CBT for Late-Life GAD in Primary Care: Enhancing Outcomes and Translational Value

初级保健中针对晚年广泛性痴呆的 CBT：提高成果和转化价值

• 批准号: 8268530
• 负责人: MELINDA A STANLEY
• 金额: $ 58.73万
• 依托单位: BAYLOR COLLEGE OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 1996
• 资助国家: 美国
• 起止时间: 1996-09-01 至 2015-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8268530
• 关键词: Address; Adherence; Aftercare; Age; Alcohol consumption; Anxiety; Attention; Belief; Caring; Clinic; Clinical Trials; Cognitive Therapy; Collaborations; Comorbidity; Competence; Computerized Medical Record; Data; Disease; Dose; Effectiveness; Elderly; Evaluation; Expectancy; Generalized Anxiety Disorder; Health Personnel; Inferior; Insurance; Intervention; Maintenance; Mediator of activation protein; Medical; Medical center; Mental Depression; Mental disorders; Modeling; Modification; Motivation; Outcome; Pain; Patient Preferences; Patients; Pharmaceutical Preparations; Phase; Primary Health Care; Procedures; Professional counselor; Provider; Psychotherapy; Randomized; Recruitment Activity; Relative (related person); Research; Research Support; Resources; Role; Sampling; Services; Severities; Site; Sleep; Specialist; Telephone; Testing; Therapeutic; Third-Party Payer; Training; Use Effectiveness; Value of Life; Veterans; Work; base; clinical practice; collaborative care; cost; cost effective; demographics; depressive symptoms; design; follow-up; functional status; improved; primary care setting; primary outcome; programs; satisfaction; secondary outcome; treatment as usual

DESCRIPTION (provided by applicant): This resubmission for a second competitive renewal project in our program of research to develop and test treatments for late-life generalized anxiety disorder (GAD) is consistent with PA 07-163, which supports research to reduce the burden of mental illness in older adults and increase efficiency and accessibility of treatment. The original study (MH53932, 01 - 05) demonstrated the efficacy of cognitive behavior therapy (CBT), relative to a minimal contact control condition (MCC), in an academic clinical trial (Stanley et al., 2003a). The ongoing renewal project (R01 MH53932, 06 - 09) extends this research to primary care. Preliminary analyses suggest greater improvement in worry and anxiety severity in CBT than UC, with improved outcomes at 6-months relative to 3-months. Attrition in CBT is low. Effect sizes are moderate and comparable to results from prior collaborative care studies. In the proposed second renewal project (years 10 - 14), we will further promote the generalizability to contemporary real-world settings by examining the effectiveness of using Anxiety Clinic Specialists (ACS) and non-expert Counselors to deliver the intervention, relative to usual care (UC). Several enhancements to our intervention support its sustainable implementation in routine clinical practice: (1) Increased collaboration with primary care through the use of electronic medical records (EMR) to identify patients and communicate with providers; (2) CBT modifications that involve modular treatment, integration of telephone-based service delivery, incorporation of patient preference, briefer sessions and simplified procedures, more attention to coexistent depression and motivation/life values, and extended duration of care using telephone-based booster sessions; and (3) Implementation in two diverse medical settings (insurance-based primary care, Veterans Affairs Medical Center) to enhance generality of findings. A total of 222 medical patients, age 60 and over, with GAD will be recruited through primary care clinics at the new study sites. Patients will be assigned randomly to CBT-ACS (expert), CBT-Counselor (non-expert), or Usual Care. Treatment will last 6 months. Pilot data support our ability to train non-experts and recruit a more diverse and severe patient sample. Outcomes are generally equivalent to or greater than the ongoing trial. Patients who complete 6 months of CBT will enter a follow-up phase, with evaluations at 9, 12, and 18 months. Patients who exit UC after 6 months will be offered CBT. Specific Aims will compare outcomes in CBT-ACS, CBT-Counselor, and UC over 6 months. Primary outcomes address severity of worry, anxiety, and GAD. Secondary outcomes assess coexistent symptoms (depression, sleep, pain, alcohol use), functional status, and satisfaction. Long-term maintenance of gains will be examined over the subsequent 12 months in the two CBT groups. Exploratory Aims will examine resource use/cost and potential moderators and mediators of outcome.

描述（由申请人提供）：在我们的研究计划中，此重新提交第二个竞争性更新项目，以开发和测试晚期普遍焦虑症（GAD）的治疗，与PA 07-163一致，该研究支持研究以减少老年人的精神疾病负担，并提高治疗效率和治疗效率。在一项学术临床试验中（Stanley等，2003a），最初的研究（MH53932，01-05）相对于最小的接触控制条件（MCC）证明了认知行为疗法（CBT）的功效。正在进行的续签项目（R01 MH53932，06-09）将这项研究扩展到初级保健。初步分析表明，与UC相比，CBT的忧虑和焦虑严重程度的改善更大，相对于3个月的6个月的预后改善。 CBT中的损耗很低。效应大小适中，可与先前的协作护理研究结果相媲美。在拟议的第二次续签项目（10-14年）中，我们将通过研究使用焦虑诊所专家（ACS）和非专家辅导员提供干预的有效性，进一步促进当代现实世界中的普遍性，相对于通常的护理（UC）。我们干预的几种增强能力支持其在常规临床实践中的可持续实施：（1）通过使用电子病历（EMR）来识别患者并与提供者进行沟通，以增加与初级保健的合作； （2）涉及模块化治疗，基于电话的服务交付的整合，患者偏好的整合，Briefer会议和简化程序的CBT修改，更多地关注共存的抑郁症和动机/生活价值以及使用基于电话的助推器会议的延长护理时间； （3）在两个不同的医疗环境（基于保险的初级保健，退伍军人事务中心）中实施，以增强发现的一般性。总共222名60岁及60岁的医学患者将通过新研究地点的初级保健诊所招募GAD。患者将被随机分配给CBT-ACS（专家），CBT-Counselor（非专家）或通常的护理。治疗将持续6个月。试验数据支持我们训练非专家并招募更多样化和严重的患者样本的能力。结果通常等于或大于正在进行的试验。完成6个月CBT的患者将进入后续阶段，评估为9、12和18个月。在6个月后退出UC的患者将提供CBT。具体目的将在6个月内比较CBT-ACS，CBT-Counselor和UC的结果。主要结果解决了担忧，焦虑和GAD的严重性。次要结果评估共存的症状（抑郁，睡眠，疼痛，饮酒），功能状态和满意度。在两个CBT组中，将在随后的12个月内检查收益的长期维护。探索目的将检查资源使用/成本和潜在的调节者和结果的调解人。

项目成果

Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial.

• DOI: 10.1001/jama.2009.458
• 发表时间: 2009-04-08
• 期刊: JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
• 影响因子: 120.7
• 作者: Stanley, Melinda A.;Wilson, Nancy L.;Novy, Diane M.;Rhoades, Howard M.;Wagener, Paula D.;Greisinger, Anthony J.;Cully, Jeffrey A.;Kunik, Mark E.
• 通讯作者: Kunik, Mark E.

Expanding the geriatric mental health workforce through utilization of non-licensed providers.

通过利用非许可提供者扩大老年心理健康劳动力。

• DOI: 10.1080/13607863.2016.1186150
• 发表时间: 2017
• 期刊: Aging & mental health
• 影响因子: 3.4
• 作者: Kunik,MarkE;Mills,WhitneyL;Amspoker,AmberB;Cully,JeffreyA;Kraus-Schuman,Cynthia;Stanley,Melinda;Wilson,NancyL
• 通讯作者: Wilson,NancyL

Treatment response for late-life generalized anxiety disorder: moving beyond symptom-based measures.

• DOI: 10.1097/nmd.0b013e31822feda6
• 发表时间: 2011-10
• 期刊: The Journal of nervous and mental disease
• 作者: Roseman AS;Cully JA;Kunik ME;Novy DM;Rhoades HM;Wilson NL;Bush AL;Stanley MA
• 通讯作者: Stanley MA

The Pittsburgh Sleep Quality Index in older primary care patients with generalized anxiety disorder: psychometrics and outcomes following cognitive behavioral therapy.

• DOI: 10.1016/j.psychres.2012.03.045
• 发表时间: 2012-08-30
• 期刊: PSYCHIATRY RESEARCH
• 影响因子: 11.3
• 作者: Bush, Amber L.;Armento, Maria E. A.;Weiss, Brandon J.;Rhoades, Howard M.;Novy, Diane M.;Wilson, Nancy L.;Kunik, Mark E.;Stanley, Melinda A.
• 通讯作者: Stanley, Melinda A.

Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings.

初级保健中晚年广泛性焦虑症的认知行为治疗：初步发现。

• 发表时间: 2003
• 期刊: The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
• 作者: Stanley,MelindaA;Hopko,DerekR;Diefenbach,GretchenJ;Bourland,StaceyL;Rodriguez,Hector;Wagener,Paula
• 通讯作者: Wagener,Paula