Modular Psychotherapy for Anxiety in

Older Primary Care Patients

Julie Loebach Wetherell, Ph.D., Catherine R. Ayers, Ph.D.,
John T. Sorrell, Ph.D., Steven R. Thorp, Ph.D.,
Roberto Nuevo, Ph.D., Wendy Belding, M.A., Emily Gray, M.D.,
Melinda A. Stanley, Ph.D., Patricia A. Areán, Ph.D.,
Michael Donohue, Ph.D., Jurgen Unützer, M.D., M.P.H.,
Joe Ramsdell, M.D., Ronghui Xu, Ph.D.,
Thomas L. Patterson, Ph.D.

Objective: To develop and test a modular psychotherapy protocol in older primary

care patients with anxiety disorders. Design: Randomized, controlled pilot study.
Setting: University-based geriatric medicine clinics. Participants: Thirty-one elderly
primary care patients with generalized anxiety disorder or anxiety disorder not
otherwise specified. Intervention: Modular form of psychotherapy compared with
enhanced community treatment. Measurements: Self-reported, interviewer-rated,
and qualitative assessments of anxiety, worry, depression, and mental health-related
quality of life. Results: Both groups showed substantial improvements in anxiety
symptoms, worry, depressive symptoms, and mental health-related quality of life.
Most individuals in the enhanced community treatment condition reported receiving
medications or some other form of professional treatment for anxiety. Across both
conditions, individuals who reported major life events or stressors and those who
used involvement in activities as a coping strategy made smaller gains than those
who did not. Conclusions: Results suggest that modular psychotherapy and other
treatments can be effective for anxiety in older primary care patients. Results further
suggest that life events and coping through increased activity may play a role in the
maintenance of anxiety in older adults. (Am J Geriatr Psychiatry 2009; 17:483–492)

Key Words: Aged, elderly, generalized anxiety disorder, cognitive-behavioral therapy

Received June 20, 2008; revised December 12, 2008; accepted January 9, 2009. From the Psychiatry Department, University of California,
San Diego, CA (JLW, CRA, SRT, WB, EG, TLP); Psychology Service, VA San Diego Healthcare System, San Diego, CA (JLW, CRA, SRT, WB, EG);
Clinical Trials and Research, San Mateo Medical Center, San Mateo, CA (JTS); Department of Psychiatry, Hospital Universitario de la Princesa, Spain
(RN); Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX (MAS); Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX (MAS); Department of Psychiatry, University of California, San Francisco, CA (PAA); Department of Family and
Preventive Medicine, University of California, San Diego, CA (MD, RX); Department of Psychiatry and Behavioral Sciences, University of
Washington (JU); and Department of Internal Medicine, University of California, San Diego, CA (JR). Send correspondence and reprint requests
to Julie Wetherell, Ph.D., UCSD Department of Psychiatry, 9500 Gilman Drive, Dept. 9116B, La Jolla, CA 92093-9116. e-mail: jwetherell@ucsd.edu
© 2009 American Association for Geriatric Psychiatry

Am J Geriatr Psychiatry 17:6, June 2009 483

Modular Psychotherapy
A nxiety disorders are common in the elderly,
with community prevalence estimates as high
as 14%, and higher rates in medical settings.1 Gener-
alized anxiety disorder (GAD) seems to be the most
prevalent condition in community samples,2 but anx-
iety disorder not otherwise specified (ADNOS) is the
diagnosis most often assigned in primary care set-
tings where older adults with anxiety typically seek
treatment.3
GAD and other anxiety syndromes are associated
with many negative outcomes, including disability,
increased health service use, poorer quality of life,
and risk of developing major depression.4 – 6 Prospec-
tive research in the elderly has demonstrated that
anxiety symptoms are associated with medical ill-
ness such as coronary heart disease,7 self-reported
mobility limitations,8 and higher levels of healthcare
utilization, including more primary care visits and
more time spent during each visit.3
Data suggest that anxiolytic medications are effec-
tive for geriatric anxiety.9,10 Many older adults, how-
ever, prefer nonpharmacological treatments for mood
symptoms.11 Although cognitive behavior therapy
(CBT) has shown some benefit for late-life anxiety,12
the evidence suggests that conventional CBT may be
less effective and associated with higher attrition
rates than in younger adults,13 supporting the need
for the development of new treatment protocols, es-
pecially ones that can be implemented in primary
care.
A relatively new approach in psychotherapy re-
search involves modular treatment, in which differ-
ent components are used depending upon the pa-
tients’ presenting problems or symptoms.14,15 This
approach is consistent with the increasing emphasis
on personalized medicine. The rationale for modular
treatment of anxiety in older primary care patients is
twofold: first, anxiety in medical settings may be
more heterogeneous than anxiety in the specialty
mental health sector, suggesting that “one-size-fits-
all” packages may be less effective in this setting.16
Second, the current cohort of older adults is, on
average, less socialized to psychotherapy and more
sensitive to the stigma associated with mental illness
than are younger adults.17 Tailoring the treatment to
the specific symptoms and needs of older partici-
pants can ensure that the psychotherapeutic process
is seen as responsive and clinically relevant as a way
of reducing attrition and enhancing engagement.
484
In the present study, we developed a modular
psychotherapy protocol to treat older primary care
patients with GAD and ADNOS. We tested the pro-
tocol against an enhanced community treatment con-
dition in which patients and their primary care pro-
viders were given information about the anxiety
diagnosis. We conceived of this project as a pilot
effectiveness study to examine how well this novel
approach to psychotherapy would work for patients
seen in Geriatric Medicine. We hypothesized that the
modular psychotherapy intervention would result in
greater decreases in anxiety and depression and
greater increases in quality of life than community
treatment.
METHODS
Participants
Patients were 31 adults at least 60 years old with a
principal (e.g., most severe) or coprincipal diagnosis
of GAD or ADNOS diagnosed according to the Anx-
iety Disorders Interview Schedule for Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edi-
tion (ADIS18) administered by a Ph.D.-level clinician.
Recruitment was conducted from August 2004 to
August 2005 using a primary care screening proce-
dure and self-referrals. A screening questionnaire
consisting of the two GAD items from the Patient
Health Questionnaire was mailed to 1,000 patients
selected at random from a list of 5,132 patients who
had received services from the UCSD Geriatrics clin-
ics within the previous year. Two hundred and three
questionnaires were returned, 89 of them with at
least one item endorsed. Fifty-eight of these patients
were screened by telephone using the Mini Interna-
tional Diagnostic Interview.19 Of those, 24 received
an in-person diagnostic interview using the ADIS,
which was conducted within approximately 2 weeks
of the phone screening. Seventeen of these patients
were enrolled; one additional patient went into the
hospital shortly after his interview and had to be
withdrawn from the study.
Thirty-one individuals contacted the study team
after seeing recruitment flyers or advertisements. Of
those, 11 did not qualify for an in-person diagnostic
interview. Of the 20 who completed the ADIS, an
Am J Geriatr Psychiatry 17:6, June 2009
 Wetherell et al.

TABLE 1. Participant Characteristics

Modular Psychotherapy Enhanced Community
Variable (n ⴝ 15) Treatment (n ⴝ 16) t (df) or ␹2 (df) p
Female 86.7% (13) 81.3% (13) 0.17 (1) 0.68
Age (years) 71.0 (7.0) 73.3 (6.3) 0.95 (29) 0.35
Education (years) 15.6 (2.9) 15.4 (2.8) 0.16 (29) 0.87
White 100.0% (15) 93.8% (15) 0.97 (1) 0.32
Married 60.0% (9) 43.8% (7) 0.82 (1) 0.36
Retired 66.7% (10) 75.0% (12) 0.80 (1) 0.37
Annual income $50K or more 40.0% (6) 50.0% (8) 0.31 (1) 0.58
Medical conditions 3.0 (1.8) 3.0 (1.4) 0.00 (29) 1.00
CIRS-G 10.1 (3.2) 11.0 (3.6) ⫺0.77 (29) 0.45
Prescribed medications (not 3.3 (2.0) 2.6 (2.0) 0.98 (29) 0.34
including psychotropics)
GAD diagnosis 86.7% (13) 87.5% (14) 0.01 (1) 0.95
Duration of most recent GAD 30.6 (31.8) 33.3 (32.5) ⫺0.23 (29) 0.82
episode (years)
Percent reporting GAD “all my life” 26.7% (4) 25.0% (4) 0.01 (1) 0.92
Comorbid Axis I conditions 3.02 (2) 0.22
0 66.7% (10) 56.3% (9)
1 13.3% (2) 37.5% (6)
2 20.0% (3) 6.3% (1)

Notes: CIRS-G ⫽ Cumulative Illness Rating Scale for Geriatrics.

additional five did not qualify. The remaining 15
patients were enrolled into the study.
Results from the Mini International Diagnostic In-
terview and ADIS concurred in 24 of the 31 cases; in
those cases in which the raters disagreed, a third
Ph.D.-level clinician viewed the videotape of the
ADIS, and diagnosis was determined by consensus.
The majority of patients who did not qualify for the
study did not meet criteria for GAD or ADNOS
(84%). Other exclusion criteria were cognitive im-
pairment (N ⫽ 1), substance use disorders within the
past 6 months (N ⫽ 1), serious medical conditions
(N ⫽ 2), and language barrier (N ⫽ 1). Written
informed consent was obtained from all participants,
and the study was conducted in compliance with the
Human Research Protections Program of the Univer-
sity of California, San Diego, CA, and a Data Safety
Monitoring Board.
Demographic and clinical information about the
participants is presented in Table 1. Almost all were
diagnosed with GAD. Overall, they were a well-
educated, affluent group. Those with higher levels of
education reported lower levels of anxiety symptoms
at baseline, r (df ⫽ 29) ⫽ ⫺0.39, p ⫽ 0.03. Although
cognitive performance as measured by the Mini-
Mental State Exam was high on average, we found a
significant inverse relationship between Mini-Mental
State Exam scores and baseline anxiety symptoms,
r (df ⫽ 29) ⫽ ⫺0.45, p ⫽ 0.01, indicating that those
with poorer cognitive functioning reported higher
levels of anxiety. This pattern is consistent with other
research on cognitive functioning and anxiety.20 Axis
I comorbidities included major depression (four pa-
tients), panic disorder (four patients), dysthymia (two
patients), agoraphobia without a history of panic dis-
order, social phobia, and specific phobia (one patient
each).
Participants were permitted to take psychotropic
medications or use concurrent mental health services
provided that they had been on a stable regimen for
at least 2 months before enrollment. We permitted
concurrent treatment to allow better generalization
of the results to primary care patients, many of
whom receive pharmacotherapy or other treatments
in that setting. Data on mental health treatment at
baseline and changes over the course of the study are
presented in Table 2. At baseline, 26.7% of the mod-
ular psychotherapy group and 50.0% of the commu-
nity treatment group were taking daily prescribed
psychotropic medication, which was not significant
according to Fisher’s exact test, p ⫽ 0.17. There were
no differences in anxiety or worry symptoms be-
tween individuals taking medications and those who
were not. An additional person in the modular psy-
chotherapy group and three in the community treat-

Am J Geriatr Psychiatry 17:6, June 2009 485

Modular Psychotherapy

TABLE 2. Mental Health Service Use at Baseline and Changes Over the Course of Study Participation
Service Modular Psychotherapy (n ⴝ 15) Enhanced Community Treatment (n ⴝ 16)
Selective serotonin reuptake Escitalopram 10 mg QD at baseline; increased Citalopram 10 mg QD
inhibitors to 20 mg QD at 4 months
Escitalopram 10 mg QD Citalopram 20 mg QD at baseline; increased to 40 mg
QD at 4 months
Fluoxetine 20 mg QD Escitalopram 20 mg QD
Paroxetine 10 mg QD at baseline; Paroxetine 20 mg QD
discontinued at 4 months Paroxetine 20 mg QD added at 4 months
Sertraline 200 mg QD
Benzodiazepines Alprazolam 0.25 mg QD Alprazolam 0.25 mg QD
Lorazepam 0.5 mg PRN Alprazolam 0.25 mg PRN at baseline; discontinued at
4 months
Clonazepam 0.5 mg QD
Lorazepam 0.5 mg PRN at baseline; increased
to 0.5 mg QD at 4 months
Other prescribed Duloxetine 30 mg QD at baseline; decreased Buspirone 30 mg QD
medications to 20 mg QD at 4 months
Zolpidem 10 mg PRN Buspirone 20 mg QD added at 4 months
Eszopiclone 1 mg PRN
Neurontin 200 mg QD at baseline; discontinued at
4 months
Neurontin 800 mg QD at baseline; increased to
900 mg QD at 4 months
Zolpidem 5 mg PRN
Trazodone 50 mg QD (2 patients)
Over the counter Diphenhydramine 25 mg PRN Diphenhydramine 25 mg QD added at 4 months
medications Diphenhydramine 25 mg PRN added at 4 months
Professional mental health Therapist: two visits Psychiatrist: five visits and therapist: six visits
services Neuropsychological testing: one visit Therapist: four visits
Therapist: two visits
Self-help groups Parkinson’s support group: one meeting Alcoholics anonymous: 84 meetings
Cancer support group: two meetings Spiritual support group: six meetings
Self-help strategies More communication with family and More communication with family and friends: 6
friends: 3
Relaxation techniques: 3 Relaxation techniques: 1
Meditation: 8 Meditation: 5
Spiritual participation: 1 Diet: 1
Self-help books: 1 Spiritual participation: 4
Talked with medical provider: 2 Self-help books: 5
Helping others: 3
Talked with medical provider: 6
Pain treatment: 3

Notes: Some individuals were taking more than one medication. QD: daily; PRN: as needed.

ment group were taking prescribed psychotropic
medications on an as-needed basis.
Procedures
Participants were randomly assigned to receive
either 12 weekly, individual sessions of modular
psychotherapy (N ⫽ 15) or enhanced community
treatment (N ⫽ 16). Twelve sessions were chosen
based on the average number of sessions delivered
in other late-life GAD treatment studies; patients
took on average 14 weeks to complete these ses-
sions.12 Randomization was performed without block-
ing or stratification, following the baseline assessment
and diagnostic case conference, using a coin toss.
Modules were included in the intervention pro-
tocol based on empirical evidence of efficacy from
previous investigations and theoretical relevance
to GAD, anxiety symptoms, and frequently comor-
bid conditions in older medical patients (for addi-
tional information about the protocol, see Ref. 21).
Modules included: 1) education about anxiety and
symptom monitoring; 2) relaxation training, in-
cluding diaphragmatic breathing, progressive
muscle relaxation, and imagery; 3) cognitive

486 Am J Geriatr Psychiatry 17:6, June 2009


restructuring; 4) thought stopping and scheduled
worry; 5) exposure through systematic desensiti-
zation; 6) behavioral activation, consisting of
pleasant events scheduling; 7) sleep hygiene
guidelines; 8) problem-solving skills training,
which involved learning to specify a problem and
brainstorm, evaluate, and implement solutions; 9)
life review, a structured journaling exercise de-
signed to change long-standing negative beliefs;
10) acceptance, which included mindfulness exer-
cises, discussion of values, and goal setting; 11)
assertiveness training; 12) time management; 13)
pain management; and 14) relapse prevention.
Most participants received seven or eight of the 14
possible modules. The decision about which mod-
ules to use for each patient was based on a problem
list generated by the patient and comorbid diagno-
ses or symptoms (e.g., those with a comorbid depres-
sion diagnosis were targeted to receive the behav-
ioral activation module). Both therapist and patient
agreed on modules that would target the patient’s
most distressing problems and symptoms. Of the 12
patients who completed the modular psychotherapy
intervention, all received education, relaxation, and
relapse prevention; 11 each received problem solving
and acceptance; 8 received thought stopping and
scheduled worry; 7 received sleep hygiene; 6 re-
ceived behavioral activation; 5 received assertiveness
training; 3 received life review; 2 each received cog-
nitive therapy and time management; and 1 received
pain management.
Patients randomized to enhanced community treat-
ment and their healthcare providers received informa-
tion about the patients’ anxiety disorder diagnosis. Pa-
tients were contacted after their in-person assessment
and informed of their diagnosis. Additionally, a letter
was sent to their healthcare provider documenting the
diagnosis and instructing them to continue to treat the
patient as they otherwise would. Patients were not
given specific referrals or other information about en-
hanced community treatment, only that they should
continue to be followed by their chosen provider. Pa-
tients received a second in-person assessment but no
other contact or referrals from study staff. Table 2 dis-
plays treatment received during the course of the
study; most participants received psychotropic medi-
cations from their community healthcare providers.
Psychotherapy was performed by M.A. and Ph.D.-
level clinicians supervised by the first author. All
Am J Geriatr Psychiatry 17:6, June 2009
Wetherell et al.
therapy sessions were videotaped and reviewed in
individual supervision sessions to maintain fidelity
to the treatment protocol. Review of a random sam-
ple of four tapes (one per therapist) for adherence
and competence (each rated on a 0 – 4 scale) by an
expert rater indicated that all therapists achieved a
score of 4 (“excellent”) on adherence, and three
scored 4 on competence (the remaining therapist
scored 3, “good”). Participants were given daily
homework assignments. They had an 82% average
completion rate, defined as the proportion of days on
which the patient reported completing at least some
homework, as documented on forms turned in
weekly to the therapists; the rate excluding data from
one participant who completed no homework was
95%. Assessments were conducted by two research
assistants who were not informed of the patients’
treatment conditions. All patients completed assess-
ments at baseline and after approximately 3– 4
months (following treatment for the modular psy-
chotherapy patients).
Measures
The Hamilton Anxiety Rating Scale22 is a 14-item
interviewer-rated measure of anxiety primarily as-
sessing somatic symptoms. It is considered the “gold
standard” outcome measure in studies of anxiety
pharmacotherapy treatment. It has been validated in
samples of older GAD patients and normal commu-
nity volunteers.23 Interrater reliability as measured
by the interclass correlation coefficient was 0.94.
The Penn State Worry Questionnaire24 is a 16-item
self-report instrument designed to measure trait
worry. It has been validated in samples of older
adults diagnosed with GAD.25 It was chosen for this
investigation because it is the most widely used self-
report measure of pathological worry. Cronbach
alpha in this study was 0.77.
The Beck Depression Inventory-II is a 21-item
self-report scale listing common symptoms of de-
pression that the respondent may have experi-
enced in the past 2 weeks.26 The scale is a revision
of one that has been used extensively in research
and clinical settings since its development in 1961
and has been used with geriatric populations.27 It
is the most widely used self-report depression
measure in clinical samples. Cronbach alpha in this
sample was 0.86.
487
Modular Psychotherapy
Mental health-related quality of life and function-
ing was evaluated using the Mental Component
Score of the Medical Outcomes study 36-item short
form self-report health survey.28 This variable is re-
ported as a T score in which higher numbers repre-
sent better quality of life. It has been validated in
large, mixed-age medical and psychiatric samples
and used with older GAD patients.29
Data were collected on medical conditions using
the Cumulative Illness Rating Scale-Geriatrics,30 and
use of health services including primary care visits,
medical specialist visits, mental health visits, and
self-help group attendance using the Cornell Service
Index.31 In keeping with the pilot nature of this
project, patients assigned to modular psychotherapy
were asked to rate the helpfulness of the individual
modules they received. Patients also rated their sat-
isfaction with the overall treatment using the 8-item
Client Satisfaction Questionnaire.32
Finally, we conducted brief, semistructured inter-
views with 26 patients, 15 in the community treat-
ment condition and 11 in the modular psychotherapy
condition, by telephone to inquire about their sub-
jective perceptions of improvement in anxiety symp-
toms (rated as “better,” “about the same,” or
“worse”). Only one patient reported worsening
symptoms, so ratings were dichotomized into im-
proved versus not improved. They were also asked
about coping strategies, life events, and other factors
that may have influenced change in anxiety levels.
Patients generated their own list of life events and
ways of coping in response to a standard set of
open-ended questions; this method could have been
biased by retrospective recall. This procedure was
added to the study after it was in progress, so calls
occurred in some cases as long as 12 months after the
4-month assessment; by that point, five individuals
had dropped out or could not be reached. Interviews
were transcribed and responses were coded by two
independent raters.
Codes were developed by the first rater based on
interview content. The kappa statistic was used to
evaluate agreement between raters on each code;
kappas ranged from 0.77 to 1.00, representing good
to excellent agreement. For analysis, we grouped the
responses into the broad categories of professional
help seeking (e.g., psychotherapy, talking to a health-
care provider about anxiety), self-help strategies
(e.g., meditation), life events or stressors (e.g., “mile-
488
stone” birthday, medical problems), and involve-
ment in activities (e.g., “keeping busy”).
Data Analysis
Analyses were conducted using SPSS release 11.5.
Groups were compared on clinical and demographic
variables using t tests and ␹2 tests. Outcomes were
evaluated using repeated measures analysis of vari-
ance (RMANOVA). Because of the high proportion
of participants receiving concurrent daily pharmaco-
therapy, this variable was included as a covariate in
the RMANOVA models. Data were analyzed on an
intent-to-treat basis; all patients completed both assess-
ments. The assumption of equality of the variance-
covariance matrices was fulfilled for all of the
RMANOVAs (Box’s M values ranging from 8.19, p ⫽
0.06, to 0.503, p ⫽ 0.93). No dependent variable dis-
played a significant departure from normality based on
Kolmogorov-Smirnov tests (z values ranging from 0.59
to 0.76).
RESULTS
Outcomes
Results from the outcome analyses are presented
in Table 3. We found substantial and comparable
decreases in anxiety, worry, and depressive symp-
toms and improvement in mental health-related
quality of life in both the community treatment and
modular psychotherapy groups. This pattern of re-
sults did not change when medication use was re-
moved from the models. The within-group mean
effect size (weighted average Hedges’ g) for change
in worry and anxiety symptoms for the modular
psychotherapy condition (g ⫽ 1.23) is somewhat
larger than in most previous studies of psychother-
apy with anxious older adults (e.g., Refs. 29, 33). The
within-group effect size for the community treat-
ment condition (g ⫽ 1.67) is, to our knowledge,
higher than has ever been reported for a minimal
contact condition in a GAD treatment study.13
The attrition rate for patients who received mod-
ular psychotherapy was 20% (although all patients in
both groups returned for posttreatment assess-
ments). The three patients who dropped out of ther-
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 Wetherell et al.

TABLE 3. Repeated Measures ANOVA Results With Effect Size Estimates and Power After Controlling for Daily Prescription
Psychotropic Medication Use
SF-36 Mental
HAMA PSWQ BDI Component Summary
Modular Psychotherapy
(n ⫽ 15)
Pre M (SD) 19.8 (7.7) 58.1 (8.4) 14.3 (9.4) 37.7 (9.3)
Post M (SD) 9.3 (6.6) 46.8 (13.6) 7.5 (4.1) 47.4 (11.5)
Enhanced community treatment
(n ⫽ 16)
Pre M (SD) 19.0 (4.3) 57.4 (5.7) 15.8 (6.9) 37.5 (8.4)
Post M (SD) 9.5 (3.9) 50.6 (7.5) 10.8 (7.0) 42.9 (12.7)
Fa (time)
Value 48.66b 23.37b 16.41b 6.42c
Partial ␩2 0.64 0.46 0.38 0.19
Mean change scores (SD)
Modular psychotherapy 10.5 (7.6) 11.3 (13.9) 6.7 (9.8) 9.8 (15.0)
Enhanced community
treatment 9.5 (4.5) 6.8 (8.0) 5.1 (6.3) 5.4 (14.3)
a
F (group)
Value 0.10 0.09 1.14 0.16
Partial ␩2 0.004 0.003 0.04 0.006
Fa (group ⫻ time)
Value 0.08 0.28 0.00 0.37
Partial ␩2 0.003 0.01 0.00 0.01

Notes: HAMA ⫽ Hamilton Anxiety Rating Scale; PSWQ ⫽ Penn State Worry Questionnaire; BDI ⫽ Beck Depression Inventory; SF-36 ⫽ MOS
Short Form 36-item Health Survey.
a
F distributed as Snedecor F with degrees of freedom ⫽ (1, 29).
b
p ⬍0.001.
c
p ⬍0.05.

apy did so after two, five, and six sessions; one cited
health problems, one a lack of time, and the third
reported that she was doing much better and no
longer required help with anxiety. Participants who
received modular psychotherapy reported higher lev-
els of satisfaction than those who did not, t(26) ⫽ 2.11,
p ⬍0.05. For modules received by at least three par-
ticipants, the mean rankings of helpfulness, from
most to least helpful, were as follows: 1) relaxation,
2) pleasant activities, 3) psychoeducation and moni-
toring, 4) acceptance, 5) worry control, 6) relapse
prevention, 7) sleep hygiene, 8) problem solving, 9)
assertiveness training, and 10) life review.
Mental Health Services Use
Table 2 displays data on changes in mental health
service use for patients in the modular psychother-
apy and community treatment conditions. There
were no statistically significant differences between
the conditions in use of “as-needed” psychotropic
medications, over-the-counter medications, profes-
sional mental health services, or self-help groups.
More individuals in the community treatment group
were taking prescribed medications for anxiety daily
at the 4-month assessment, 56.3% versus 26.7%; this
difference approached statistical significance accord-
ing to Fisher’s exact test, p ⫽ 0.096. Across both
groups, those taking such medications (N ⫽ 13)
showed less change in their worry symptoms than
those who were not (N ⫽ 18), t(29) ⫽ 2.34, p ⫽ 0.03.
Semistructured Interviews
A significantly higher proportion of the modular
psychotherapy group than the community treatment
group reported subjective improvement in anxiety,
90.9% versus 40.0%, p ⫽ 0.01 according to Fisher’s
exact test. Those who reported improvement, how-
ever, did not show greater change on objective mea-
sures of anxiety or worry than those who reported no
improvement. Specific self-help strategies are dis-
played in Table 2. Across both conditions, individu-
als who reported receiving professional help for anx-
iety (N ⫽ 15) and those who used self-help strategies
like bibliotherapy or meditation (N ⫽ 18) showed no

Am J Geriatr Psychiatry 17:6, June 2009 489

Modular Psychotherapy
greater change in anxiety or worry symptoms than
those who did not (N ⫽ 11 and N ⫽ 8, respectively).
Individuals who reported major life events, either
positive or negative, or stressors (N ⫽ 11) showed
less change in anxiety symptoms than those who did
not report such events (N ⫽ 15): t(24) ⫽ 2.44, p ⫽
0.02. Those who reported increasing their engage-
ment in activities (e.g., keeping busy, getting more
involved in groups or organizations; N ⫽ 10) showed
less change in anxiety symptoms than those who did
not (N ⫽ 16), t(24) ⫽ 2.26, p ⫽ 0.03.
CONCLUSIONS
In a comparison between a modular form of psycho-
therapy and enhanced community treatment (in
which patients and their primary care providers
were given information about their anxiety diagno-
sis), both groups experienced equivalent symptom-
atic improvement. Substantial, statistically significant
improvements were found in anxiety symptoms,
worry, depressive symptoms, and mental health-re-
lated quality of life in both groups.
Individuals in both conditions used a wide va-
riety of anxiety management strategies, including
medications, psychotherapy, and various self-help
techniques. Despite randomization, a higher pro-
portion of individuals in the community treatment
group were using psychotropic medications; med-
ication use was therefore included as a covariate
in the analyses. Those who used medications
showed less improvement in worry symptoms
than those who did not, suggesting that medica-
tion use might have represented a marker for treat-
ment resistance rather than a successful treatment
strategy in this sample.
Professional services and self-help techniques were
not associated with greater improvement in anxiety.
Although individuals reported pleasant activities as
the second most helpful module, those who in-
creased their involvement in activities showed
smaller declines in their anxiety symptoms than
those who did not. These results are interesting given
that behavioral activation has been an effective treat-
ment for geriatric depression. “Keeping busy” may
be an unhelpful avoidance strategy for anxious older
490
adults. Major life events, both positive and negative,
and stressors were also associated with less improve-
ment in anxiety symptoms. This finding is consistent
with much research documenting that stress is asso-
ciated with both positive and negative events, and
further suggests that factors beyond an individual’s
control may influence anxiety outcomes regardless of
treatment.
Overall, these data provide no evidence that a
modular psychotherapy protocol for anxiety in older
primary care patients is more effective than en-
hanced community treatment, when the latter in-
volves aggressive pharmacotherapy and multiple
other services and strategies. Although the within-
group effect size for the modular psychotherapy in-
tervention was quite high relative to other late-life
anxiety trials, the effect size in the community treat-
ment condition was substantially higher than has
been reported in the past for a minimal contact con-
dition. Thus, results from this study should not be
used to support an argument that services available
in most primary care practices are sufficient to treat
chronic anxiety in older adults.
Other forms of psychotherapy currently under in-
vestigation in younger adults with GAD and similar
disorders include an integration of CBT and inter-
personal therapy,34 acceptance and commitment
therapy,35 attention training,36 and therapies target-
ing intolerance of uncertainty,37 emotion dysregula-
tion,38 and metacognition.39 Only two have been
tested with older adults: Ladouceur et al.37 reported
success treating eight older GAD patients using ther-
apy based on the intolerance of uncertainty model,
and Papageorgiou and Wells36 published a case se-
ries of three geriatric patients with hypochondriasis
who responded to attention training.
Age-related changes may make some of these al-
ternatives particularly appropriate for anxious older
adults. For example, some evidence suggests that
older adults regulate emotion better than do younger
adults,40 making an emotion regulation-based ap-
proach potentially appealing for use in geriatric pop-
ulations. With the high prevalence and negative con-
sequences associated with anxiety in late life, testing
such innovative protocols with older anxiety disor-
der patients should be a high priority.
The chief clinical implication is that many types of
interventions and strategies can lead to improve-
ments in symptoms and quality of life for older
Am J Geriatr Psychiatry 17:6, June 2009

people with anxiety. This is a positive message for
older adults with this chronic and distressing condi-
tion. It is important to note, however, that the level of
care provided in this study across both the modular
psychotherapy and community treatment conditions
is not representative of care for late-life anxiety dis-
orders in most primary care settings. These results
should be interpreted with some caution given that
this sample was white, well educated, and wealthy.
Participants had the means and access to alternative
treatments such as yoga and meditation classes.
Older persons without the protective factors and
resources of subjects in our sample may not have
shown improvements despite positive attitudes
about care.
References
1. Bryant C, Jackson H, Ames D: The prevalence of anxiety in older
adults: methodological issues and a review of the literature. J
Affect Disord 2008; 109:233–250
2. Flint AJ: Generalised anxiety disorder in elderly patients: epide-
miology, diagnosis and treatment options. Drugs Aging 2005;
22:101–114
3. Stanley MA, Roberts RE, Bourland SL, et al: Anxiety disorders
among older primary care patients. J Clin Geropsychology 2001;
7:105–116
4. de Beurs E, Beekman AT, van Balkom AJ, et al: Consequences of
anxiety in older persons: its effect on disability, well-being and
use of health services. Psychol Med 1999; 29:583–593
5. Schoevers RA, Deeg DJ, van Tilburg W, et al: Depression and
generalized anxiety disorder: co-occurrence and longitudinal
patterns in elderly patients. Am J Geriatr Psychiatry 2005;
13:31–39
6. Wetherell JL, Thorp SR, Patterson TL, et al: Quality of life in
geriatric generalized anxiety disorder: a preliminary investigation.
Psychiatr Res 2004; 38:305–312
7. Kubzansky LD, Kawachi L, Weiss ST, et al: Anxiety and coronary
heart disease: a synthesis of epidemiological, psychological, and
experimental evidence. Ann Behav Med 1998; 20:47–58
8. Mehta KM, Yaffe K, Brenes GA, et al: Anxiety symptoms and
decline in physical function over 5 years in the health, aging and
body composition study. J Am Geriatr Soc 2007; 55:265–270
9. Lenze EJ, Rollman BL, Shear MK, et al: Escitalopram for older
adults with generalized anxiety disorder: A randomized con-
trolled trial. JAMA 2009; 301:295–303
10. Pinquart M, Duberstein PR: Treatment of anxiety disorders in older
adults: a meta-analytic comparison of behavioral and pharmacolog-
ical interventions. Am J Geriatr Psychiatry 2007; 15:639 – 651
11. Gum AM, Areán PA, Hunkeler E, et al: Depression treatment
preferences in older primary care patients. Gerontologist 2006;
46:14 –22
12. Ayers CR, Sorrell JT, Thorp SR, et al: Evidence-based psycho-
logical treatments for late-life anxiety. Psychol Aging 2007;
22:8 –17
13. Chambless DL, Peterman M: Evidence on cognitive-behavioral
therapy for generalized anxiety disorder and panic disorder: the
second decade, in Contemporary Cognitive Therapy: Theory,
Am J Geriatr Psychiatry 17:6, June 2009
Wetherell et al.
Scientifically, it is of interest to discover why the
types of psychotherapy for geriatric anxiety investi-
gated thus far seem to work less well than medica-
tions10 or than psychotherapy for anxiety in younger
individuals,13 whereas the same is not true for geri-
atric depression.41 Additional research on psychoso-
cial, biological, and cognitive factors associated with
anxiety disorders in late life may ultimately inform
new and more effective behavioral treatment protocols.
The authors gratefully acknowledge the contributions
of Georgia Birchler, Debora Goodman, Dilip V. Jeste,
M.D., Laura Otis, Ph.D., and Murray B. Stein, M.D.,
M.P.H. This research was supported by NIMH grant
MH067643.
Research, and Practice. Edited by Leahy RL. New York, Guilford,
2004, pp 86 –115
14. Chorpita BF, Daleiden EL, Weisz JR: Modularity in the design and
application of therapeutic interventions. Appl Prev Psychol 2005;
11:141–156
15. Lang AJ, Norman GJ, Casmar PV: A randomized trial of a brief
mental health intervention for primary care patients. J Consult
Clin Psychol 2006; 74:1173–1179
16. Olfson M, Broadhead WE, Weissman MM, et al: Subthreshold
psychiatric symptoms in a primary care group practice. Arch Gen
Psychiatr 1996; 53:880 – 886
17. Sirey JA, Bruce ML, Alexopoulos GS, et al: Stigma as a barrier to
recovery: perceived stigma and patient-rated severity of illness as
predictors of antidepressant drug adherence. Psychiatr Serv
2001; 52:1615–1620
18. DiNardo PA, Brown TA, Barlow DH: Anxiety Disorders Interview
Schedule for DSM-IV. Boston, MA, Center for Stress and Anxiety
Related Disorders, Boston University, 1994
19. Sheehan DV, Lecrubier Y, Sheehan KH, et al: The Mini-Inter-
national Neuropsychiatric Interview (M.I.N.I): the develop-
ment and validation of a structured diagnostic psychiatric
interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;
59(suppl 20):22–33
20. Beaudreau SA, O’Hara R: Late-life anxiety and cognitive impair-
ment: a review. Am J Geriatr Psychiatry 2008; 16:790 – 803
21. Wetherell JL, Sorrell JT, Thorp SR, et al: Psychological interven-
tions for late-life anxiety: a review and early lessons from the
CALM Study. J Geriatr Psychiatr Neurol 2005; 18:72– 82
22. Hamilton M: The assessment of anxiety states by rating. Br J Med
Psychol 1959; 32:50 –55
23. Diefenbach GJ, Stanley MA, Beck JG, et al: Examination of the
Hamilton Scales in assessment of anxious older adults: a replica-
tion and extension. J Psychopathol Behav Assessment 2001; 23:
117–124
24. Meyer TJ, Miller ML, Metzger RL, et al: Development and valida-
tion of the Penn State Worry Questionnaire. Behav Res Ther
1990; 28:487– 495
25. Stanley MA, Novy DM, Bourland SL, et al: Assessing older adults
with generalized anxiety: a replication and extension. Behav Res
Ther 2001; 39:221–235
491
Modular Psychotherapy
26. Beck AT, Steer RA, Ball R, et al: Comparison of Beck Depression
Inventories-IA and -II in psychiatric outpatients. J Pers Assessment
1996; 67:588 –597
27. Steer RA, Rissmiller DJ, Beck AT: Use of Beck Depression Inven-
tory-II with depressed geriatric inpatients. Behav Res Ther 2000;
38:311–318
28. Ware JE, Kosinski M, Gandek B: SF-36 Health Survey: Manual and
Interpretation Guide. Lincoln, RI, QualityMetric, Inc, 2000
29. Wetherell JL, Gatz M, Craske MG: Treatment of generalized anx-
iety disorder in older adults. J Consult Clin Psychol 2003; 71:
31– 40
30. Miller MD, Paradis CF, Houck PR, et al: Rating chronic medical
illness burden in geropsychiatric practice and research: applica-
tion of the Cumulative Illness Rating Scale. Psychiatr Res 1992;
41:237–248
31. Sirey JA, Meyers BS, Teresi JA, et al: The Cornell Service Index as
a measure of health service use. Psychiatr Serv 2005; 56:1564 –
1569
32. Larsen DL, Attkisson CC, Hargreaves WA, et al: Assessment of
client/patient satisfaction: development of a general scale. Eval
Prog Plan 1979; 2:197–207
33. Stanley MA, Beck JG, Novy DM, et al: Cognitive-behavioral treat-
ment of late-life generalized anxiety disorder. J Consult Clin
Psychol 2003; 71:309 –319
492
34. Newman MG, Castonguay LG, Borkovec TD, et al: Integrative
psychotherapy, in Generalized Anxiety Disorder: Advances in
Research and Practice. Edited by Heimberg RG, Turk CL, Mennin
DS. New York, Guilford, 2004, pp 320 –350
35. Roemer L, Orsillo SM: An open trial of an acceptance-based
behavior therapy for generalized anxiety disorder. Behav Ther
2007; 38:72– 85
36. Papageorgiou C, Wells A: Effects of attention training on hypo-
chondriasis: a brief case series. Psychol Med 1998; 28:193–200
37. Ladouceur R, Léger É, Dugas M, et al: Cognitive-behavioral treat-
ment of generalized anxiety disorder (GAD) for older adults. Int
Psychogeriatr 2004; 16:195–207
38. Mennin DS: Emotion regulation therapy: an integrative approach
to treatment-resistant anxiety disorders. J Contemp Psychother
2006; 36:95–105
39. Wells A, King P: Metacognitive therapy for generalized anxiety
disorder: an open trial. J Behav Ther Exp Psychiatry 2006; 37:
206 –212
40. Charles ST, Carstensen LL: Emotion regulation and aging, in
Handbook of Emotion Regulation. Edited by Gross JJ. New York,
Guilford, 2007, pp 307–327
41. Pinquart M, Duberstein PR, Lyness JM: Treatments for later-life
depressive conditions: a meta-analytic comparison of pharmaco-
therapy and psychotherapy. Am J Psychiatr 2006; 163:1493–1501
Am J Geriatr Psychiatry 17:6, June 2009