Cognitive Behavior Therapy for Anxiety and Related Disorders in Older People

Does cognitive behavior therapy (CBT) decrease anxiety symptoms in adults older than 55 years?

Compared with minimal management (ie, no formal treatment), 10 to 15 sessions of CBT reduce posttreatment anxiety severity for 2 to 8 weeks in persons older than 55 years (standardized mean difference [SMD] = −0.51; 95% CI, −0.36 to −0.66; number needed to treat [NNT] = 5).¹ (Strength of Recommendation [SOR]: B, low certainty of evidence.) This reduction is not sustained 3 to 6 months posttreatment. Symptoms of worry and depression also are improved 2 weeks after 10 to 15 CBT sessions, and these improvements are sustained at 3 to 6 months posttreatment. (SOR: B, low-certainty evidence.) Available evidence is insufficient to determine the benefits of CBT compared with other psychological therapies in adults older than 55 years.

Anxiety and related disorders (including panic disorder, agoraphobia, generalized anxiety disorder [GAD], social anxiety disorder, specific phobia, obsessive-compulsive disorder, and posttraumatic stress disorder [PTSD]) are the most common mental health conditions in the United States, affecting more than 40 million adults, which is a prevalence of 19.1%.^1,2 In US adults older than 55 years, the estimated prevalence of anxiety disorders ranges from 6% to 12%, and these disorders are associated with an increased risk of coronary heart disease and a higher mortality rate.¹

CBT is an intervention that incorporates muscle relaxation, cognitive restructuring, and behavioral adaptation to target behavioral, cognitive, and experiential avoidance behaviors typical of anxiety disorders.³ Although CBT is considered the first-line psychological treatment for anxiety disorders, the average age of participants in most studies is younger than 55 years, and many studies exclude older participants. The authors of this Cochrane review sought to assess the effects of CBT on anxiety symptom severity among patients older than 55 years compared with control groups (ie, minimal management, other non-CBT psychological therapies).¹ Minimal management was described as standard care or no treatment (waiting list). Other non-CBT psychological treatments consisted of psychodynamic (Freudian), humanistic (discussion groups, relaxation training, or nondirective general support via telephone calls), and relaxation therapies.

This Cochrane review included 21 randomized controlled trials with 1,234 patients in seven countries, with 57% of studies conducted in the United States.¹ All studies included patients older than 55 years (mean age = 65–71 years) diagnosed with an anxiety disorder based on Diagnostic and Statistical Manual of Mental Disorders criteria (versions III, III-R, IV, and 5 were used). GAD was the most common diagnosis at 48%. Nineteen of the studies compared CBT with minimal management for anxiety disorders; two compared CBT with other non-CBT psychological therapy in patients with PTSD only. Studies that used psychological therapy models based on social constructionist principles (a focus on ways that individuals and groups participate in the construction of their perceived social reality) or CBT in combination with pharmacotherapy were excluded from this review.

The primary outcome assessed was reduction in anxiety severity as determined by clinical recovery noted on a diagnostic interview or a validated observer-rated or self-report instrument. The outcomes were assessed at 2 weeks postintervention and then multiple times (details of the timing not available) up to 6 months.¹ Secondary outcomes included symptoms of worry or depression using validated self-report questionnaires.