This is the first study of telephone-delivered CBT for late-life anxiety disorders. The results indicate that participants who received CBT experienced a greater improvement in self-report and clinician-rated worry and anxiety symptoms than participants who received information-only. Furthermore, these participants also demonstrated greater reductions in anxiety sensitivity and insomnia. Thus, CBT delivered by telephone shows promise for treating symptoms of both GAD and Panic Disorder among older adults.
Follow-up data, collected 6 months after completing the treatment, indicate maintenance of improvement in worry symptoms. Although the reductions in anxiety sensitivity and insomnia were no longer significantly different between the 2 conditions, differential improvements in mental health quality of life emerged, favoring the CBT-T condition. We speculate that this may be due to the maintenance of improvement in worry, but this finding needs to be replicated in future studies before firm conclusions can be drawn. This may also suggest that a longer intervention or more intense follow-up may be needed.
We found moderate to large (.61–.85) effect sizes for post-treatment data, and large effect sizes for 6 month follow-up data (.80–.99). This compares favorably with the findings of a face-to-face CBT intervention for late-life GAD (13
); our effect size for the PSWQ was smaller but our effect size for the HAM-A was much larger. Similarly, our effect sizes were also comparable with the mean between group effect size of .71 reported by Borkovec and Ruscio (5
) in a meta-analysis of CBT for GAD in adults. Thus, the CBT-T intervention appears to be strong enough to produce changes in symptoms that are comparable to face-to-face studies of CBT for anxiety.
Older adults appear to find telephone-delivered psychotherapy to be a suitable option. Drop out rates were lower than studies of psychotherapy for late-life anxiety (8
). Similarly, participant satisfaction with the intervention is comparable to the level of satisfaction reported by older adults in a study of face-to-face CBT for late-life GAD (13
). Furthermore, both participants and therapists reported high degrees of working alliance, indicating that a strong therapeutic relationship was established. Anecdotally, some participants reported that they were impressed with the level of detail with which the therapists could remember their particular sessions. It should be noted, however, that participants who did not like the lack of face-to-face contact may have refused to participate in the study.
The presentation of information through telephone sessions and supplemented with a workbook allowed for both visual and auditory processing of information. By presenting the didactic information in written format prior to the telephone sessions, participants were able to read the material multiple times and make note of questions. This may be particularly relevant for older adults with GAD, as they experience poorer short-term memory than nonanxious older adults (36
). Anecdotal comments indicated that some participants did reread materials and referred back to chapters over the course of the intervention.
There are a number of limitations of this study. The sample size was relatively small, with a total of 60 participants randomized to 2 conditions. The participants were <70 years old on average, which may not be representative of most homebound older adults. There was a lack of homogeneity of the sample in terms of diagnosis. Although this reduces the disorder specific conclusions that can be made, this heterogeneity in diagnosis increases the generalizability of findings, particularly to nonacademic settings. Conversely, the sample was homogenous in terms of demographic characteristics, with most of the sample consisting of well-educated white women. Regarding the design of the study, CBT-T was compared with an information-only condition rather than a structurally equivalent comparison group with similar levels of treatment credibility and outcome expectations (37
). Thus we are unable to conclude that the changes in outcomes were a result of the specific cognitive-behavioral skills rather than the effects of attention. A third limitation of the study was the poor internal consistency of the STAI-T, which was chosen a priori as an outcome measure. Other limitations include a lack of assessment of treatment fidelity and reliability of diagnoses. Further, the 8th grade reading level may limit accessibility to people with very limited education. Finally, the fact that telephone psychotherapy is not reimbursable under Medicare regulations at this time may weaken the current public health significance of this study; however, studies such as this one that demonstrate the effectiveness of alternative modes of delivery may at some point lead to changes in reimbursement policies.
CBT-T may be useful in a stepped care approach to late-life anxiety, particularly if its cost-effectiveness is established. A recent study found that a stepped-care approach to the prevention of late-life anxiety and depressive disorders, which included CBT delivered by bibliotherapy in conjunction with 2–3 nurse visits or telephone calls, was successful in reducing the 12-month incidence of anxiety and depressive disorders by 50% among older adults with subthreshold symptoms (38
). Participants in the current study had more severe symptoms, as they met diagnostic criteria for anxiety disorders. However, participants did evidence significant reductions in anxiety and related symptoms, and lasting reductions in worry. Many older adults prefer psychotherapy to pharmacotherapy (39
). Results suggest that this may be a viable option for anxious older adults who are unable to attend regular face-to-face therapy sessions. The mixed long-term findings suggest that more follow-up sessions may need to be integrated into telephone treatment in order to provide the same kind of lasting results that face-to-face treatment provides.