Controlling Anxiety in Late Life (CALL)

Anxiety complaints are among the most ubiquitous and debilitating mental health problems in older adults. If left untreated, anxiety complaints have a tendency to become chronic. This increases the risk of developing anxiety and depressive disorders and somatic diseases prevalent in older adults, such as hypertension and coronary heart disease. Notwithstanding the prevalence and personal and societal impact of anxiety, there is a scarcity of fundamental and clinical research into control of anxiety in the elderly; studies have tended to focus on depression and cognitive decline. Several meta-analyses on the treatment of late-life anxiety suggest that it can be effectively treated with face-to-face cognitive-behavioral therapy (CBT). Up to date only one RCT examined the efficacy, long-term outcomes, and cost-effectiveness of a transdiagnostic therapist-guided eHealth CBT program for adults over 60 years of age with stress and anxiety with positive results. Notwithstanding these promising results, a number of important issues still need to be addressed in order to further our knowledge about the prevention of anxiety complaints in older persons: (a) The vast majority of older people with anxiety do not receive appropriate treatment and preventive interventions for anxiety complaints in older adults are almost non-existing; (b) Given the high prevalence of anxiety complaints in the elderly and the rise in life expectancy, even in affluent societies the existing health care system cannot adequately address the need for prevention and treatment in a traditional way; (c) Some studies suggest that particularly the cognitive aspects of challenging cognitions of traditional CBT are problematic for older adults and that so-called third generation cognitive-behavior therapies that do not focus on cognitive content, but promote cognitive flexibility in emotion regulation and behaviors aimed at realizing important life goals may be more widely applicable in older adults; (d) As many individuals with anxiety complaints also suffer from depression, there is a need to examine the effectiveness of transdiagnostic interventions that focus on factors, such as emotion regulation and goal orientation, that underlie both anxiety and depression. In order to address the intervention gap and to address these issues, we propose to execute a randomized controlled trial, to compare the (cost-)effectiveness of eHealth plus face-to-face contacts (blended care) versus treatment-as-usual (TAU) in older adults aged 55 to 75 years with mild to moderate anxiety complaints recruited in general practice. More specifically, we think that the evidence-based eHealth intervention Living to the Full in the Third Life Phase (LF-TLP) constitutes a promising and easy-to-implement indicated prevention in primary care. LF-TLP enhances the use of more flexible emotion regulation and behaviors aimed at realizing important life goals. Moreover, LF-TLP also targets symptoms of anxiety and depression simultaneously. Moreover, LF-TLP may especially appeal to older adults, as it concurs with the reorientation on important life values and associated value-directed behavior change in this life phase. The eHealth intervention Living to the Full has already proven to be effective in the treatment of depressive and stress problems, both in a face-to-face and self-help/online treatment format, with minimal coaching and high adherence. To promote acceptance and compliance we will combine this intervention with a limited amount of face-to-face contacts with the POH-GGZ (blended care). We will conduct a pragmatic parallel-groups cluster randomized single-blind trial. 36 POH-GGZ of the Leiden Primary Care Research Network (LEON) of the department of Public Health and Primary Care of the Leiden University Medical Center and from the wider The Hague area will be randomized to LF-TLP or treatment-as-usual (TAU). TAU will be delivered according to the NHG guideline for anxiety complaints. About 120 participants in each study arm will be recruited by means of a large-scale internet-based screening in enlisted older persons aged 55 to 75 years. In addition eligible consulting patients from the participating GP practices will be invited to participate. There will be four main measurements via an on online-survey program and interviews conducted by telephone: before the start of the intervention (T1), directly following the intervention (T2: 3 months after baseline), and again six and twelve months after baseline (T3 and T4). We expect that in comparison to TAU, LF-TLP will be an acceptable, efficacious and cost-effective indicated preventive intervention.