Escitalopram for Older Adults With Generalized Anxiety Disorder

Abstract

Context Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in older adults; however, few data exist to guide clinicians in efficacious and safe treatment. Selective serotonin reuptake inhibitors (SSRIs) are efficacious for younger adults with GAD, but benefits and risks may be different in older adults. Objective To examine the efficacy, safety, and tolerability of the SSRI escitalopram in older adults with GAD. Design, Setting, and Participants A randomized controlled trial in primary care practices and related specialty clinics in Pittsburgh, Pennsylvania, of 177 participants aged 60 years or older with a principal diagnosis of GAD randomized to receive either escitalopram or placebo and conducted between January 2005 and January 2008. Interventions Twelve weeks of 10 to 20 mg/d of escitalopram (n=85) or matching placebo (n=92). Main Outcome Measures Cumulative response defined by Clinical Global Impressions-Improvement score of much or very much improved; time to response; and anxiety and role functioning changes measured by the Clinical Global Impressions-Improvement scale, Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Late-Life Function and Disability Instrument activity limitations subscale, and the role-emotional impairment and social function subscales of the Medical Outcome Survey 36-item Short Form. Results In the primary analytic strategy in which participants (n=33) were censored at the time of dropout, mean cumulative response rate for escitalopram was 69% (95% confidence interval [CI], 58%-80%) vs 51% (95% CI, 40%-62%) for placebo (P=.03). A conservative intention-to-treat analysis showed no difference in mean cumulative response rate between escitalopram and placebo (57%; 95% CI, 46%-67%; vs 45%; 95% CI, 35%-55%; P=.11). Participants treated with escitalopram showed greater improvement than with placebo in anxiety symptoms and role functioning (Clinical Global Impressions-Improvement scale: effect size, 0.93; 95% CI, 0.50-1.36; P<.001; Penn State Worry Questionnaire: 0.30; 95% CI, 0.23-0.48; P=.01; activity limitations: 0.32; 95% CI, 0.01-0.63; P=.04; and the role-emotional impairment and social function: 0.96; 95% CI, 0.03-1.90; P=.04). Adverse effects of escitalopram (P<.05 vs placebo) were fatigue or somnolence (35 patients [41.1%]), sleep disturbance (12 [14.1%]), and urinary symptoms (8 [9.4%]). Conclusions Older adults with GAD randomized to escitalopram had a higher cumulative response rate for improvement vs placebo over 12 weeks; however, response rates were not significantly different using an intention-to-treat analysis. Further study is required to assess efficacy and safety over longer treatment durations. Trial Registration clinicaltrials.gov Identifier: NCT00105586

Interventions for generalized anxiety disorder in older adults: Systematic review and meta-analysis

“…Some pharmacological trials defined response as decrease of baseline anxiety scores of at least 25% (e.g., Bresolin et al, 1988;Frattola et al, 1992), whereas others required a decrease of at least 50% (e.g., Kimura et al, 2003). Some studies defined a response as having received a clinician rating of being improved or much improved (e.g., Lenze et al, 2009) or required a combination of a clinician rating and a change from baseline in a score (Montgomery, Chatamra, Pauer, Whalen, & Baldinetti, 2008). Still other investigators considered that response was achieved when GAD was no longer diagnosable and there was a decrease of at least one fifth in the majority of the outcome measures (e.g., Mohlman & Gorman, 2005;Stanley, Hopko, et al, 2003).…”

Inappropriate treatments for patients with cognitive decline

“…Among alternative maintenance treatments, we should mention mood stabiliser anticonvulsants (such as pregabalin, whose indications include generalised anxiety disorder). 14,15 Another class is constituted by antidepressants with an anxiolytic or sedative effect (especially when symptoms of depression are present): escitalopram, 16 venlafaxine, 17 duloxetine, 18 trazodone, 19,20 and mirtazapine. 21 Additional alternative treatments include melatonin (for treating behavioural changes associated with circadian rhythm disturbances) 22 ; and atypical neuroleptics previously administered to patients with this profile (for example, low doses of quetiapine, i.e.…”

Therapeutics in Late-Life Anxiety Disorders—An Update

“…Both paroxetine and CBT were effective in the treatment of late-life PD [42•]. Lenze and colleagues reported modest efficacy of escitalopram compared to placebo in late-life GAD [43]. Augmentation or combination studies of antidepressants and psychotherapy in late-life ADs are scarce.…”