Longitudinal association between medication adherence and glycaemic control in Type 2 diabetes.

AIM: Despite the widespread assumption that adherence drives glycaemic control, there is little published support for this in Type 2 diabetes. The study objective was to determine whether self-reported medication adherence predicts future glycaemic control in Type 2 diabetes, after accounting for baseline control. METHODS: Medication adherence (4-item Morisky scale), glycaemic control (HbA(1c)%), and other variables were assessed in 287 adult primary care patients prescribed oral medication (40% also on insulin) for Type 2 diabetes. Glycaemic control was reassessed 6 months later. Regression analyses examined concurrent and future glycaemic control as a function of baseline medication adherence after adjustment for baseline glycaemia and other potential confounders. RESULTS: Only half of patients reported high adherence. Cross-sectional adjusted analysis replicated prior reports of an adherence-HbA(1c) association (P = 0.011). Even after adjusting for baseline HbA(1c), each one-point increase in baseline Morisky total score was associated with a 1.8 mmol/mol (or 0.16%) increase in HbA(1c) measured 6 months later. Additionally, baseline endorsement of forgetting to take medication was associated with a 4.7 mmol/mol (or 0.43%) increase in 6-month HbA(1c) (P = 0.005). This effect persisted after adjusting for psychological distress and did not vary by key demographic and medical features. CONCLUSIONS: Even after stringent adjustment for baseline glycaemic control, self-reported adherence to diabetes medication predicts long-term glycaemic control. The Morisky scale is an easy-to-use clinical tool to identify patients whose glycaemic control will subsequently worsen, regardless of age, gender and psychological distress.

Association between depression and concurrent Type 2 diabetes outcomes varies by diabetes regimen.

AIMS: Although depression has weak associations with several Type 2 diabetes mellitus (DM) outcomes, it is possible that these associations are concentrated within certain patient subgroups that are more vulnerable to their effects. This study tested the hypothesis that depression is related to glycaemic control and diabetes-related quality of life (DQOL) in patients who are prescribed injected insulin, but not those on oral glucose-lowering agents alone. METHODS: Participants (103 on insulin, 155 on oral glucose-lowering agents alone) with Type 2 DM were recruited from a large US healthcare system and underwent assessment of glycaemic control (glycated haemoglobin; HbA(1c)), medication adherence and diabetes self-care behaviours, DQOL and depression (none, mild, moderate/severe). RESULTS: There was a significant regimen x depression interaction on HbA(1c) (P = 0.002), such that depression was associated with HbA(1c) in patients using insulin (beta = 0.35, P < 0.001) but not in patients using oral agents alone (beta = -0.08, P = NS). There was a similar interaction when quality of life was analysed as an outcome (P = 0.002). Neither effect was mediated by regimen adherence. CONCLUSIONS: The generally weak association between depression and glycaemic control is concentrated among patients who are prescribed insulin. Similarly, the association between depression and illness quality of life is strongest in patients prescribed insulin. Because this is not attributable to depression-related adherence problems, psychophysiological mechanisms unique to this group ought to be carefully investigated. Clinicians might be especially vigilant for depression in Type 2 DM patients who use insulin and consider its potential impact upon their illness course.

Prevalence of nonadherence with maintenance mesalamine in quiescent ulcerative colitis.

OBJECTIVE: There are scant data regarding outpatient adherence in quiescent ulcerative colitis aside from patients enrolled in controlled clinical trials. We conducted a prevalence study to determine the medication adherence rate of maintenance therapy and to identify possible risk factors for nonadherence. METHODS: Outpatients with clinically quiescent ulcerative colitis for >6 months on maintenance mesalamine (Asacol, Procter and Gamble, Cincinnati, OH) were eligible. Patients were interviewed regarding disease history, and demographics were obtained from medical records. Refill information for at least 6 months was obtained from computerized pharmacy records. Adherence was defined as at least 80% consumption of supply dispensed. Using nonadherence as the outcome of interest, stratified analysis and regression modeling were used to identify significant associations. RESULTS: Data were complete for the 94 patients recruited. The overall adherence rate was found to be 40%. The median amount of medication dispensed per patient was 71% (8-130%) of the prescribed regimen. Nonadherent patients were more likely to be male (67% vs 52%, p < 0.05), single (68% vs 53%, p = 0.04), and to have disease limited to the left side of the colon versus pancolitis (83% vs 51%, p < 0.01). Sixty-eight percent of patients who took more than four prescription medications were found to be nonadherent versus only 40% of those patients taking fewer medications (p = 0.05). Age, occupation, a family history of inflammatory bowel disease, length of remission, quality-of-life score, or method of recruitment (telephone interview vs clinical visit) were not associated with nonadherence. Logistic regression identified that a history of more than four prescriptions (odds ratio [OR] 2.5 [1.4-5.7]) and male gender (OR 2.06 [1.17-4.88]) increased the risk of nonadherence. Two statistically significant variables, which were protective against nonadherence, were endoscopy within the past 24 months (OR 0.96 [0.93-0.99]) and being married (OR 0.46 [0.39-0.57]). CONCLUSION: Nonadherence is associated with multiple concomitant medications, male gender, and single status. These patient characteristics may be helpful in targeting those patients at higher risk for nonadherence.

Differential fear of cardiopulmonary sensations in emergency room noncardiac chest pain patients.

Fear of bodily sensations has received extensive attention in relation to panic disorder, and more recently, other types of anxiety pathology and chronic pain problems. Extending this work, the present study examined fear of bodily sensations and its underlying dimensions in emergency room patients with Noncardiac Chest Pain (NCCP; n = 63). We posited a "differential specificity" hypothesis, expecting that specific cardiopulmonary fears would be more strongly associated with NCCP symptoms relative to other bodily fears. As hypothesized, participants reported cardiopulmonary sensations as significantly more fear-provoking than numbness, dissociation, and gastrointestinal sensations. Additionally, regression analysis indicated that after accounting for theoretically relevant demographic variables and health status, cardiopulmonary fear was the best predictor of a composite index of cardiac complaints intensity, even after removing variance related to the absolute number of cardiac complaints. We discuss these findings in relation to the specific role for the fear of cardiopulmonary sensations in chest pain complaints, with implications for better understanding the underlying psychological processes involved in NCCP.

Development of the diabetes problem-solving measure for adolescents.

PURPOSE: This paper describes the development and psychometric properties of the Diabetes Problem-Solving Measure for Adolescents (DPSMA). METHODS: The DPSMA is a structured, interview-based questionnaire that examines how adolescents with type 1 diabetes solve diabetes-related self-management problems. Seventeen diabetes-related self-management problem vignettes were derived from a survey of adolescents and their parents. The vignettes were reviewed and finalized by a multidisciplinary team of diabetes experts. A sample of 43 adolescents, 13 to 17 years old, with type 1 diabetes, was used to establish the psychometric properties of the instrument. RESULTS: The scale demonstrated acceptable internal consistency and interrater reliability. Predicted relationships with scores on concurrently administered measures of adherence, diabetes quality of life, and metabolic control provided support for construct validity. CONCLUSIONS: The results suggest that the DPSMA has acceptable internal consistency, interrater reliability, and construct validity. It may be a useful tool to help healthcare providers understand the diabetes-related problem-solving abilities of their adolescent patients.

Sildenafil in the treatment of erectile dysfunction after radical prostatectomy.

OBJECTIVES: To evaluate the efficacy of sildenafil for the treatment of erectile dysfunction after radical prostatectomy and to determine whether age, preservation of the neurovascular bundles (NVBs), or the interval between surgery and the initiation of sildenafil therapy influences the response to sildenafil. METHODS: We began this study in April 1998, immediately after the Food and Drug Administration approved sildenafil. We surveyed 170 men who had undergone radical retropubic prostatectomy, had not recovered natural erections sufficient for intercourse, and subsequently received sildenafil between 3 and 24 months postoperatively. The data were collected through a confidential mail survey conducted by a clinical nurse. The men used a dose of 50 mg sildenafil and increased this to 100 mg if they did not obtain an adequate response. RESULTS: In the 120 men who began taking sildenafil at least 12 months after surgery, the overall response rate was 29%. Results varied markedly by patient age and number of NVBs preserved. In men younger than 55 years in whom both NVBs had been preserved, the response rate was 80%. In contrast, no patient older than 55 years in whom only one NVB had been preserved reported an adequate response. Regardless of age, no patient in whom both NVBs had been excised reported success with sildenafil. Of the 50 patients who began taking sildenafil less than 9 months after surgery and who had not recovered natural sexual function, none reported erections adequate for intercourse using sildenafil. CONCLUSIONS: Sildenafil is an effective treatment for men with erectile dysfunction after radical retropubic prostatectomy, particularly in younger men in whom both NVBs have been preserved. It is ineffective in men in whom both NVBs have been excised, and it is also ineffective in older men in whom only one NVB has been preserved. Sildenafil appears ineffective in the first 9 months after prostatectomy.

Sleep latency and duration estimates among sleep disorder patients: variability as a function of sleep disorder diagnosis, sleep history, and psychological characteristics.

STUDY OBJECTIVES: Insomnia patients often report greater sleep disturbance than found via polysomnography; yet the specific patient factors related to such sleep time misperceptions are poorly understood. We sought to characterize the extent to which a diverse group of patients complaining of insomnia (n=104) misperceive overnight total sleep time and sleep latency, and to identify patient factors associated with these variations. DESIGN: Cross-sectional. SETTING: University based sleep disorders center. PATIENTS: Sleep disorder groups consisted of patients with psychophysiological insomnia (n=19), sleep state misperception (n=8), insomnia with depressive disorder (n=11), insomnia secondary to Axis I psychiatric disorder other than depression (n=21), periodic limb movement disorder (n=24), and obstructive sleep apnea (n=21). MEASUREMENT AND RESULTS: Patients completed a sleep history questionnaire and the MMPI, underwent overnight diagnostic polysomnographic assessment, and then estimated their total sleep time and sleep latency the subsequent morning. On average, patients overestimated sleep latency, but were equally likely to underestimate vs. overestimate total sleep time. Sleep time misperception was associated with longer periods of wakefulness following sleep onset, greater self-perceived sleep impairment, as well as several psychological dimensions. CONCLUSIONS: Patient factors, including sleep quality, perceptions of habitual sleep time, and current psychopathology, potentially influence sleep time estimation. Whereas psychological factors may lead to exaggeration of sleep disturbance among some patients, sleep quality itself may also influence the congruence between subjective and objective indices of sleep.

The peterborough hospital human tissue bank.

The Peterborough Hospital Human Tissue Bank, based in the Cellular Pathology Department of the District Hospital, has been successful in supplying commercial biomedical companies with human tissue for research purposes. Tissue is obtained from routine surgical specimens sent to the laboratory for diagnostic testing and from cadaveric donors examined in the hospital mortuary. All tissue is obtained legally and with the full informed consent of the patient, donor or relative, as appropriate. The mechanism of retrieving, storing and supplying human tissue is described. In publishing the activities of the tissue bank at Peterborough, we wish to encourage others to consider the availability of human tissue in their locality. We recommend a strict legal and ethical code, particularly in relation to fully informed consent.

Visualization of enzyme-catalyzed reactions using pH indicators: rapid screening of hydrolase libraries and estimation of the enantioselectivity.

The use of pH indicators to monitor hydrolase-catalyzed reactions is described. The formation of acid following an enzyme-mediated hydrolysis causes a drop in the pH that can be visualized by a change in the color of the indicator-containing solution. The best indicators are those showing a color transition within the operational pH range of the hydrolases, like bromothymol blue and phenol red. The enantioselectivity of lipases and esterases can be estimated using single isomers under the same conditions and comparing the color turnover for each one. The method has been tested to quickly evaluate the enantioselectivity of a lipase towards a set of ester substrates and applied to the hierarchical screening of a library of thermophilic esterases.

Differential rates of psychopathology symptoms in periodic limb movement disorder, obstructive sleep apnea, psychophysiological insomnia, and insomnia with psychiatric disorder.

STUDY OBJECTIVE: To determine patterns and relative intensity of psychopathology, as measured by the Minnesota Multiphasic Personality Inventory (MMPI), in 108 patients with either psychophysiological insomnia (PI; n=20), insomnia with psychiatric disorder (IPD; n=30), periodic limb movement disorder (PLM; n=28), or obstructive sleep apnea (OSA; n=30). DESIGN: Cross-sectional. SETTING: University sleep disorders center. MEASUREMENTS AND RESULTS: Subjects completed the MMPI prior to overnight diagnostic polysomnographic assessment followed by Multiple Sleep Latency Test (MSLT). Seventy five percent of the entire sample had at least one MMPI elevation (T>70). Groups showed significant baseline differences in age, BMI, and MSLT latency (all ps<.05). Logistic regression indicated that even after statistically controlling for these three diagnostic covariates, MMPI elevation was more likely among PLM and IPD patients than OSA or PI patients (all ps<.05). Followup pairwise comparisons indicated that this same pattern of group differences occurred for the Depression, Psychasthenia, and Schizophrenia scales (all ps<.05). CONCLUSIONS: Irrespective of age, obesity, and daytime sleepiness, patients with untreated PLM or IPD are more likely to experience clinically significant psychological difficulties than those with either OSA or PI. These differences are most likely to be manifested in terms of depressive symptoms, anxiety symptoms (tension, worry, guilt), social alienation, and diminished mental concentration. Finally, PLM may be associated with greater MMPI elevations than previously suspected, and agree with earlier clinical reports of high rates of psychiatric treatment in PLM.

Assessing depressive symptoms in multiple sclerosis: is it necessary to omit items from the original Beck Depression Inventory?

Overlap between depression scale item content and medical symptoms may exaggerate depression estimates for patients with multiple sclerosis (MS). We reconsider Mohr and co-workers' (1997) recommendation to omit Beck Depression Inventory (BDI) items assessing work ability (item 15), fatigue (17), and health concerns (20) for MS patients. Subjects were medical patients with either MS (n = 105) or a medical disorder for which the BDI is empirically supported [diabetes mellitus (DM), n = 71; chronic pain (CP), n = 80], psychiatric patients with depressive disorder (MDD; n = 37), and healthy controls (HC; n = 80). Relative scores for the eight "somatic" BDI items were analyzed by multivariate analysis of variance with demographic variables and BDI total as covariates. The only significant difference was MS > HC (item 15). On raw scores, MS patients exceeded HCs on items 15 and 21 (sexual disinterest), but this was attributable to the low HC item endorsement. There were no other differences on somatic items or item-total correlations. Scale consistency was good across groups, regardless of item omission. Somatic items were unassociated with major MS parameters. We thus encourage continued application of the full BDI for assessing depressive symptoms in patients with MS.

Thermal biofeedback for claudication in diabetes: a literature review and case study.

Temperature biofeedback (TBFB) is designed to alter cutaneous temperature in treated extremities by providing information corresponding to minor temperature fluctuations in the context of therapeutic structure and reinforcement. Toe TBFB may improve vascular flow and walking tolerance in patients with peripheral vascular disease. This case study documents improved walking in a diabetes patient with lower extremity complications, and suggests TBFB might increase lower extremity temperature and blood flow volume pulse in uncomplicated diabetes. Ankle-brachial index (ABI) and walking function were assessed in a 60-year-old woman with type 2 diabetes and intermittent claudication, before and after five sessions of TBFB applied to the ventral surface of the great toe. Toe temperature increased during feedback phases but not during baseline phases. Improvements were seen in ankle-brachial index, walking distance, walking speed, and stair climbing. This case indicates the need for extended and controlled study of TBFB for improved vascular and ambulatory function in diabetic claudication.

A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea.

STUDY OBJECTIVE: To compare the MMPI responses between nonapneic primary snoring (PS) and obstructive sleep apnea (OSA). DESIGN: Cross sectional with matched samples. SETTING: University sleep disorders center. PATIENTS: All PS patients (n = 49) available in a series of 428 clinical referrals to a sleep disorders center, and age and gender-matched OSA patients (n = 49) selected from the 199 available OSA patients in the series. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Subjects completed the MMPI prior to overnight diagnostic polysomnographic assessment and multiple sleep latency test (MSLT). OSA patients exhibited a mean of 2.3 elevated MMPI scales, which was significantly more than the PS mean of 1.6 elevations, and attributable to higher OSA scores on Depression (D) and Hypochondriasis (Hs). Approximately twice as many OSA patients than PS patients showed disturbed scores on D (49% vs. 25%, p < .05) and Hy (35% vs. 16%, p < .05). On nine of the ten MMPI clinical scales, both patient groups exceeded the elevation rate expected in nondistressed individuals. Among OSA patients, but not PS patients, number of MMPI elevations had a significant negative correlation with sleep efficiency and average blood saturation during NREM, and a significant positive correlation with wake time after sleep onset. CONCLUSIONS: Compared to patients with PS, those with OSA have more intense depressive symptoms (e.g., pessimism, inactivity, guilt) and somatic concerns. General psychopathology is associated with blood oxygen saturation only among OSA patients. Nonetheless, PS patients show psychological maladjustment that is qualitatively similar, but quantitatively less severe, than that characterizing OSA.

MMPI correlates of sleep and respiratory disturbance in obstructive sleep apnea.

STUDY OBJECTIVE: To evaluate associations between polysomnographic variables in obstructive sleep apnea (OSA) and a variety of psychological responses (including depressive symptoms) as assessed by the Minnesota Multiphasic Personality Inventory (MMPI). DESIGN: Cross-sectional. SETTING: University sleep disorders center. PATIENTS: One-hundred seventy eight consecutive clinical OSA patients. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Patients completed the MPI prior to overnight diagnostic polysomnography. Fifty-eight percent demonstrated at least one MMPI elevation (mean = 1.8 elevations), with Depression (D) elevated for 32%, Hypochondriasis (Hs) for 30%, and Hysteria (Hy) for 21%. Thirty-eight percent demonstrated two or more elevations, with several variations of Hs-D and Hs-D-Hy configurations evident. "Conversion V" profiles were fairly rare, and a large number of miscellaneous configurations occurred once. Significant correlations were detected between several MMPI scale scores and total sleep time, the apnea-hypopnea index (AHI) during REM, and particularly arterial oxygen saturation, even when partialling out variance related to body mass index (BMI). In contract, D scores were not correlated with any polysomnographic parameters. Based upon MMPI configuration, the sample was subdivided into the following seven profile groups: Nonelevated (n = 74); Single D (n = 11); Single non-D (n = 25); Combined D plus (a) HS or HY (n = 7), (b) Hs and Hy (n = 10), or (c) other (n = 29); and Multiple non-D (n = 22). Multivariate analysis controlling for age and gender indicated higher AHI in the Single non-D, Combined D plus other, and Multiple non-D groups, compared to the Single D group. Also, there was lower average oxygen saturation in the Multiple non-D group, compared to Single D, Single non-D, and Nonelevated groups. The Combined D plus HS and/or Hy groups did not differ from each other or from other groups, even when merged. The Multiple non-D findings were unattributable to any specific scale or overall number of elevations. CONCLUSIONS: OSA patients who have core depressive symptoms (as measured by MMPI scale D) without significant psychological symptoms in other areas tend to have less severe OSA, whereas those with a diverse set of other psychological symptoms overshadowing depressive symptoms (e.g., somatic focus, emotional reactivity, family/marital problems, cognitive problems, etc.) tend to have greater AHI and lower oxygen saturation. Although it seems probable that these MMPI differences primarily reflect OSA effects, prospective research is needed to confirm this hypothesis.

Cardiac exposure history as a determinant of symptoms and emergency department utilization in noncardiac chest pain patients.

Although comparative studies differentiate noncardiac chest pain (NCCP), panic disorder, and coronary artery disease (CAD), little research has examined the defining features of NCCP, such as cardiac complaints, medical utilization, and learning history. We administered self-report measures to 80 Emergency Department (ED) patients with a primary complaint of chest pain who were subsequently found to not have CAD. Forty-eight percent of the ED utilization variance was accounted for by NCCP duration, age, cardiac distress symptoms, and prior exposure to both siblings' and friends' cardiac distress symptoms. In turn, 67% of the variance in cardiac distress symptoms was explained by education, age, NCCP duration, number of illnesses, noncardiac panic symptoms, prior exposure (friends), and prior observation of others' cardiac distress. No effects emerged for gender, ethnicity, avoidance, or depression. Results suggest that beyond the effects of age and distress intensity, prior exposure to other people's cardiac distress may influence NCCP.

Prevalence of somatic indicators of distress in diabetes patients: comparison to psychiatric patients and community nonpatients.

OBJECTIVE: Because psychiatric screening methods are usually developed using psychiatric samples but not medical samples, they often include distress indicators that overlap with medical illness. This potentially inflates psychopathology estimates for medically ill patient groups. The objective of this study was to determine whether somatic distress indicator base rates are elevated in diabetes patients. METHOD: The occurrence of Symptom Checklist 90-R (SLC-90-R) somatic symptoms was studied in fifty-six diabetes mellitus patients (27 insulin dependent, 29 non-insulin dependent) with non-elevated SLC-90-R profiles, as compared to both community nonpatient and psychiatric patient norms. RESULTS: Of the fifteen SCL-90-R items rated by endocrinologists as most likely to be diabetes-related, nine were endorsed more frequently by diabetes patients than by nonpatients: faintness/dizziness (endorsed by 36% of diabetics), reduced libido (endorsed by 41%), anenergia (68%), memory problems (66%), trembling (18%), numbness (55%), weakness (39%), overeating (59%), and somatic concerns (41%). Anergia and faintness/dizziness were endorsed more frequently by psychiatric patients than diabetes patients, whereas numbness was endorsed more often by diabetes patients. CONCLUSIONS: Conservatism is warranted when applying these somatic indicators of distress to diabetes patients. Further studies are needed to determine whether such illness overlap biases case classification.

Daily activity level buffers stress-glycemia associations in older sedentary NIDDM patients.

Examined glycemic associations with medical variables, activity, daily stress, and mood state in 72 older patients with non-insulin-dependent diabetes mellitus (NIDDM). On three occasions over a 2-week observation period, subjects provided measures of everyday life stress, negative mood state, and daily activities. At the end of this period, fructosamine was assayed to measure glycemic control throughout the assessment period. After controlling for medical variables (age, illness duration, body mass index, caloric intake, and activity) and the main effects of psychological factors (stress; anxious, angry, and depressed mood states), stress interacted with activity such that glycemic elevation was positively associated with stress for subjects below the activity median but not for those above the median. This was unattributable to any overall activity-related differences in fructosamine, stress, or mood. None of the mood states interacted with activity. The findings suggest that extremely low levels of activity may strengthen life stress-glycemia associations in NIDDM.

Elevated glycosylated albumin in NIDDM is a function of recent everyday environmental stress.

OBJECTIVE: To evaluate the association of recent daily environmental stress (daily hassles) with glycemia in NIDDM. RESEARCH DESIGN AND METHODS: Fifty-five NIDDM patients reported the number and intensity of daily hassles occurring during the past week and concurrently underwent glycemic assessment. RESULTS: Hassles were generally unassociated with demographic variables, illness duration, treatment regimen, and the presence of complications. Multiple regression analysis indicated that hassles (in both frequency and intensity) were positively associated with recent glycemia (glycosylated albumin [GA]), even after statistically controlling for long-term glycemia (glycosylated hemoglobin [HbA(1c)]). The subtypes of hassles having the most potent relationships with GA were work and family/friend-related stressors. CONCLUSIONS: The frequency and perceived impact of everyday minor stress have proximal positive associations with glycemia that do not necessarily reflect chronic hyperglycemia. Stress arising from work and family/friend sources may be particularly relevant.

Psychological predictors of glycemic change with relaxation training in non-insulin-dependent diabetes mellitus.

BACKGROUND: Previous findings are unclear regarding the possible glycemic benefits of applying behavioral relaxation training in non-insulin-dependent diabetes mellitus (NIDDM). METHODS: Subjects with NIDDM were randomized to relaxation training (6 sessions of progressive muscle relaxation and imagery, n = 12) or control treatment (routine medical care, n = 10). Physiological measures were total glycosylated hemoglobin (GHb) and area under the 2-hour oral-glucose-tolerance curve (AUC). Psychological measures of generalized distress, anxiety and daily stress were also administered. All subjects were assessed before and after the 8-week intervention, and again at 16 weeks of long-term follow-up. RESULTS: There were no postintervention group differences in physiological variables. Highly distressed subjects and those who rated their glucose as more stress responsive tended to practice relaxation less between sessions. Within the treated group only, lower preintervention stress responsivity was associated with greater improvement in GHb, and lower anxiety and distress levels predicted long-term improvement in AUC. CONCLUSIONS: It remains unclear whether relaxation training produces glycemic benefits in NIDDM. Perhaps the least anxious and stress-responsive patients only benefit from group-based relaxation training, whereas anxious individuals require intensive individually administered interventions.