Finally, long-term or maintenance treatment of late-life anxiety with medication has not been studied (although we are currently carrying out a study of maintenance effects of SSRI treatment in late-life GAD), and no augmentation strategies can be recommended with confidence. Combining medication and psychotherapy for late-life anxiety disorders The inadequacy of Inhibitors,research,lifescience,medical monotherapy is well known in mood and anxiety disorders, and combination treatments may be more effective.179 Antidepressants and CBT

have different mechanisms and may be able to treat different components of the illness.180,181 Combination treatment in older adults might best be carried out sequentially, rather than simultaneously initiated,

to maximize costeffectiveness and allow the patient and provider to focus sequentially on different aspects of Inhibitors,research,lifescience,medical treatment, rather than divide focus among multiple treatments and components of illness at once.182 The hope is that, with two treatments targeting the different facets of the illness, persistent residual features and relapse are less likely. Supporting this assertion, a recent review of meta-analyses concluded that psychotherapies involving Inhibitors,research,lifescience,medical cognitive and behavioral strategies for GAD are superior to nondirective therapy and pill placebo, and equivalent to pharmacotherapy in the acute phase of treatment, with Inhibitors,research,lifescience,medical robust effects extending as far as 10 years following discontinuation of treatment.183 In one study of anxious

older adults, benefits of CBT were increased at 1-year follow-up in patients who had been treated for at least 3 months with medications prior to receiving CBT, suggesting that sustained or increasing gains are buy NVP-BKM120 possible for older adults receiving CBT for anxiety following Inhibitors,research,lifescience,medical an acute course of pharmacotherapy.184 The strategy of sequencing medication with CBT is controversial in the anxiety disorders.185,186 Pharmacotherapy might interfere with the challenging of catastrophic beliefs during psychotherapy, individuals treated with medications may be less motivated to engage in psychotherapy, and psychotherapy in the context of medications may result in state-dependent learning that does not persist after the medication is discontinued.187,188 Because of this, we are currently testing until the strategy of sequenced medication and CBT within a controlled study design. Future directions in treatment development: new targets and one large barrier The preceding sections raise several avenues for novel treatment development. Our findings with cortisol in late-life GAD are summed up as such: elevated cortisol is associated with GAD, is reducible with treatment, and when reduced during treatment is associated with neuropsychological improvements (in memory).