Mean uncontrolled effect sizes suggest that: (1
) spontaneous remission of symptoms during a wait-list period is unlikely; (2
) active control conditions had moderate effects for both anxiety and depressive symptoms; (3
) compared to active control conditions, psychosocial treatments have relatively large effects on depressive symptoms and a larger effect on anxiety symptoms; and (4
) there are no apparent outcome differences among conditions on depressive symptoms.
When treatment samples are compared to active control conditions on anxiety measures, the mean controlled effect sizes for RT (.90), CBT with RT (0.33), and CBT without RT (0.00) compare with results previously reported by others: a mean controlled effect size of 0.71 for CBT for GAD in the general population and 0.83 for pharmacotherapy for anxiety in older adults (22
). There are no apparent outcome differences among the three treatment types on depressive symptoms, with all effect sizes in the small range.
We chose to present both uncontrolled and controlled results (e.g., within and between groups), as meta-analyses of psychotherapy studies for GAD frequently calculate effects both ways (e.g., 53
). Response rates in treatment studies appear to vary depending upon the type of control condition (54
). For this reason, it seems appropriate to report both sets of results, as has been done in recent meta-analyses of pharmacotherapy for late-life anxiety and depression also published in this journal (22
Most psychotherapy treatment studies in late-life anxiety do not include active control conditions, so that more than twice as many comparisons are included in (uncontrolled effect sizes) as in (controlled effect sizes). Of note, if were limited to those studies included in , the uncontrolled effect sizes reported for CBT+RT, CBT-RT, and RT would be .93, 1.20, and 1.50, respectively. These results are broadly consistent with in suggesting that RT may be somewhat more effective for geriatric anxiety than the alternatives tested to date. However, this also suggests that all three treatments were compared to somewhat powerful control conditions, and more equitable (ideally, identical) control conditions would help to reveal any true differences between treatments.
Results for CBT-RT vary widely between uncontrolled and controlled studies. Although the 5 studies included in show that patients do make gains after CBT-RT, two of the three studies, conducted by different investigative teams, comparing CBT-RT to an active alternative condition () found that the alternative condition led to greater gains than did CBT-RT. This may suggest that CBT-RT could be a relatively weak intervention for late-life anxiety, but certainly more research is needed.
All but two of the studies examined psychotherapies administered in groups. Individual therapy is often expected to yield superior outcomes when compared to group therapy. However, both of the studies which offered individual treatment (49
) were in the CBT categories (with or without RT), and thus this distinction does not appear to explain the results.
The results of this study suggest that relaxation training and cognitive therapy are effective psychosocial treatments for older adults with anxiety disorders or symptoms. CBT (alone or augmented with RT) does not appear to add anything beyond RT alone, although a direct comparison is challenging given differences in control conditions. Relaxation training is a brief intervention that brings rapid relief, and training providers to do relaxation training appropriately is simpler than training them in more complex CBT methods. Moreover, older adults report high levels of satisfaction with relaxation training (57
). A psychosocial treatment that combines components (e.g., CBT techniques plus relaxation training) may be attractive because it offers a variety of skills, but the results of our analysis suggest that more does not always mean better for anxious samples of older adults.
Our analysis of the relatively small treatment outcome literature for older adults with anxiety disorders or symptoms has several limitations. We developed our own taxonomy to describe the treatments used in these studies. Other researchers may have defined the treatment categories differently. However, the interrater reliability on our categories was perfect. One of our goals was to compare psychosocial treatments based on whether they included relaxation training. Treatment components were not often directly compared within studies, however, and more dismantling studies are needed to demonstrate the true value of relaxation training.
We found significant heterogeneity among the results of the RT studies, with apparent outliers falling in both the positive and negative direction. RT protocols vary and can include diaphragmatic breathing, imagery, progressive muscle relaxation, and meditation techniques. The studies conducted by De Berry and colleagues (40
), which had larger effects than other investigations, included meditation to a greater extent than the other RT protocols. It is possible that meditation may offer benefits beyond what are achieved with other RT strategies. Overall, our conclusions with respect to the effectiveness of RT should be tempered with the knowledge that different RT protocols may lead to different results.
Three of the studies we examined did a direct comparison of active psychotherapies, as opposed to an active control condition. Sallis et al. (58
) compared a relaxation-based “anxiety management training” (without other CBT components, but including imagery, relaxation, and meditation) with a CBT-based “depression treatment” (without relaxation training, but including pleasant event monitoring, problem solving, and cognitive restructuring). Both treatments separately fared poorly against a robust “placebo” control (including self-disclosure and reflection of feelings), but an effect size analysis favored the CBT-based depression treatment on anxiety measures (mean d
= 0.77) though ironically not on depression measures (mean d
= .03) when CBT and relaxation were compared directly. DeBerry et al. (42
) compared progressive muscle relaxation with imagery and meditation (without explicit cognitive therapy) to cognitive restructuring and assertiveness training (without relaxation training). An effect size analysis revealed that relaxation was superior to CBT on anxiety measures (mean d
= 1.39) and depression measures (mean d
= 0.82). Stanley and colleagues (48
) compared CBT with relaxation training to supportive psychotherapy. Results indicated that both treatments significantly and equivalently reduced anxiety, worry, and depression.
Results were confounded by different sample characteristics and different comparison groups. The majority of the studies recruited samples with primary GAD, PD with or without agoraphobia, or subjective reports of anxiety. Our review included those with anxiety disorders and those with sub-threshold symptoms, for whom the magnitude of change is typically smaller. Indeed, the different results obtained from the Sallis et al. (58
) and DeBerry et al. (42
) studies may be attributable to sample differences, as the Sallis sample was recruited for having moderate anxiety (and depression) while the DeBerry sample had only “complaints of anxiety” (and slightly lower trait anxiety scores compared to the Sallis sample at baseline). None of the studies solely focused on social phobia or specific phobias, and none included subjects with known OCD or PTSD.
As noted above, however, baseline severity of anxiety symptoms as measured by the Spielberger trait anxiety scale was quite consistent across studies. Fewer than half of the studies included clinician-rated measures. This is especially important because the Hamilton Anxiety Scale is the standard in most drug studies. Researchers are therefore encouraged to include this scale in studies of late-life anxiety. Furthermore, in the four studies that included both clinician- rated and self-report measures, clinician-rated measures tended to yield larger effects (d = 1.37) than self-report measures (d = .81); this difference, however, was not statistically significant.
Recommendations and Future Directions
This study adds to the literature on late-life anxiety disorders by comparing different types of behavioral interventions. As such, it represents the closest approximation available to a dismantling study. Such studies are important to guide both clinicians in the selection of appropriate treatments, as well as interventions researchers in developing new forms and combinations of treatments.
The results must be interpreted with caution because of methodological limitations of analyses based on a small number of studies, differences in sample selection, and diverse control conditions (when controls were used). We suggest that in order to strengthen this nascent literature, psychotherapy studies of late-life anxiety should include active comparison conditions whenever possible. It is also important for researchers to identify the specific components involved in CBT (and other multi-component treatments), and true dismantling studies could add greatly to the theoretical and practical foundations of psychotherapy for older adults. Researchers should similarly take great care in selecting and describing control conditions. It is a great challenge to discover relatively inert but credible active control conditions, as evidenced by this review. Studies that compare two or more distinct and well-defined treatments to a well-defined control condition will greatly advance research on treatments for late-life anxiety, as would dismantling studies that compare separate components of treatments.