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Context: Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in older adults; however, few data exist to guide clinicians in efficacious and safe treatment. Selective serotonin reuptake inhibitors (SSRIs) are efficacious for younger adults with GAD, but benefits and risks may be different in older adults.Objective: To examine the efficacy, safety, and tolerability of the SSRI escitalopram in older adults with GAD.Design, Setting, and Participants: A randomized controlled trial in primary care practices and related specialty clinics in Pittsburgh, Pennsylvania, of 177 participants aged 60 years or older with a principal diagnosis of GAD randomized to receive either escitalopram or placebo and conducted between January 2005 and January 2008.Interventions: Twelve weeks of 10 to 20 mg/d of escitalopram (n = 85) or matching placebo (n = 92).Main Outcome Measures: Cumulative response defined by Clinical Global Impressions-Improvement score of much or very much improved; time to response; and anxiety and role functioning changes measured by the Clinical Global Impressions-Improvement scale, Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Late-Life Function and Disability Instrument activity limitations subscale, and the role-emotional impairment and social function subscales of the Medical Outcome Survey 36-item Short Form.Results: In the primary analytic strategy in which participants (n = 33) were censored at the time of dropout, mean cumulative response rate for escitalopram was 69% (95% confidence interval [CI], 58%-80%) vs 51% (95% CI, 40%-62%) for placebo (P = .03). A conservative intention-to-treat analysis showed no difference in mean cumulative response rate between escitalopram and placebo (57%; 95% CI, 46%-67%; vs 45%; 95% CI, 35%-55%; P = .11). Participants treated with escitalopram showed greater improvement than with placebo in anxiety symptoms and role functioning (Clinical Global Impressions-Improvement scale: effect size, 0.93; 95% CI, 0.50-1.36; P < .001; Penn State Worry Questionnaire: 0.30; 95% CI, 0.23-0.48; P = .01; activity limitations: 0.32; 95% CI, 0.01-0.63; P = .04; and the role-emotional impairment and social function: 0.96; 95% CI, 0.03-1.90; P = .04). Adverse effects of escitalopram (P < .05 vs placebo) were fatigue or somnolence (35 patients [41.1%]), sleep disturbance (12 [14.1%]), and urinary symptoms (8 [9.4%]).Conclusions: Older adults with GAD randomized to escitalopram had a higher cumulative response rate for improvement vs placebo over 12 weeks; however, response rates were not significantly different using an intention-to-treat analysis. Further study is required to assess efficacy and safety over longer treatment durations.Trial Registration: clinicaltrials.gov Identifier: NCT00105586. [ABSTRACT FROM AUTHOR]

Many patients with complicated grief suffer severe symptoms for several years after the loss, interfering with daily life. We sought to determine which elements of a patient's daily routine were likely to be missed or added. Sixty-four patients completed a diary each evening for 2 weeks. The diary asked whether each of 13 daily life activities were done or missed on that day. Comparisons were made with 64 matched healthy control participants. Patients were significantly more likely than controls to miss contact with another person, breakfast, lunch, dinner, starting work, and going outside, and to add a nap and evening snack. [ABSTRACT FROM AUTHOR]

Context: Panic disorder (PD) may be treated with drugs, psychosocial intervention, or both, but the relative and combined efficacies have not been evaluated in an unbiased fashion.Objective: To evaluate whether drug and psychosocial therapies for PD are each more effective than placebo, whether one treatment is more effective than the other, and whether combined therapy is more effective than either therapy alone.Design and Setting: Randomized, double-blind, placebo-controlled clinical trial conducted in 4 anxiety research clinics from May 1991 to April 1998.Patients: A total of 312 patients with PD were included in the analysis.Interventions: Patients were randomly assigned to receive imipramine, up to 300 mg/d, only (n=83); cognitive-behavioral therapy (CBT) only (n=77); placebo only (n=24); CBT plus imipramine (n=65); or CBT plus placebo (n=63). Patients were treated weekly for 3 months (acute phase); responders were then seen monthly for 6 months (maintenance phase) and then followed up for 6 months after treatment discontinuation.Main Outcome Measures: Treatment response based on the Panic Disorder Severity Scale (PDSS) and the Clinical Global Impression Scale (CGI) by treatment group.Results: Both imipramine and CBT were significantly superior to placebo for the acute treatment phase as assessed by the PDSS (response rates for the intent-to-treat [ITT] analysis, 45.8%, 48.7%, and 21.7%; P=.05 and P=.03, respectively), but were not significantly different for the CGI (48. 2%, 53.9%, and 37.5%, respectively). After 6 months of maintenance, imipramine and CBT were significantly more effective than placebo for both the PDSS (response rates, 37.8%, 39.5%, and 13.0%, respectively; P=.02 for both) and the CGI (37.8%, 42.1%, and 13.0%, respectively). Among responders, imipramine produced a response of higher quality. The acute response rate for the combined treatment was 60.3% for the PDSS and 64.1% for the CGI; neither was significantly different from the other groups. The 6-month maintenance response rate for combined therapy was 57.1% for the PDSS (P=.04 vs CBT alone and P=.03 vs imipramine alone) and 56.3% for the CGI (P=.03 vs imipramine alone), but not significantly better than CBT plus placebo in either analysis. Six months after treatment discontinuation, in the ITT analysis CGI response rates were 41.0% for CBT plus placebo, 31.9% for CBT alone, 19.7% for imipramine alone, 13% for placebo, and 26.3% for CBT combined with imipramine.Conclusions: Combining imipramine and CBT appeared to confer limited advantage acutely but more substantial advantage by the end of maintenance. Each treatment worked well immediately following treatment and during maintenance; CBT appeared durable in follow-up. JAMA. 2000;283:2529-2536 [ABSTRACT FROM AUTHOR]

OBJECTIVE: The authors assessed whether adding cognitive behavior therapy (CBT) to imipramine for patients with panic disorder decreased the severity of side effects and dropouts from side effects. METHOD: Data were analyzed for 172 panic disorder patients who were randomly assigned to receive imipramine alone, imipramine plus CBT, or placebo. Mixed-effects models were used to assess longitudinal differences among the treatment groups with respect to side effect burden and dropout rates during the acute, maintenance, and follow-up phases of treatment. RESULTS: Patients treated with imipramine plus CBT experienced less severe fatigue/weakness, dry mouth, and sweating and had a lower rate of dropout due to side effects compared with those treated with imipramine only. CONCLUSIONS: The addition of CBT to medication treatment with imipramine was associated with less severe side effects and fewer dropouts due to perceived side effects than treatment with imipramine alone. [ABSTRACT FROM AUTHOR]

This study examined attrition in a multisite clinical trial for panic disorder. Of 379 eligible patients, 19 refused treatment (5% Refusal Rate), 104 discontinued treatment prematurely (19% Dropout Rate) or were withdrawn by the investigators (8% Withdrawal Rate), and 256 completed the treatment (68% Completion Rate). Logistic regression was used to examine 5 domains theorized to be related to attrition (e.g., diagnostic severity, treatment factors). Few variables were associated with increased odds of attrition at padj < 0.004. Younger age was the only independent predictor of attrition in the demographic factor model. Diagnostic severity and comorbidity, panic disorder symptom severity, treatment factors, and therapist factors were unrelated to study attrition. Patient dropout was highest after treatment sessions that targeted interoceptive and situational exposure exercises. Findings suggest that attrition may not strongly threaten the validity of results from treatment outcome studies. [ABSTRACT FROM AUTHOR]

A recent double-blind, placebo-controlled trial (Barlow et al., 2000 JAMA. 283:2529-2536) examined separate and synergistic effects of psychological and pharmacological treatments for panic disorder. One finding warranting further investigation involved relatively high relapse rates of participants who received cognitive-behavioral therapy (CBT) + imipramine when compared with those receiving CBT + placebo. In this article, we investigate why CBT was less effective in protecting against relapse for individuals in the active drug condition. We hypothesized that participants correctly deduced treatment assignments and, for those taking imipramine, this was associated with the belief that they were no longer taking active drug after discontinuation, accounting for increased relapse rates. Contrary to hypothesis, there were no group differences in frequencies of guessing drug or placebo, nor were specific beliefs about taking drug or placebo differentially associated with relapse. Other possible reasons for differential relapse rates and treatment implications are discussed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Des- pite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder. [ABSTRACT FROM AUTHOR]

This study examined the effect of maternal depression and anxiety on child treatment outcome. Psychiatric assessments were conducted on 180 mother-child pairs when the child entered treatment in a community mental health center and six months later. Children whose mothers were depressed or anxious were significantly more impaired than children of mentally healthy mothers at both time points. Both groups of children improved at approximately the same rate. The findings suggest that early mental health screening of children and their mothers may be important preventive practices. Addressing the mental health needs of mothers and children simultaneously may be an effective method of reducing their mental health problems. [ABSTRACT FROM AUTHOR]