procedures described in Stanley et al. (1996), but the design will allow clearer conclusions about the efficacy of this approach. Durability of treatment effects also will be examined over a 1-year follow-up interval, and sample size will be sufficient to allow preliminary examination of response predictors. In an early report of data from the first 21 participants in this trial, potentially meaningful decreases in worry, anxiety, and depression were noted after CBT, as well as increases in life satisfaction and quality of life (Stanley, Beck, Novy, Averill, & Swann, 1997). Although no statistical analyses yet had been conducted, mean scores in the minimal contact control group suggested no meaningful changes in these constructs at posttreatment assessment. In another trial currently in progress, the efficacy of CBT for older adults with GAD is being evaluated for patients taking benzodiazepines on a regular, prescribed schedule. Patients are assigned to CBT with medical management or medical management alone for a period of 13 weeks. Medical management involves meeting with a psychiatrist on a weekly basis to devise and carry out a schedule for medication reduction, which typically occurs by reducing daily doses approximately 20% each week. CBT includes relaxation training, cognitive therapy, reduction of anxiety-maintaining behaviors, exposure to anxietyproducing situations, and improving daily structure. In a preliminary report of the first 12 patients included in this trial (Gorenstein, Papp, & Kleber, 1997), potentially greater decreases in various measures of worry and anxiety were apparent after CBT with medical management than medical management

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alone. Statistical analyses also had not yet been conducted for these data given small sample sizes, but it was of particular interest that improvement after CBT seemed to occur despite meaningful reductions in benzodiazepine use that did not occur in the medical management condition. Overall, then, available data attest to the potential benefits of CBT for latelife GAD. Nevertheless, a wide range of unanswered questions remain, and significant additional research is necessary. Suggestions for this future work are detailed in the following section.

FUTURE DIRECTIONS Given the very early state of literature evaluating CBT for late-life GAD, future studies will need to address basic efficacy questions, issues related to sample identification, and breadth of outcome assessment. Specific suggestions across these domains are offered as follows. Efficacy Studies Despite encouraging evidence for the effects of CBT, further programmatic investigations are needed to establish efficacy. Specifically, more stringent tests are needed to compare CBT with other rival interventions, both psychosocial and pharmacologic. These tests control for processes independent of specific treatments and common to all interventions (Chambless & Hollon, 1998). Given preliminary findings suggesting equivalent effects after CBT and nondirective supportive therapy (Stanley et al., 1996), it will be particularly important to establish whether cognitive behavioral interventions are the psychosocial treatment of choice for older adults with GAD. As noted earlier, one additional component of such a study may address the relative effects of treatments conducted in group and individual formats. Cost–benefit analyses of various types and modes of treatment also will need to be considered, given the emphasis in the current health care environment on efficiency of service delivery. Another particularly important comparison would involve CBT and pharmacotherapy, the current mainstay of anxiety management for the elderly (Salzman, 1991). However, before such a study is planned, there must be an empirically supported determination of an optimal medication and dosage for anxious, older adults. Solid empirical data are not yet available in this domain. Ultimately, combinations of treatments also will need to be compared. As soon as the most powerful psychosocial and pharmacologic interventions are established, for example, their effects will need to be compared for treatments conducted both alone and in combination. A common design would include five cells: pharmacotherapy, placebo, CBT (if this is the psychosocial treatment of choice), CBT plus pharmacotherapy, and CBT plus placebo.

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Investigation of the interplay (interaction or moderator effects) between potentially relevant personal characteristics (e.g., level of cognitive functioning, level of optimism) or environmental variables (e.g., degree of social support) with CBT is another area for future research. Studies along this line report intriguing early findings with younger adults suggesting that patients who are reactant (resistant) benefit more from nondirective therapy or paradoxical treatment than from cognitive or behavioral interventions (e.g., Beutler et al., 1991). It will be important to investigate the extent to which these types of interactive effects generalize to older, anxious individuals and to explore the roles of other potentially relevant moderating characteristics. Information from these types of investigations could help practitioners select among possible beneficial treatments for a particular patient. As soon as efficacy has been more firmly established, another challenge for future research is to investigate the extent to which CBT for late-life GAD works in a clinical setting under naturalistic conditions. In designing “effectiveness” studies with greater clinical realism for older adults, for instance, it will be important to include participants who are seeking services in primary care settings and those who reside in retirement or institutionalized settings. It also will be necessary to broaden traditional inclusion criteria to test the effects of treatment on a more heterogeneous segment of the older population, that is, those with cognitive impairment, serious medical conditions, or those with coexistent psychiatric disorders. Sample Identification In ongoing, well-controlled clinical trials of CBT for older adults with GAD (Gorenstein et al., 1997; Stanley et al., 1997), participants have been included based on diagnosis of GAD as determined by semistructured interviews. One such commonly implemented diagnostic procedure requires two independent administrations of the standardized interview, typically over a minimum of 2 weeks. However, diagnosing GAD in this fashion with younger patients typically produces interrater reliability coefficients that are inadequate or marginal (Chorpita, Brown, & Barlow, 1998; Di Nardo, Moras, Barlow, Rapee, & Brown, 1993). Furthermore, significant overlap between GAD and affective disorders among older adults (Flint, 1994) poses special problems for the reliable establishment of diagnoses. In research with younger, anxious adults, Di Nardo et al. (1995) demonstrated that disagreement errors were the result of symptom interpretation, threshold severity (i.e., whether functional impairment is high enough to warrant diagnosis), and misinterpretation of diagnostic rules. Mannuza et al. (1989) found that disagreements often were the result of interviewer error. Future research is needed to explore the frequencies with which these and other types of rater disagreements (e.g., differential weighting of the clinical picture; complete diagnostic criteria; insufficient questioning by

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the interview; subject variance) occur with older adults. Hopefully, ways to address the problem (e.g., greater detailed probing on the interview) will follow. Alternative methods for identifying appropriate patients also may be warranted, for example, using cutoff scores on reliable and valid questionnaires to complement interview data (Chambless & Hollon, 1998). As noted previously, it also will be important for future research to explore the usefulness of CBT with a broader segment of the older population. Treatment outcome research traditionally has focused on fairly restrictive groups of patients who meet strict inclusion and exclusion criteria. In both the younger and older adult anxiety literatures, for example, patients with serious medical problems, comorbid psychiatric disorders, and concomitant medications typically are excluded. Among older adults, these procedures are particularly limiting in terms of generalizability of study findings. Moreover, most treatment studies for older adults have focused on efficacy in the “young-old,” that is, ages 65 to 74. As such, future work will need to broaden typical inclusion criteria to study treatment effects in even older individuals with multiple medical and psychiatric problems. In this regard, the scope of sampling will need to be expanded to include patients from primary care settings and persons in assisted living, as well as those with some degree of cognitive impairment. Focus on these special populations may require customizing current CBT manuals. In a related vein, treatment efficacy across ethnic groups has not been studied systematically in younger or older adult samples. In particular, the impact of CBT on the range of somatic symptoms and bodily idioms often found with younger, anxious adults of Hispanic and African-American backgrounds has not been assessed with older adults (Neal-Barnett & Smith, 1997; Salman, Diamond, Jusino, Sanchez-LaCay, & Liebowitz, 1997). In these populations, the roles of family variables, spirituality, and interpretation of somatic symptoms may be of particular importance. Furthermore, the usefulness of CBT procedures in languages other than English has yet to be investigated with older adults. Outcome Assessment Early outcome evaluations of CBT for late-life anxiety typically focused on data from two or three self-report measures of anxiety and related symptoms (e.g., DeBerry, 1982; DeBerry et al., 1989). More recently, semistructured interviews and clinical rating scales also have been used (Stanley et al., 1996). Ideally, however, full evaluation of treatment effects should include self-report, clinician-rated, and behavioral measures of target symptoms, associated conditions, and overall functioning (e.g., quality of life, social functioning). With the exception of preliminary data from a measure of behavioral indicators of anxiety (e.g., nail biting, lack of eye contact) currently being developed (Novy, Stanley, Swann, Averill, Breckenridge, & Akkerman, 1997), the method of behavioral observations for the assessment of anxiety rarely is used. This type of

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assessment may be of particular importance for older adults with restricted cognitive functioning. Hence, broadening of outcome assessment with regard to method and domain is an important future direction. It will be important for future work to evaluate the impact of treatment not only on severity of psychiatric symptomatology, but also on variables such as general functional capacity, quality of life, and social interaction. Moreover, it will be important to consider the extent to which there are any negative effects of treatment (Chambless & Hollon, 1998). At present, there also are few data to support the endurance of improvement from CBT for older adults with GAD. Only one study (Rickard et al., 1994) included a 1-year follow-up. However, assessment in this case was limited to self-report measures of anxiety and associated symptoms, and followup evaluation included only about half of study completers. At least one study currently in progress (e.g., Stanley et al., 1997) will assess the endurance of improvement on a broader scope of relevant domains across 1 year. Future work should continue to examine treatment effects over long-term intervals.

SUMMARY GAD is a significant public health concern for older adults. Although treatment typically includes pharmacologic interventions provided by primary care physicians, recent research has begun to document the potential usefulness of psychosocial approaches, most notably CBT. Despite encouraging results of early research, however, methodologic limitations exist, and further programmatic efforts are needed. The continuing maturation of the research base on CBT for late-life GAD will determine the extent to which efficacy and generalizability of findings can be established. Several important efforts in this domain are ongoing, and other directions for future research have been offered here.

REFERENCES Alexopoulos, G. S. (1991). Anxiety and depression in the elderly. In C. Salzman & B. D. Lebowitz (Eds.), Anxiety in the elderly: Treatment and research (pp. 63–77). New York: Springer. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders, 3rd ed. Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: Author. Beck, J. G., Stanley, M. A., & Zebb, B. J. (1996). Characteristics of generalized anxiety disorder in older adults: A descriptive study. Behaviour Research and Therapy, 34, 225–234. Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., Bergan, J., Mere, K., & Merry, W. (1991). Predictors of differential response to cognitive, experimental, and self-directed psychotherapeutic procedures. Journal of Consulting and Clinical Psychology, 59, 333–340. Bland, R. C., Newman, S. C., & Orn, H. (1988). Prevalence of psychiatric disorders in the elderly in Edmonton. Acta Psychiatrica Scandanavia, 77, 57–63.

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