Generalized anxiety disorder (GAD) is one of the most common psychiatric conditions among older adults with serious negative consequences, including functional impairment, risk of depression, and mortality. Although preliminary evidence suggests that selective serotonin reuptake inhibitor (SSRI) medications are effective for GAD in older adults, most patients treated with SSRIs do not make a complete recovery, and many have continuing concerns about medications which can lead to early discontinuation and possibly relapse. Thus, strategies to enhance response and improve adherence in GAD patients treated with SSRIs have a high public health significance. Cognitive-behavioral therapy (CBT) has also demonstrated efficacy for late-life GAD and is potentially helpful for addressing concerns about medications, as well as building skills to manage anxiety whether or not medications are discontinued. Furthermore, affective neuroscience provides a strong rationale for a sequence of SSRI treatment followed by CBT. In GAD the prefrontal cortex appears to suppress limbic activity. SSRI medications reduce activity in the limbic system, potentially freeing prefrontal resources to learn skills in CBT. This appealing rationale for an SSRI-CBT sequence has not yet been tested in GAD and may be particularly relevant for older adults, who have, on average, lower levels of prefrontal resources than younger adults. We propose to create a psychotherapy augmentation protocol integrating a modular form of CBT with Concordance Therapy (CBT-Concord), a medication adherence therapy designed for geriatric depression, for older adults with GAD who have made a partial response to escitalopram. In Phase I we will conduct an """"""""open-label"""""""" trial of CBT-Concord with approximately 12 older GAD patients, and in Phase II we will conduct a randomized trial comparing escitalopram plus CBT-Concord to escitalopram plus clinical management with 40 older GAD patients. Outcomes to be examined include symptomatology, quality of life, functioning, and medication adherence and attitudes. The objective of this line of research is to test this augmentation strategy in a larger multi-site trial, with the ultimate goal of improving treatment effectiveness for late-life GAD.
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