Journal of Consulting and Clinical Psychology Copyright 2003 by the American Psychological Association, Inc.

2003, Vol. 71, No. 1, 31– 40 0022-006X/03/$12.00 DOI: 10.1037/0022-006X.71.1.31

Treatment of Generalized Anxiety Disorder in Older Adults

Julie Loebach Wetherell Margaret Gatz

University of California, San Diego and University of Southern California
VA San Diego Healthcare System

Michelle G. Craske
University of California, Los Angeles
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Older adults with generalized anxiety disorder (GAD; N ⫽ 75; M age ⫽ 67.1 years) were randomly
This document is copyrighted by the American Psychological Association or one of its allied publishers.

assigned to cognitive– behavioral therapy (CBT), a discussion group (DG) organized around worry-
provoking topics, or a waiting period. Participants in both active conditions improved relative to the
waiting list. Although CBT participants improved on more measures than DG participants, the authors
found only 1 significant difference immediately after treatment and no differences at 6-month follow-up.
Effect sizes were smaller than in younger samples, but CBT showed large effects and DG showed
medium-sized effects. Overall, results indicate that brief treatment of late-life GAD is beneficial, but they
provide only limited support for the superiority of CBT to a credible comparison intervention.

Although anxiety disorders, like most psychological conditions,
are less common among older adults than among younger people,
epidemiological evidence suggests that anxiety is a major problem
in late life. Anxiety disorders overall are more prevalent than either
depression or severe cognitive impairment among people over 65
years old (Regier et al., 1988). Generalized anxiety disorder
(GAD) is about as prevalent as major depression (Blazer, George,
& Hughes, 1991; Regier et al., 1988). Older people consume a
disproportionate share of antianxiety medications, suggesting that
anxiety symptoms are common in this population (Graham &
Vidal-Zeballos, 1998). Yet despite its prevalence, anxiety in older
persons has received relatively little research attention.
The consequences of anxiety in late life are potentially serious.
Anxiety symptoms and disorders are associated with increased
Julie Loebach Wetherell, Department of Psychiatry, University of Cal-
ifornia, San Diego and VA San Diego Healthcare System, San Diego,
California; Margaret Gatz, Department of Psychology, University of
Southern California; Michelle G. Craske, Department of Psychology, Uni-
versity of California, Los Angeles.
The study was supported by National Institute for Mental Health Grant
NRSA MH-11972. We thank Krista Barbour, Serena Bezdjian, Christy-Joy
Brendel, Sandra Ceman, Marla Cook, Antonia Glowacki, Katie Grubbs,
Houri Hintiryan, Jeff Huang, Beverly Hurd, May Jawad, Hillary Le Roux,
Cassandra Lehman, T. J. McCallum, Mary Michlovich, Joyce Oo, Jennifer
Paek, Cynthia Pearson, Deborah Pontillo, Gayneen Saul, Sandy Schwartz,
Melinda Stanley, Lori Stone, Elaine Tan, Kecia Watari, and Charles
Wilkinson for their assistance with the project and Gerald Davison, David
Lavond, Teresa Seeman, and members of the Section on Clinical Research
in Aging and Psychology for their helpful comments on drafts of this
article.
Correspondence concerning this article should be addressed to Julie
Loebach Wetherell, Department of Psychiatry, University of California,
San Diego, VA San Diego Healthcare System, 3350 La Jolla Village Drive
(116A-1), San Diego, California 92161. E-mail: jwetherell@ucsd.edu
31
disability, lower levels of well-being, and inappropriate use of
medical services among older adults (De Beurs et al., 1999).
Anxiolytic medications, including benzodiazepines, are the most
common treatment for late-life anxiety (Blazer et al., 1991). These
medications can cause tolerance and withdrawal, falls and acci-
dents, cognitive impairment, drug interactions, and toxicity (Kra-
sucki, Howard, & Mann, 1999; Salzman, 1991). Although safer
medications, particularly selective serotonin reuptake inhibitors,
are often used to treat geriatric anxiety, they can be associated with
unpleasant side effects, and some older people prefer not to take
them. Additional safe and effective treatments that are acceptable
to an older population are clearly needed.
Few investigations have examined the psychological treatment
of anxiety in older adults (see reviews by Krasucki et al., 1999;
Wetherell, 1998). Virtually all randomized trials of behavioral
treatment for GAD have excluded participants over the age of 65
(e.g., Barlow, Rapee, & Brown, 1992; Borkovec & Costello,
1993). Most treatment outcome studies of anxiety in older adults
have used community or senior center volunteers with subjec-
tive anxiety symptoms rather than individuals with diagnosed
anxiety disorders (e.g., DeBerry, Davis, & Reinhard, 1989; Sallis,
Lichstein, Clarkson, Stalgaitis, & Campbell, 1983; Scogin, Rick-
ard, Keith, Wilson, & McElreath, 1992). The findings from these
studies might not generalize to a clinically anxious older
population.
Only a few studies have randomly assigned older adults who
met diagnostic criteria for anxiety disorders to different treatment
conditions. In a sample that consisted mostly of panic disorder
patients, Barrowclough et al. (2001) found that individual, home-
delivered cognitive– behavioral therapy (CBT) was more effective
than supportive counseling on self-ratings of anxiety and depres-
sion, with better performance for CBT on most measures across a
12-month follow-up period. Stanley, Beck, and Glassco (1996)
found that supportive psychotherapy and CBT were equally effec-
 32 WETHERELL, GATZ, AND CRASKE

tive in decreasing anxiety, depression, and specific fear symptoms Table 1

in a group of older GAD patients. In a follow-up study, Stanley et Demographics
al. (in press) found evidence for the efficacy of CBT over minimal
contact control, with gains maintained over a 1-year follow-up Variable n % M SD
period. Another recently completed study of GAD patients with Gender
anxiolytic dependence (Gorenstein et al., 2002) found that CBT Men 15 20
plus medication management was more effective than medication Women 60 80
management alone in reducing scores on several subscales of a Race
Caucasian/White 58 77
measure of general psychopathology, with equivalent efficacy in
Latino/a 8 11
reducing dependence on anxiolytic medications. However, there African American/Black 6 8
were no Group ⫻ Time interactions, indicative of differential Asian American 3 4
efficacy, on specific measures of worry, state or trait anxiety, or Marital status
depression. The present study was the first to compare CBT for Married 27 36
Widowed 19 25
late-life GAD with both a comparison intervention and a waiting
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Divorced 19 25
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list (WL). Never married 6 8

The current investigation compares CBT with a discussion Separated 2 3
group (DG) and a WL among 75 older adults with GAD. We Cohabiting 2 3
Work status
hypothesized that participants in the CBT condition would show
Retired 44 59
greater improvement on measures of anxiety, worry, depression, Working 20 27
and quality of life than DG or WL participants after treatment. We Homemaker 4 5
further predicted that CBT participants would maintain their gains Disabled 4 5
better than DG participants. Unemployed 3 4
Comorbid psychiatric diagnosis
Specific phobia 15 20
Method Any depressive diagnosis 14 19
Social phobia 11 15
Participants Panic disorder 6 8
Posttraumatic stress disorder 5 7
Eligible participants had a principal diagnosis of GAD according to Obsessive–compulsive disorder 4 5
Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Hypochondriasis 1 1
Psychiatric Association, 1994) criteria. Exclusion criteria were age un- Any comorbid diagnosis 39 52
der 55, history of mania or psychosis, cognitive impairment as indicated by Any treatment history 66 88
a score of less than 24 on the Mini-Mental State Examination (Folstein, Psychotherapy 60 80
Folstein, & McHugh, 1975), current participation in psychotherapy, alco- Medications 52 69
Current psychotropic medications
hol or other substance abuse within 6 months, commencement of psy-
Taken daily 22 29
chotropic medication within 2 months, and lack of a recent medical Taken at least twice a week 8 11
check-up to rule out alternative causes of anxiety symptoms. Individuals Type
stabilized on psychotropic medication for at least 2 months were asked not Antidepressant 17 23
to change their dose or type of medication for the duration of the study. Benzodiazepine 11 15
Individuals with comorbid depression, dysthymia, or other anxiety disor- Buspirone 3 4
ders were not excluded from participation, as long as their principal Over the counter 5 7
diagnosis was GAD. More than one psychotropic 7 9
Participants were recruited through hospital-affiliated health education Age 67.1 8.2
Education 14.5 2.2
programs, senior centers, and the media (Wetherell & Gatz, 2001). Over a
Mini-Mental State Examination score 28.5 1.4
2-year recruitment period, 498 people contacted the project and were Age of onset of anxiety 37.6 28.7
screened over the telephone. In-person diagnostic interviews were con- Duration of anxiety (years) 29.4 28.7
ducted with 144 individuals, of whom 91 were invited to participate in the Number of medical conditions 6.8 4.4
research. Sixteen refused before providing preliminary data, and 75 par- Primary care visits, last 6 months 2.7 3.6
ticipants were randomized into the study.
Table 1 presents demographic information about the sample. The most
common medical conditions among the participants were osteoarthritis waiting period (n ⫽ 23). WL participants were offered CBT after com-
(36%) and hypertension (32%). Thirty percent of the women had under- pleting the waiting period. Trained research assistants who were not aware
gone a hysterectomy, and 60% of the men reported prostate problems. of the treatment condition to which participants were assigned performed
Individuals with disorders or symptoms that mimic anxiety were also assessment interviews before and after the intervention. CBT and DG
invited to participate in the study, provided that the individual was under participants also completed assessments at a 6-month follow-up period.
the care of a physician and the disorder was considered medically con- Participants received gift certificates from a local grocery store in the
trolled. The most common of these types of conditions in this sample were amount of $5 for the pretreatment assessment and $10 for each of the
stomach or intestinal disorders (24%), asthma (20%), thyroid or endocrine posttreatment and follow-up assessments.
disorders (19%), and arrhythmia (19%). The overall program was advertised as “worry reduction classes” be-
cause research has suggested that older adults may resist services labeled
Procedures as mental health treatment (e.g., Allen, Walker, Shergill, D’Ath, & Katona,
1998; Mickus, Colenda, & Hogan, 2000). Both active conditions met 90
Participants were randomly assigned in small groups to one of three min weekly in one of five community locations most convenient to par-
conditions: 12 sessions of CBT (n ⫽ 26) or DG (n ⫽ 26) or a 12-week ticipants. They met in groups of 4 to 6 older adults and one leader.
 TREATMENT OF GAD IN OLDER ADULTS
CBT consisted of relaxation training, cognitive restructuring, and worry
exposure. Leaders used a manual based on Craske, Barlow, and O’Leary
(1992) with minor modifications for older adults: Elements such as time
management and benzodiazepine withdrawal were omitted and examples
were made more relevant to older people. Participants were taught about
the nature and purpose of anxiety; how to monitor anxiety symptoms and
situations; progressive, passive, applied, and cue-controlled muscle relax-
ation; risk estimation and decatastrophizing; imaginal and in vivo system-
atic desensitization; and worry behavior prevention. CBT participants were
asked to spend approximately 30 min per day on homework exercises.
The DG condition was designed to be comparable to CBT in level of
structure, with participants required to adhere to an agenda during sessions
and with homework assignments of similar duration. DG consisted of a
series of 12 discussions focused on topics known to be worry-provoking
for older adults, including memory problems, health concerns, loss of
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independence, and death of friends and family. A brief reading assignment
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or photograph was used each session to stimulate discussion on the as-
signed topic. The DG manual included a list of questions for each topic as
well as general directions for leading a group discussion taken from Hyman
(1980). Leaders provided validation and supportive listening while using
the questions to maintain group focus on the assigned topic; they encour-
aged group participation, peer support, and information sharing, but they
did not teach skills or differentially reinforce coping strategies. DG mem-
bers were asked to spend 30 min per day keeping a journal of anxiety
thoughts and experiences consistent with the assigned topic.
Four advanced doctoral students in clinical psychology, including the
principal investigator, led the groups. Three leaders had specialized train-
ing in therapy with older adults. To the extent possible, leaders were
counterbalanced across treatment conditions to avoid confounding the
effectiveness of the therapist with the effectiveness of the therapeutic
model. Because of scheduling constraints, one leader led only one CBT
group. All other leaders led at least one CBT group and at least one
discussion group. The principal investigator treated 11 CBT participants
and 10 DG participants. After completion of the groups, leaders rated their
respective belief in the effectiveness of CBT and DG; three leaders,
including the principal investigator, reported more confidence in CBT, and
one leader reported more confidence in DG.
All sessions were audiotaped for supervision and evaluation of treatment
adherence. Therapists received weekly supervision from experts in CBT
for anxiety disorders (Michelle G. Craske) and in aging (Margaret Gatz and
Cynthia Pearson). Supervisors were expected to ensure a minimum level of
competence in their respective therapeutic modality, but therapist compe-
tence was not formally assessed.
During the initial session, CBT and DG participants rated the credibility
of the treatment rationale and their expectations for improvement using a
five-item questionnaire developed by Borkovec and Nau (1972). Cron-
bach’s alpha for the four credibility items in the present sample was .83.
After the intervention, participants rated enjoyment, perceived effective-
ness, likelihood of recommending the intervention to a friend, likelihood of
participating again in the future, and perceived improvement.
To measure adherence, a rater unaware of study hypotheses coded three
randomly selected audiotapes from every group for fidelity to the thera-
peutic model using a codebook and form based on recommendations by
Waltz, Addis, Koerner, and Jacobson (1993). The rater assessed the ap-
proximate amount of time spent (none, less than 10 min, 10 –30 min, or
more than 30 min) on eight different content activities (e.g., review of
monitoring, relaxation, or worry exposure homework; talking about read-
ing assignment or photograph). The rater also evaluated the relative amount
of participation by the leader and members and the amount of interaction
among the members on 3-point scales (leader does most of the talking,
members do most of the talking, or both talk equally; members talk mostly
to leader, members talk mostly to each other, or members talk equally to
leader and to each other). Finally, the rater counted the frequency of seven
specific behaviors used as indices of group process (e.g., leader focuses
33
group back on topic or on new topic, leader provides support, members
give advice or make suggestions). On the basis of a review of four
audiotapes (10% of those rated) by two independent raters, interrater
reliability (r) of the 17 adherence items was .87.
Measures
Anxiety and worry. The Anxiety Disorders Interview Schedule for
DSM–IV (ADIS-IV; DiNardo, Brown, & Barlow, 1994) is a structured
interview for anxiety, depression, and related disorders. Each disorder is
rated on a 0 (none) to 8 (very severe) scale of severity/disablement. The
principal investigator administered the ADIS-IV at intake. A second rater
experienced in ADIS-IV administration and blind to the interviewer-
assigned diagnosis reviewed 25 randomly selected diagnostic audiotapes.
Raw percentage agreement on the GAD diagnosis was 88%, ␬ ⫽ .75.
Interrater reliability for the initial GAD severity rating was .87.
Research assistants administered the GAD section of the ADIS-IV
(DiNardo et al., 1994) at the posttreatment and follow-up assessment
interviews. The principal investigator rated GAD severity unaware of any
identifying information about the participant on the basis of written re-
sponses to ADIS-IV questions recorded by the research assistants. A
second blind rater reviewed a random sample of 25 sets of ADIS-IV
responses; interrater reliability was .82.
A question embedded in the ADIS-IV (DiNardo et al., 1994), “On an
average day over the past month, what percentage of the day did you feel
worried?” was used as an outcome measure, as it has been in several GAD
treatment studies (Barlow et al., 1992; Stanley et al., 1996).
The Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Bork-
ovec, 1990) is a 16-item self-report instrument measuring pathological
worry. It has been validated in a sample of older adults diagnosed with
GAD (J. G. Beck, Stanley, & Zebb, 1995). Cronbach’s alpha in the present
sample was .81.
The Hamilton Anxiety Rating Scale (Hamilton, 1959) is a 14-item
interviewer-rated measure of anxiety primarily assessing somatic symp-
toms. It has been validated in a sample of older GAD patients and
nondiagnosed community volunteers (J. G. Beck, Stanley, & Zebb, 1999).
In the present study, research assistants used a structured interview guide
to increase reliability of the instrument (Bruss, Gruenberg, Goldstein, &
Barber, 1994). Interrater reliability was .81, based on 37 randomly selected
audiotapes reviewed by a second rater.
The Beck Anxiety Inventory (A. T. Beck, Epstein, Brown, & Steer,
1988) is a 21-item self-report questionnaire designed specifically to dis-
tinguish cognitive and somatic symptoms of anxiety from those of depres-
sion. It has been validated in older community, medical, and psychiatric
outpatient samples (Morin et al., 1999; Steer, Willman, Kay, & Beck,
1994; Wetherell & Areán, 1997). Cronbach’s alpha was .90 in the present
sample.
Depression. The Hamilton Depression Rating Scale (Hamilton, 1960)
is a widely used 17-item interviewer-rated instrument that has been vali-
dated with older GAD patients (J. G. Beck et al., 1999). Research assistants
used a structured interview guide to increase reliability (Williams, 1988).
Interrater reliability based on a sample of 34 randomly selected audiotapes
was .88.
The Beck Depression Inventory (A. T. Beck, Rush, Shaw, & Emery,
1979) is a 21-item self-report scale listing common symptoms of depres-
sion that the respondent may have experienced in the past week. The scale
has often been used with geriatric populations (Gallagher, 1986). Cron-
bach’s alpha was .77 in the present sample.
Quality of life. The Medical Outcomes Study short form self-report
health survey (RAND Health Sciences Program, 1992) was used to mea-
sure quality of life related to mental and physical health. It has been
validated in large, mixed-age medical and psychiatric samples (McHorney,
Ware, & Raczek, 1993; Ware & Sherbourne, 1992). Items assessing
anxiety and depressive symptoms were omitted from the scale because of
duplication with other measures. Three subscales, scored from 0 to 100
 34 WETHERELL, GATZ, AND CRASKE
with higher scores representing better functioning, were chosen for the
present study because they are more closely associated with mental health
than with physical health (McHorney et al., 1993). Cronbach’s alphas were
as follows: Role Functioning Limitations Due to Emotional Problems;
(three items), .58; Social Functioning (two items), .81; and Energy/Vitality
(four items), .89.
Measures of clinical significance. Participants were classified as treat-
ment responders if they showed at least 20% improvement on at least three
of the four main anxiety and worry outcome measures in the current study:
the GAD severity rating, Penn State Worry Questionnaire, Hamilton Anx-
iety Rating Scale, and Beck Anxiety Inventory. This type of composite
incorporates data from both self-report and interviewer-rated instruments,
yields a relatively robust estimate of participants who made clinically
significant gains, and has been used frequently in the GAD treatment
literature (Barlow et al., 1992; Borkovec & Costello, 1993; Stanley et al.,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
1996).
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Participants were classified as achieving high end-state functioning if
they scored within one standard deviation of the mean for a normal older
adult sample on at least three of the four main anxiety and worry outcome
measures (Barlow et al., 1992; Borkovec & Costello, 1993; Stanley et al.,
1996). In the present study, high end-state functioning for each measure
was defined as scoring 2 or less on the GAD severity rating, 37 or less on
the Penn State Worry Questionnaire, 10 or less on the Hamilton Anxiety
Rating Scale, and 14 or less on the Beck Anxiety Inventory (Morin et al.,
1999; Stanley et al., 1996).1
Data Analysis
Data were analyzed using SAS release 8.1 (SAS Corporation; Cary,
NC). Comparisons included tests of randomization and the experimental
manipulation as well as tests of study hypotheses using chi-square tests, t
tests and paired t tests adjusted for unequal variance where necessary, the
nonparametric Wilcoxon’s rank sum test, analyses of variance (ANOVAs),
and repeated measures ANOVAs. To minimize Type II error in a small
study with limited power to detect between-group differences, the inves-
tigators did not perform corrections for multiple comparisons. Effect size
estimates for each outcome variable are presented to enable the reader to
evaluate the strength of the findings and the likelihood that they result from
chance.
Results
Randomization, Attrition, Attendance, and Process
Prior to attrition, the CBT and DG conditions did not differ by
gender, race, marital status, work status, presence of a comorbid
psychiatric diagnosis, treatment history, current psychotropic med-
ication use, age, education, Mini-Mental State Examination score,
age of onset or duration of anxiety, number of medical conditions,
or primary care visits. The groups also did not differ on pretreat-
ment values of the variables used as outcome measures. CBT and
DG participants did not differ in their assessment of the credibility
of the treatment rationale, 27.5 versus 25.9, F(1, 47) ⫽ 0.68, p ⫽
.41, or their expectations for improvement, 69.2 versus 61.0, F(1,
48) ⫽ 1.34, p ⫽ .25.
Attrition was defined as refusing further participation in the
project or attending half or fewer of the scheduled group sessions.
The overall attrition rate at 12 weeks was 24%, with 8 individuals
dropping out from each of CBT and DG (31%) and 2 from WL
(9%). There were trends toward higher attrition in each of the
active conditions than in WL, ␹2(1, N ⫽ 49) ⫽ 3.66, p ⫽ .06, but
there was no difference in attrition between CBT and DG, ␹2(1,
N ⫽ 52) ⫽ 0.00, p ⫽ 1.00. Attritters were more likely to have a
history of psychotropic medication use than completers, ␹2(1, N ⫽
75) ⫽ 4.26, p ⫽ .04, although current medication use did not
distinguish dropouts from completers. Among those who were not
assigned to WL, individuals whose groups were led by the prin-
cipal investigator were significantly more likely to complete the
program than individuals who had other therapists, ␹2(1, N ⫽
52) ⫽ 4.93, p ⫽ .03.
Of the 2 participants who failed to complete their post-WL
assessment, 1 decided to pursue alternative treatment and the other
could not be reached. Following the post-WL assessment, 19 of the
remaining 21 WL participants chose to begin CBT. Two declined
because of transportation problems and schedule conflict. Five of
the 19 began CBT but subsequently dropped out, representing an
attrition rate of 26%.
Reasons for attrition from CBT, both immediately and after the
WL, included lack of time or schedule conflict (4), health prob-
lems (3), not finding it helpful (2), finding it burdensome or
aversive (2), and increased depression (1; the participant was
referred for individual treatment). One other participant who
started CBT after the waiting period stopped attending and could
not be reached to provide a reason. Reasons for attrition from DG
included poor attendance (3), not finding it helpful (1), busy
schedule (1), never having attended in spite of telephone and
mailed reminders (1), attending first session for 10 min, leaving for
a doctor’s appointment, and never returning (1), and removal from
the study because the discussion group format was not appropriate
for a lone individual after other group members dropped out (1; the
participant received individual CBT instead and was not included
in analyses of outcome data). One DG participant was lost to
follow-up because she moved out of state. All other CBT and DG
participants who completed treatment provided 6-month follow-up
data.
After attrition, significantly more WL participants than DG
participants had comorbid psychiatric diagnoses, ␹2(1, N ⫽
39) ⫽ 4.17, p ⫽ .04. CBT participants had significantly more
medical conditions than DG participants, t(34) ⫽ 2.37, p ⫽ .02.
Finally, CBT participants scored significantly less favorably than
DG participants on baseline Role Functioning, t(34) ⫽ ⫺2.83, p ⬍
.01. There were no other significant differences in demographics,
outcome variables, or credibility and expectations among the con-
ditions after attrition.
CBT completers did not differ from DG completers in atten-
dance but had significantly better homework compliance, 77%
versus 55%, t(34) ⫽ 2.13, p ⫽ .04. Participants in CBT groups led
by the principal investigator had a trend toward higher attendance
rates, 92% versus 78%, t(16) ⫽ 2.07, p ⫽ .06, and significantly
better homework compliance, 95% versus 49%, t(6.31) ⫽ 3.33,
p ⫽ .01 (unequal variance), than other CBT participants. There
were no differences by leader in the DG condition. Finally, CBT
completers rated their intervention more favorably and perceived
more improvement than DG completers, ts(34) ⫽ 2.88 – 4.39, ps ⬍
.01.
1
Lateral frontalis electromyogram and salivary cortisol data were also
collected as outcome measures. Because of methodological problems and
missing data, results were not easily interpretable and are thus not pre-
sented.
 TREATMENT OF GAD IN OLDER ADULTS 35
Adherence ratings indicate that the conditions differed appro-
45.2 (25.8)

19.1 (10.9)

41.3 (43.3)
58.3 (21.8)
39.5 (19.2)
4.7 (1.6)

65.7 (9.7)
16.0 (7.2)

11.3 (5.4)
19.5 (9.0)

priately in content. DG had greater participation and interaction

Post

among members, including more instances of members providing

support and advice, and CBT leaders spent more time instructing
(n ⫽ 21)
Wait list

and made more suggestions. Assignment of homework, leader

interventions to keep the groups on topic, leader support, verbal-
48.2 (25.5)
63.9 (11.3)

20.2 (12.3)

18.6 (10.6)

46.0 (40.1)
53.8 (28.4)
40.0 (20.4)

ized complaints or criticisms, and levels of support and sugges-

5.1 (0.9)

16.1 (8.3)

12.5 (5.8)

tions/advice from leader and participants combined did not differ

Pre

between the conditions, suggesting that the groups were compa-

rable in level of structure and certain nonspecific elements. DG
participants laughed more often, but CBT participants tended to
report higher ratings of enjoyment after the intervention.
Follow-upa

30.3 (25.7)
59.2 (12.0)

56.9 (38.7)
73.5 (23.8)
47.1 (19.3)
3.2 (2.0)

11.7 (6.7)
11.6 (9.5)

8.9 (5.3)
12.1 (6.4)
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Treatment Outcome
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Table 2 displays mean scores and standard deviations on indi-

vidual measures, and Table 3 displays repeated measures ANOVA
Discussion group

results for the main effect for time and for the Group ⫻ Time
35.8 (27.2)

14.2 (10.4)

48.1 (38.3)
70.8 (25.0)
46.4 (16.8)
(n ⫽ 18)

3.1 (1.5)

60.1 (8.8)
13.0 (8.0)

11.0 (6.0)
13.0 (7.0)

interaction. Because of the preexisting difference in Role Func-

Post

tioning, analysis of covariance, with the pretest score as the co-

variate, was used to compare the conditions on this variable. At
posttreatment, main effects for time were significant for all mea-
sures except the Beck Anxiety Inventory and the Hamilton De-
pression Rating Scale. Group ⫻ Time interactions were significant
35.6 (25.3)

50.0 (28.6)
66.2 (22.4)
44.2 (16.6)
5.1 (1.1)

65.6 (7.7)
16.6 (6.8)
13.6 (8.2)

12.2 (4.2)
16.8 (8.3)
for six measures: the GAD severity rating, percentage of day
Pre

worried, Penn State Worry Questionnaire, Beck Depression Inven-

tory, Role Functioning, and Energy/Vitality. CBT participants
improved more than WL participants on five measures: the GAD
severity rating, F(1, 37) ⫽ 20.34, p ⬍ .01; Penn State Worry
Questionnaire, F(1, 37) ⫽ 4.03, p ⫽ .05; Beck Depression Inven-

24.8 (15.8)
57.5 (12.9)

61.1 (32.8)
74.2 (26.8)
45.3 (22.3)
Follow-up

2.6 (1.6)

9.0 (4.3)
10.4 (6.0)

7.8 (3.6)
9.5 (5.4)
tory, F(1, 36) ⫽ 6.33, p ⫽ .02; Role Functioning, F(1, 36) ⫽ 7.21,
p ⫽ .01; and Energy/Vitality, F(1, 35) ⫽ 7.13, p ⫽ .01, and had

Note. GAD ⫽ generalized anxiety disorder; Pre ⫽ pretreatment; post ⫽ posttreatment.

One discussion group participant was lost to follow-up, so n ⫽ 17 for follow-up data.
a trend toward more improvement on percentage of day worried,
Cognitive–behavioral therapy
F(1, 37) ⫽ 3.03, p ⫽ .09. DG participants improved relative to WL
on two measures: the GAD severity rating, F(1, 37) ⫽ 12.11, p ⬍
.01, and the Penn State Worry Questionnaire, F(1, 37) ⫽ 6.06, p ⫽

25.3 (22.8)
58.1 (14.0)

63.0 (36.0)
68.1 (22.0)
46.7 (17.1)
(n ⫽ 18)

2.4 (1.6)

11.2 (4.7)
12.9 (9.6)

9.2 (4.7)
11.1 (6.7)
Post
.02, with a trend toward more improvement on the Beck Depres-
sion Inventory, F(1, 36) ⫽ 3.63, p ⫽ .06. CBT participants
improved more than DG participants on one measure: percentage
of day worried, F(1, 33) ⫽ 5.45, p ⫽ .03, with trends toward
greater improvement on Role Functioning, F(1, 33) ⫽ 3.36, p ⫽

44.9 (20.4)
63.6 (10.3)

24.1 (29.8)
53.5 (18.6)
35.3 (18.4)
.08, and Energy/Vitality, F(1, 34) ⫽ 2.87, p ⫽ .10.

4.9 (0.8)

14.2 (4.9)
16.0 (8.8)

10.4 (5.1)
15.9 (6.8)
Pre
Table 4 presents paired t tests, effect size estimates, and per-
centage change over time for each condition calculated over the
pre- to posttreatment and pretreatment to follow-up intervals. At
posttreatment, CBT participants had improved significantly on the
GAD severity rating, percentage of day worried, Hamilton Anxiety

Hamilton Depression Rating Scale

Rating Scale, Beck Depression Inventory, Role Functioning, So-

Penn State Worry Questionnaire

Hamilton Anxiety Rating Scale
cial Functioning, and Energy/Vitality. They had a trend toward

Beck Depression Inventory

improvement on the Penn State Worry Questionnaire. DG partic-

Beck Anxiety Inventory

ipants had improved significantly on the GAD severity rating,

Variable

GAD severity rating

Penn State Worry Questionnaire, Hamilton Anxiety Rating Scale,

Social Functioning
Mean (SD) Scores

% of day worried

Role Functioning
Anxiety and worry
and Beck Depression Inventory. WL participants did not change

Energy/Vitality
significantly on any measure.

Quality of life
Effect size estimates (d) were calculated as the difference be-

Depression
tween mean pre- and posttreatment scores divided by the pooled

Table 2
standard deviations (Cohen, 1988). In general, effect sizes for CBT
were in the large range at posttreatment (mean d ⫽ .79) with small

a
 36 WETHERELL, GATZ, AND CRASKE

Table 3
Repeated Measures Analysis of Variance Results

3 (group) ⫻ 2 2 (group) ⫻ 2
(time; pre–post) (time; pre–follow-up)

Variable F df p F df p

Anxiety and worry

GAD severity rating
Time 72.72 1, 54 ⬍.01 51.96 1, 33 ⬍.01
Group ⫻ Time 10.99 2, 54 ⬍.01 0.22 1, 33 .64
% of day worried
Time 4.19 1, 53 .05 10.50 1, 33 ⬍.01
Group ⫻ Time 3.13 2, 53 .05 2.45 1, 33 .13
Penn State Worry Questionnaire
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Time 5.15 1, 54 .03 10.66 1, 33 ⬍.01

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Group ⫻ Time 3.44 2, 54 .04 0.00 1, 33 .96

Hamilton Anxiety Rating Scale
Time 5.99 1, 54 .02 33.69 1, 33 ⬍.01
Group ⫻ Time 1.37 2, 54 .26 0.00 1, 33 .99
Beck Anxiety Inventory
Time 0.55 1, 54 .46 9.60 1, 33 ⬍.01
Group ⫻ Time 0.46 2, 54 .63 1.78 1, 33 .19
Depression
Hamilton Depression Rating Scale
Time 2.48 1, 54 .12 12.65 1, 33 .01
Group ⫻ Time 0.00 2, 54 .99 0.21 1, 33 .65
Beck Depression Inventory
Time 8.18 1, 53 ⬍.01 18.75 1, 33 ⬍.01
Group ⫻ Time 3.57 2, 53 .04 0.18 1, 33 .67
Quality of life
Role Functioninga
Group 4.54 2, 53 .02 0.74 1, 32 .40
Social Functioning
Time 5.68 1, 52 .02 8.44 1, 30 ⬍.01
Group ⫻ Time 1.10 2, 52 .34 0.61 1, 30 .44
Energy/Vitality
Time 3.94 1, 52 .03 4.16 1, 33 .05
Group ⫻ Time 3.94 2, 52 .03 1.09 1, 33 .30

Note. pre–post ⫽ pre–posttreatment; pre–follow-up ⫽ pretreatment–follow-up; GAD ⫽ generalized anxiety

disorder.
a
Because of preexisting differences in role functioning, data for this variable were analyzed using analysis of
covariance with the pretest score as the covariate.

to medium effects for DG (mean d ⫽ .36), and essentially no
effects for WL (mean d ⫽ .05).
After 12 weeks, 22% of CBT participants, 39% of DG partici-
pants, and 86% of WL participants still met GAD diagnostic
criteria. The differences between CBT and WL and between DG
and WL were statistically significant, ␹2(1, N ⫽ 39) ⫽ 15.89, p ⬍
.01, and ␹2(1, N ⫽ 39) ⫽ 9.24, p ⬍ .02, but the difference between
CBT and DG was not, ␹2(1, N ⫽ 36) ⫽ 1.18, p ⫽ .28. For both
CBT and DG, 33% of participants were classified as treatment
responders, compared with only 1 WL participant (5%). Differ-
ences between active conditions and WL were significant, ␹2(1,
N ⫽ 39) ⫽ 5.37, p ⫽ .02, but there was no difference between
CBT and DG, ␹2(1, N ⫽ 36) ⫽ 0.00, p ⫽ 1.00. No participants in
any condition met criteria for high end-state functioning initially.
Following treatment, 22% of CBT and DG participants were
functioning in the normal range on at least three main outcome
measures, compared with none of WL participants. Again, differ-
ences were significant for CBT and for DG relative to WL, ␹2(1,
N ⫽ 39) ⫽ 5.20, p ⫽ .02, but there was no difference between
active conditions, ␹2(1, N ⫽ 36) ⫽ 0.00, p ⫽ 1.00.
Using an intent-to-treat analysis, in which participants who
dropped out of the study were included using data from their
last measurement period carried forward, we found that 54% of
those initially randomized to CBT, 50% of those randomized to
DG, and 13% of those randomized to WL no longer met criteria
for GAD after 12 weeks. The differences between CBT and WL
and DG and WL were statistically significant, ␹2(1, N ⫽
49) ⫽ 8.97, p ⬍ .01, and ␹2(1, N ⫽ 49) ⫽ 7.58, p ⬍ .01, but
the difference between CBT and DG was not, ␹2(1, N ⫽
52) ⫽ 0.08, p ⫽ .78. Twenty-three percent of CBT participants,
27% of DG participants, and 4% of WL participants were
classified as treatment responders. The difference between CBT
and WL just failed to achieve significance because of dropout
in the CBT condition, ␹2(1, N ⫽ 49) ⫽ 3.50, p ⫽ .06, but the
difference between DG and WL was significant, ␹2(1, N ⫽
49) ⫽ 4.55, p ⫽ .03. There was no significant difference
between CBT and DG, ␹2(1, N ⫽ 52) ⫽ 0.10, p ⫽ .75.
Differences between both active conditions and WL were sig-
nificant for participants achieving high end-state functioning,
15% for CBT, 15% for DG, and 0% for WL, ␹2(1, N ⫽
 TREATMENT OF GAD IN OLDER ADULTS 37

49) ⫽ 3.85, p ⫽ .05, but there was no difference between CBT

8
6
⫺3
1
5

10
⫺5

⫺1
⫺10
8
%
and DG, ␹2(1, N ⫽ 52) ⫽ 0.00, p ⫽ 1.00.

Pre–posttreatment
At 6-month follow-up, time effects were significant for all

.32
.12
⫺.17
.01
.09

.21
⫺.09

⫺.03
⫺.11
.18
measures, but there were no significant Group ⫻ Time interaction
d
Wait list

effects indicating no differential treatment effects between CBT

and DG (Table 3). CBT participants made significant gains from

.15
.61

.43
.45
.93
.77

.67

.39
.54
.25
p
baseline to follow-up on all measures (Table 4). DG participants
1.48 made gains on 5 of 10 measures. Effect sizes increased over the
0.52
⫺0.77
0.08
0.30

0.81
⫺0.43

0.87
0.62
⫺1.19
follow-up period for both active conditions (mean ds ⫽ .97 for
t

CBT and .51 for DG).

At follow-up, 28% of CBT participants and 47% of DG partic-
37
15
10
30
15

27
28

7
14
11
%

ipants met criteria for GAD, ␹2(1, N ⫽ 35) ⫽ 1.39, p ⫽ .24. Fifty
percent of CBT participants and 53% of DG participants were
1.22
.21
.65
.73
.23

.69
.64

.21
.32
.16
Pre–treatment–

classified as treatment responders, ␹2(1, N ⫽ 35) ⫽ 0.03, p ⫽ .86,

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

follow-up
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and 28% of CBT participants and 29% of DG participants had

⬍.01
.26
.04
⬍.01
.23

.03
.02

.53
.11
.53
achieved high end-state functioning, ␹2(1, N ⫽ 35) ⫽ 0.01, p ⫽
p

Note. d was calculated as (Mpretreatment ⫺ Mposttreatment)/standard deviationpooled. GAD ⫽ generalized anxiety disorder; Quest. ⫽ Questionnaire.
.91.
Discussion group

4.66
1.18
2.25
3.79
1.26

2.44
2.56

⫺0.64
⫺0.64
⫺1.70
t

Because quality-of-life variables were scored in the opposite direction from other measures, negative t values represent improvement. Discussion
In a study comparing CBT with an equally credible comparison
39
⫺1
8
22
⫺4

10
23

⫺4
7
5
%

intervention and with a waiting list in treating GAD in older adults,

Pre–posttreatment

CBT was clearly superior to WL. The comparison intervention was

1.54
⫺.01
.67
.49
⫺.06

.24
.50

.13
⫺.06
.19
d

also superior to the waiting list, but less decisively. When CBT
was compared with the comparison intervention, limited evidence
⬍.01
.79
⬍.01
⬍.01
.70

.20
.03

.59
.52
.84
Paired t Tests and p Values, Effect Size Estimates, and Percentage Change Over Time by Condition

favored CBT.
p

CBT participants improved relative to WL on five study mea-

sures, with a trend toward superior performance on a sixth. CBT
3.35
5.68
⫺0.28

4.06
⫺0.39

1.33
2.30

⫺0.54
⫺0.66
0.20
t

showed transfer effects on depressive symptoms and quality of life

as well as effects on anxiety and worry, suggesting that the benefits
of treatment were multidimensional. DG participants improved
10
38
45

37
35

25
40

39
28
154
%

relative to WL on two measures of anxiety and worry, with a trend

.53
1.92
1.11

1.13
.76

.60
1.05

.91
.49
1.18

toward improvement on a measure of depression, and CBT per-

Pre–treatment–

formed better than DG on one measure of worry, with trends

follow-up

toward superior performance on two measures of quality of life. At

⬍.01
⬍.01
.03
⬍.01
⬍.01

.02
⬍.01

⬍.01
.03
.03
p

6-month follow-up, gains were maintained or enhanced for both

Cognitive–behavioral therapy

active conditions, but there were no differential treatment effects.

Effects were large for CBT, medium for DG, and virtually non-
5.55
3.42
2.37
4.47
3.11

2.64
3.64

⫺3.45
⫺2.36
⫺2.41
t

existent for WL. It should be noted that CBT participants did more
homework than DG participants. CBT participants also appeared
to prefer their intervention, with higher levels of satisfaction and
51
44
9
21
19

12
30

27
32
161
%

perceived improvement than DG participants. Overall, there are

some indications that CBT may be superior to a credible nonspe-
Pre–posttreatment

2.08
.91
.45
.63
.34

.24
.71

.72
.64
1.18
d

cific group intervention for generalized anxiety in older adults, but

the data are not strong enough to support this conclusion
⬍.01
.02
.07
.03
.19

.42
⬍.01

⬍.01
.03
.02

unambiguously.
p

Results do support the conclusion that treatment is superior to

WL. Relative to WL, fewer treated participants met criteria for
6.87
2.50
1.96
2.45
1.35

0.82
3.59

⫺3.70
⫺2.43
⫺2.69

GAD and more were treatment responders and achieved high

t

end-state functioning, with no significant differences between

CBT and DG. One in three treated participants made clinically
Penn State Worry Quest.

meaningful improvement, and 22% scored in the normal range on

Hamilton Depression
GAD severity rating

measures of worry and anxiety after the intervention. By 6-month

Social Functioning
Hamilton Anxiety
% of day worried

Role Functioning
Beck Depression
Anxiety and worry

follow-up, 51% of the treated participants had made clinically

Variable

Energy/Vitality
Beck Anxiety

meaningful improvement, and 29% had achieved high end-state

Quality of lifea

functioning. The basic pattern of results, that more treated partic-

Depression

ipants than WL participants made clinically meaningful gains but

Table 4

that CBT did not differ from DG, remained the same following an
intent-to-treat analysis. This study provided no evidence that a
a
 38 WETHERELL, GATZ, AND CRASKE
substantial proportion of older adults with GAD recover over a
12-week period without treatment.
The current study is consistent with much of the GAD treatment
outcome literature in finding relatively few significant differences
between CBT and a comparison condition (Blowers, Cobb, &
Mathews, 1987; Borkovec & Mathews, 1988; White, Keenan, &
Brooks, 1992), although some studies with younger participants
have found that treatments with cognitive and behavioral compo-
nents are superior to supportive and psychodynamic approaches
(Borkovec & Costello, 1993; Durham et al., 1994). Among older
adults, Stanley et al. (1996) found that almost twice as many GAD
patients responded to supportive therapy (54%) as responded to
CBT (28%), and an intervention oriented toward self-disclosure
and reflection of feelings decreased anxiety levels in an older adult
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
sample with anxiety and depressive symptoms, whereas a behav-
ioral anxiety management intervention did not (Sallis et al., 1983).
These findings suggest that additional research is needed to de-
velop more effective and specific forms of treatment for general-
ized anxiety in older adults. In particular, the findings suggest that
tailoring the standard CBT group treatment package to include
more of the interactive elements characteristic of DG may enhance
treatment outcome for anxious older adults who may be lonely or
socially isolated.
Several recent meta-analyses of treatment outcome studies with
younger GAD patients have suggested that effects are generally
quite large, with 45%–55% of participants treated with CBT
achieving high end-state functioning and mean effect sizes of
approximately 1.7 at posttreatment and 2.0 at follow-up (Borkovec
& Whisman, 1996; Chambless & Gillis, 1993; Durham & Allan,
1993). Gains in the present study were smaller but comparable to
results obtained by Stanley et al. (1996) in their sample of older
GAD patients receiving CBT. Attrition in this study was higher
than the average for younger GAD samples (Borkovec & Whis-
man, 1996) but was comparable to other investigations of anxiety
treatment in older adults (Sallis et al., 1983; Stanley et al., 1996).
Attrition may have been influenced by the decision to frame the
groups as classes; had participants thought of the project as treat-
ment, they may have been less likely to drop out. Notably, most
treatment studies of anxiety in older adults to date have been
conducted in a small group format, whereas studies with younger
adults more typically use individual therapy. Individual treatment
for GAD appears to be associated with better outcomes than group
interventions (Fisher & Durham, 1999).
Clinical significance is an issue that has received increased
attention in the treatment outcome literature, including a Special
Section of this journal (June, 1999). In that issue, Kendall, Marrs-
Garcia, Nath, and Sheldrick (1999) recommend performing nor-
mative comparisons as a measure of clinical significance. A com-
parison of treatment completers in the present study with a
normative sample of older adults on Penn State Worry Question-
naire scores (J. G. Beck et al., 1995) revealed that, on average,
individuals in the present study remained different from the non-
clinical norm, both statistically and in terms of clinical equiva-
lence, after treatment. This finding suggests that although partic-
ipants in both treatment conditions improved relative to a waiting
list on this measure, the clinical significance of the change may be
limited.
Participants in the present study differ from typical younger
adult samples in several ways that may have influenced outcome.
Participants had experienced anxiety symptoms for an average of
almost 30 years, 40% were taking psychotropic medications, and
almost 90% had previous experience with psychological or phar-
macological treatment. Previous research has suggested that these
factors may be associated with poorer GAD treatment outcome
(Butler, 1993; Durham & Allan, 1993; Seivewright, Tyrer, &
Johnson, 1998; Wardle, 1990). Thus, the present sample was likely
quite treatment resistant; it is encouraging that many individuals
improved following a 12-week intervention nonetheless.
One limitation of the current study is the variability associated
with different group leaders. Participants in the principal investi-
gator’s CBT groups tended to have lower rates of attrition, higher
attendance, and better homework compliance than other partici-
pants. This may have been due to perceived higher status attributed
to the investigator as director of the research project, more initial
contact with the investigator, a sense of personal commitment to
help the investigator with the research, or, conceivably, real dif-
ferences in skill among leaders. Moreover, participants in the
principal investigator’s CBT groups had better outcomes than
participants in CBT groups led by other therapists, but there were
no differences in outcomes by leader among discussion groups.
This finding suggests that the results may have been different had
the current study used a more uniform group of therapists.
A related issue is the allegiance of the therapists and investiga-
tor. Three of four study therapists, including the principal inves-
tigator, had greater faith in the effectiveness of CBT than in the
discussion group. Had all therapists been as committed to CBT as
the investigator, the findings for CBT may have been stronger but
less generalizable. The fact that most therapists had a stronger
allegiance to CBT makes it difficult to conclude that any differ-
ences in outcomes were the result of differential efficacy of the
treatments rather than of the effects of therapist and investigator
allegiance.
Another weakness of this study is the small and relatively
homogeneous participant pool. Participants were mostly White,
female, well-educated, and active. Thus, results may not generalize
to older GAD patients who are male, frail, have low education or
socioeconomic status, or are from non-European ethnic back-
grounds. Additionally, power to detect significant differences be-
tween CBT and an alternative treatment was limited due to the
small sample and smaller than expected effect sizes. Because of
the low power, no attempt was made to control alpha for tests of
multiple outcome variables. Null hypothesis significance testing,
however, has often been criticized, and arguments have been made
for alternative methods of evaluating experimental findings (e.g.,
Krueger, 2001). In the present report, effect sizes are presented for
each outcome variable to facilitate evaluation of the findings.
Last, participants were diagnosed on the basis of only one
structured interview. Borkovec and Whisman (1996) recommend
that, because GAD has the lowest interrater agreement among the
anxiety disorders, all GAD treatment studies should include two
separate diagnostic interviews to reduce the number of false-
positive cases. This limitation may not pose a major concern.
Although we performed only one diagnostic interview per partic-
ipant in the present study, we found, on the basis of multiple
indicators of anxiety and worry administered over two separate
measurement occasions (diagnostic interview and pretreatment
assessment), that none of the participants had attained high end-
 TREATMENT OF GAD IN OLDER ADULTS
state functioning prior to treatment, suggesting that these individ-
uals were indeed clinically anxious.
The greatest strength of this investigation is that it was the first
psychotherapy outcome study to date to randomize older adults
with a diagnosed anxiety disorder to alternative interventions or to
a waiting period to control for spontaneous recovery. Other meth-
odological strengths included use of a reliable diagnostic instru-
ment, use of blind outcome raters, balance of participants on
psychotropic medications across conditions, balance of therapists
across conditions, assessment of participants’ expectancy, use of
manualized treatment protocols, use of adherence ratings, and use
of an adequate follow-up period (Borkovec & Whisman, 1996).
An additional refinement was the use of a comparison condition
more closely matched in structure to CBT than supportive psycho-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
therapy is. Finally, the inclusion of participants who were medi-
cally ill or taking psychotropic medications made this sample
somewhat more representative of older GAD patients in the com-
munity than has been typical in many treatment outcome studies.
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Received January 30, 2001
Revision received October 12, 2001
Accepted October 15, 2001 䡲