ORLANDO – Do SSRIs actually work for late-life generalized anxiety disorder?
"I think the answer is, ‘Yes, a little.’ The benefits are limited in the randomized controlled trials and in my own clinical experience. Many people will get some benefit, but fairly few will get such a substantial benefit that that’s all they need. Maybe on the order of 40% at most," Dr. Eric J. Lenze said at the annual meeting of the American Association for Geriatric Psychiatry.
He should know. He was the principal investigator in two of the three randomized, placebo-controlled trials that have established the efficacy of selective serotonin reuptake inhibitors for later-life generalized anxiety disorder (GAD), including by far the largest study, involving escitalopram (JAMA 2009;301:295-303).
For patients who don’t achieve remission of anxiety symptoms with SSRI monotherapy, a good option – and one of proven benefit – is dual therapy along with cognitive-behavioral therapy (CBT). In a randomized, placebo-controlled clinical trial involving 73 older adults with GAD, Dr. Lenze and his coinvestigators showed that during a lead-in phase with 12 weeks of open-label escitalopram, participants showed a modest reduction in worry symptoms on the Penn State Worry Questionnaire, but if they then had CBT added, they showed a substantial further reduction in worry, compared with those who did not receive CBT. Continued escitalopram prevented relapse, but for many patients CBT allowed sustained drug-free remission (Am. J. Psychiatry 2013;170:782-9).
The concept is that starting out with an SSRI helps reduce the patient’s distress and somatization, then adding the CBT addresses the underlying pathologic worry.
Dr. Eric Lenze
"The combination seems to be effective, and it’s an attractive one. CBT has what the psychologists call ‘durable’ benefits: You get a course of CBT, it’s stopped, and those benefits are maintained," explained Dr. Lenze, professor of psychiatry at Washington University in St. Louis.
The beauty of CBT in the context of late-life anxiety is that relaxation training appears to be the single most effective component of CBT for this condition, as has been shown by investigators at the University of California, San Diego (Am. J. Geriatr. Psychiatry 2009;17:105-15).
"This is important because relaxation training – deep breathing, muscle relaxation, and pleasant imagery – is also the easiest component of CBT, which means that if I had the time in my clinic, even I could probably pull this off with patients. If you have a bevy of therapists you can refer to, your patients will get benefit from it," the psychopharmacologist continued.
Pharmacologic options beyond the three SSRIs supported by placebo-controlled, randomized trial evidence – sertraline, citalopram, and escitalopram – include the various other SSRIs. In addition, two selective norepinephrine reuptake inhibitors (SNRIs) – venlafaxine and duloxetine – are supported by retrospective analyses of earlier Food and Drug Administration approval studies that showed the drugs appeared equally efficacious in young adults and the elderly with GAD.
Also, a large multisite study of pregabalin for late-life GAD showed it was effective starting at 50 mg b.i.d. and titrating up as tolerated to 100 mg t.i.d. And a multicenter study showed quetiapine XR was effective at much lower doses than those used for schizophrenia. But neither pregabalin nor quetiapine XR approved for GAD.
The use of benzodiazepines is problematic. They induce falls and cognitive impairment at a lower dose than is effective for anxiety. And short-acting benzodiazepines are not safer than long-acting ones. Yet benzodiazepines, to Dr. Lenze’s dismay, are heavily prescribed for late-life anxiety, especially by primary care physicians.
"I sometimes do use benzos, but I would say about 10 times less than many of my colleagues. By the time a patient with anxiety gets to a psychiatrist, they’re probably already on a benzo. For most of my patients, one of the key questions in my mind is, ‘When am I going to start tapering that benzo someone else put them on?’ " according to Dr. Lenze.
That’s why "Think twice about prescribing a benzodiazepine" is on his list of eight rules for the management of anxiety.
Dr. Lenze reported having received research grants from Roche and Lundbeck.
Eight rules for managing late-life anxiety
Dr. Lenze’s work with older patients who have anxiety has led him to develop the following checklist that should help you respond to these patients with compassion:
• Include an objective measurement of severity in assessment. Patients with GAD will often come in for a follow-up visit unaware that they’re now spending much less of their day wracked by worry and that they now feel they have some ability to stop it. It helps to show them the earlier numbers.