Cognitive Behavioral Therapy versus Yoga for the Treatment of Worry in Anxious Older Adults: A

Randomized Preference Trial

Gretchen A. Brenes, Ph.D., MPISuzanne C. Danhauer, Ph.D., MPI

Gena Hargis, M.P.H., Project Manager

Disclosures

Dr. Brenes, Dr. Danhauer, and Ms. Hargis have nothing to disclose.

Background

Anxiety disorders-most prevalent psychiatric disorders in

older adults

Associated with numerous negative outcomes

Treatment of late-life anxiety

Why this study?

Cognitive Behavior Therapy (CBT) delivered by

telephone is successful in improving anxiety, depression,

sleep, and quality of life

Stakeholder Feedback:

Wanted choice

Wanted CBT as an option

Wanted yoga as an option

Did not want medication

Specific Aims

Primary Aim: Compare the effects of CBT and yoga on worry Secondary Aim: Compare the effects of CBT and yoga

on anxiety and sleep Exploratory Aims: Determine participant preference for CBT vs. yoga Examine preference effects on worry, anxiety, sleep,

adherence to treatment, and attrition rates Examine selection effects on worry, anxiety, sleep,

adherence to treatment, and attrition rates

Questions this study answers

How does yoga compare with CBT for reducing worry and anxiety and improving sleep? When given a choice, which treatment do people prefer

for reducing worry? Are treatment outcomes improved when people choose

their treatment (preference and selection effects)? Are adherence rates higher when people choose

treatments than when they are told which treatment they will receive? Are there differences in satisfaction based on whether a

person chooses their treatment vs. being told which treatment they will receive?

Study Design for Randomized Preference Trial

Participants: Goal of N = 500

Inclusion criteria: ≥60 years elevated worry

Exclusion criteria: currently receiving psychotherapy currently practicing yoga current alcohol/substance abuse dementia global cognitive impairment current psychotic symptoms active suicidal ideation change in psychotropic medications in the last month hearing loss

Recruitment

Sources of recruitment identified by value system for age Physicians Newspaper vs social media Churches Community groups Neighborhood magazines Local community establishments

Recruitment: Lessons Learned

Identify key community stakeholders for credibility

Multiple exposures to recruitment materials from credible resources

Visuals for postcard

Description of CBT

10 weekly telephone sessions with a study coach

Workbook

Cognitive behavioral model of anxiety Relaxation Cognitive restructuring Sleep hygiene Problem-solving

Worry control

Behavioral activation

Exposure therapy

Pain

Relapse prevention

Description of Yoga Intervention

20 bi-weekly yoga classes Gentle Hatha yoga based on “Yoga for Seniors”

book/program (by Carol Krucoff) Adapted for older adults and accommodates individuals

of varying levels of physical functioning Focused on breathing, posture practice, and

meditation/relaxation

Measures

Week 0 Week 6 Week 11 Week 37

Penn State Worry Questionnaire-Abbreviated (PSWQ-A)(Primary Outcome)

X X X X

PROMIS Anxiety(Secondary Outcome)

X X X X

Insomnia Sleep Index(Secondary Outcome)

X X X X

PROMIS 29(Exploratory Outcome)

X X X

PROMIS Depression (Exploratory Outcome)

X X X

PROMIS Physical Function(Exploratory Outcome)

X X X

GAD-7(Exploratory Outcome)

X X X

Stakeholder Engagement

Clinical stakeholders are physicians who provide clinical care to older adults; assisted with recruitment

Community stakeholders are local organizations (Shepherd’s Center) and local churches; assisted with advertisement and publicity; enhanced visibility and sustainability within the community

Patient stakeholders are older adults with personal experience with worry/anxiety; provided feedback on measurement tools and interventions, assisted with development of recruitment strategies and materials, provided suggestions for timing and location of classes

Stakeholder Engagement: Lessons Learned

Clinical stakeholders: relationships with clinician/patient

Community stakeholders: multi-faceted community connection for sustainability

Patient stakeholders: incorporating feedback from the population

Sample Characteristics

Number of Participants 500

Age [Mean (SD)] 66.5(5.2)Gender

Male 67(13.4%)Female 433(86.6%)

RaceAfrican Am./Black 74(14.8%)Caucasian/White 394(78.8%)Other 32(6.4%)

Psychotropic Medication UseAny 218(43.6%)Anti-depressants 145(29%)Anxiolytics 100(20%)Anti-psychotics 10(2%)Stimulants 10(2%)Sleep medication 70(14%)

Education<8th grade 1(0.2%)8-10th grade 7(1.4%)11-12th grade 66(13.2%)>12th grade 426(85.2%)

Answers to Study Questions

How does yoga compare with CBT for reducing worry and anxiety and improving sleep?

Both CBT and yoga improved worry, anxiety, and sleep, but CBT is superior to yoga for improving sleep outcomes.

Answers to Study Questions

When given a choice, which treatment do people prefer for reducing worry?

People chose CBT and yoga at an equal rate.

Answers to Study Questions

Are treatment outcomes improved when people choose their treatment ?

Choosing a treatment does not produce better results than being assigned to a treatment.

Answers to Study Questions

Are adherence rates higher when people choose a treatment?

Participants who chose CBT completed more sessions than participants who were randomized to CBT. Participants who chose yoga completed a similar number of sessions as participants who were randomized to yoga.

Answers to Study Questions

Does satisfaction differ based on whether a person chose their treatment or not?

People who chose their treatment were as satisfied as people assigned to a treatment.

Discussion

CBT and yoga improved worry, anxiety, and sleep CBT was superior to yoga for improving sleep outcomes No preference or selection effects

Strengths

Randomized preference trial: Compare randomized and preference effects Largest study of CBT and yoga for worry and anxiety Careful assessment of adherence and fidelity Stakeholder involvement

Limitations

Willingness to be randomized Differences in frequency and format between CBT and

yoga Predominantly white, well-educated sample Intervention specific barriers (transportation)

Take Home Messages

Both CBT and yoga are helpful for reducing worry and anxiety in older adults. If someone has high worry and sleep problems, CBT is

recommended. As a provider, making a specific recommendation of a

treatment (CBT or yoga) does not produce better outcomes than encouraging the patient to choose a treatment.