CBT Augmentation of SSRI Treatment for Geriatric GAD

描述（由申请人提供）：广泛性焦虑症（GAD）是老年人中最常见的精神疾病之一，具有严重的负面后果，包括功能障碍、抑郁风险和死亡率。虽然初步证据表明，选择性5-羟色胺再摄取抑制剂（SSRI）药物对老年人GAD有效，但大多数接受SSRI治疗的患者并没有完全康复，许多人仍然担心药物可能导致早期停药和可能复发。因此，策略，以提高响应和改善与SSRIs治疗的GAD患者的依从性有很高的公共卫生意义。认知行为疗法（CBT）也证明了对晚年GAD的有效性，并且可能有助于解决对药物的担忧，以及建立管理焦虑的技能，无论是否停止药物治疗。此外，情感神经科学为SSRI治疗后进行CBT提供了强有力的理由。在广泛性焦虑症中，前额叶皮层似乎抑制了边缘系统的活动。SSRI药物减少了边缘系统的活动，可能会释放前额资源来学习CBT中的技能。SSRI-CBT序列的这一吸引人的理由尚未在GAD中进行过测试，可能与老年人特别相关，他们的前额叶资源平均水平低于年轻人。我们建议创建一个心理治疗增强方案，将模块化形式的CBT与一致性治疗（CBT-Concord）相结合，这是一种专为老年抑郁症设计的药物依从性治疗，适用于对艾司西酞普兰有部分反应的GAD老年人。在I期，我们将在大约12名老年GAD患者中进行CBT-Concord的“开放标签”试验，在II期，我们将在40名老年GAD患者中进行一项随机试验，比较艾司西酞普兰加CBT-Concord与艾司西酞普兰加临床管理。要检查的结果包括泌尿学，生活质量，功能，药物依从性和态度。这一系列研究的目的是在一个更大的多中心试验中测试这种增强策略，最终目标是提高老年GAD的治疗效果。

DESCRIPTION (provided by applicant): 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.