Stress Control: A Controlled Comparative Investigation of Large Group Therapy for Generalized Anxiety Disorder

Increased Risk of Generalized Anxiety Disorder According to Frequent Sedentary Times Based on the 16th Korea Youth Risk Behavior Web-Based Survey

This study aimed to identify the association between sedentary behavior and anxiety disorders in 53,510 Korean adolescents. It analyzed data from the 16th (2020) Korea Youth Risk Behavior Web-based Survey (KYRBS). The dependent variable was the generalized anxiety disorder-7 (GAD-7). The GAD-7 scores were divided into normal, mild, moderate, and severe levels. The independent variables were sedentary time for learning, other sedentary times, total sedentary time, and regular physical activity. The confounding variables were sex, grade, stress, depression, substance abuse, suicidal thoughts, violent victimization, drinking, smoking, sleep satisfaction, and smartphone addiction. A chi-squared test, one-way analysis of variance, and logistic regression analysis were used for analysis. After adjusting for all confounding variables, the risk of severe level in GAD-7 increased by 1.045 times each time the sedentary time for learning based on increased by one hour. In other sedentary time and total sedentary time, the risk of severe level in GAD-7 increased by 1.025 times and 1.045 times per hour, respectively. However, in regular physical activity, after adjusting for the confounding variables, there was no significant association with the GAD-7 levels. Therefore, to prevent generalized anxiety disorders in Korean adolescents, it is necessary to reduce the overall sedentary times including sedentary time for learning.

A Psychoeducational CBT-based Group Intervention ("Drop It") for Repetitive Negative Thinking: Theoretical Concepts and Treatment Processes

Repetitive negative thinking (RNT)-such as worry and rumination-is an important transdiagnostic factor in the onset, course, and recurrence of depressive and anxiety disorders. This article describes a psychoeducational cognitive behavioral therapy (CBT)-based group intervention entitled "Drop It" that focuses exclusively on treating RNT in patients with major depressive disorder and/or generalized anxiety disorder. The theoretical concepts and treatment goals of the intervention are outlined. The organization and therapeutic processes of the different sessions are described and illustrated with statements of participants. Special attention is given to how the intervention capitalizes on the group structure and process to maximize the effectiveness of psychoeducation and CBT-based techniques. We also provide practical guidelines for clinicians treating patients with RNT.

Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis

OBJECTIVES

This review sought to evaluate the effectiveness of the 'Stress Control' (SC) large psychoeducational 6-session group programme developed to increase access to treatment for patients with anxiety and depression.

DESIGN

Systematic review and meta-analysis (Prospero registration: CRD42020173676).

METHODS

Pre-post and post-treatment follow-up effect sizes were extracted and synthesized in a random effects meta-analysis, and variations in effect sizes were investigated via moderator analyses. Secondary analyses synthesized between-group effect sizes from controlled studies containing comparator treatments and calculated the average dropout rate. The quality of the meta-analysis was assessed using the GRADE approach.

RESULTS

Nineteen studies with pre-post treatment outcomes were included. The average group size was N = 39, and the average dropout rate was 34%. Pooled effect sizes indicated moderate pre-post treatment reductions in anxiety (ES = 0.58; CI 0.41 to 0.75; N = 5597; Z = 7.13; p < .001), moderate reductions in depression (ES = 0.62; CI 0.44 to 0.80; N = 5538, Z = 7.30; p < .001), and large reductions in global distress (ES = 0.86; CI 0.61 to 1.11; N = 591; Z = 7.41; p < .001). At follow-up, improvements in anxiety, depression, and global distress were maintained. When SC was compared to active and passive controls, outcomes were equivalent for anxiety (ES = 0.12, 95% CI -0.25 to 0.49, Z = -0.70; p = .482) and depression (ES = 0.15, 95% CI -0.24 to 0.54, Z = 0.84; p = .401).

CONCLUSIONS

SC appears to be a clinically effective and durable low-intensity group intervention that facilitates access to treatment for large patient numbers. However, conclusions are limited by the low methodological quality of the evidence.

PRACTITIONER POINTS

The stress control version of large group psychoeducation is appropriate and effective for mild-to-moderate anxiety and depression The evidence base for stress control is predominantly made up of practice-based studies Stress control needs to form one component of the overall offer made to patients presenting with mild-to-moderate anxiety and depression The competencies required to deliver such groups need better specification.

The impact of a Stress Control course delivered in partnership with a sports organisation on mental health outcomes in a general population

Mental health problems have a significant impact globally in terms of social and economic costs. Increasing access to and uptake of mental health interventions (particularly by men) remains a challenge for service providers. The current study sought to examine the efficacy of a delivering a Stress Control intervention in partnership with a community sporting organisation (the Gaelic Athletic Assocaition, GAA) in ameliorating mental health difficulties in a general population. Measures of anxiety, depression and quality of life were administered before and after the delivery of the 6-week programme. A focus group was conducted afterwards to gather qualitative data on participants’ experiences of the intervention. Statistically significant decreases in depression scores were found following attendance at the course: t (94) = 3.14, p = .002, with a large effect size (0.5) (n = 95). There was an increase in the number of male attendees compared with clinic-based courses. Thematic analysis of the focus group data revealed a number of key themes including increased accessibility in terms of the scale and context of the delivery of the course. Delivering large-scale psychoeducational courses like Stress Control in partnership with the GAA represents a promising avenue for increasing access (for males in particular) to an effective intervention for improving mental health outcomes

Key learning aims

(1)

Preventing depression in the community by voluntary sector providers (PERSUADE): intervention development and protocol for a parallel randomised controlled feasibility trial

INTRODUCTION

Depression is now the most common illness worldwide affecting more than 300 million people. Studies modelling the impact of depression interventions have shown that the burden of depression cannot be minimised by more than 35% with existing treatments. There is a need to develop better preventative interventions. The overall aim of this programme of work is to develop interventions to reduce depression symptom scores and prevent development of depression in people with subthreshold depression. The objectives are to adapt a low intensity community-based depression prevention intervention, establish the acceptability and uptake of this model and conduct a parallel randomised controlled feasibility trial to inform a full-scale trial.

METHODS AND ANALYSIS

Focus groups will be run with members of the public, voluntary sector providers and researchers to inform the adaptation of an existing depression prevention course. Sixty-four people with subthreshold depression, as represented by a score of between 5 and 9 on the Patient Health Questionnaire-9 depression measure, will be recruited to take part in the feasibility trial. Participants will be randomised equally to the intervention or usual care control groups. Participants in the intervention group will receive the new revised manual and attend a 1-day workshop delivered by voluntary sector service providers. Outcome measures will be completed 3 months after baseline. Quantitative data on recruitment, randomisation, attendance, retention, questionnaire completion rates will be collected. Primary analyses will be descriptive and a process evaluation will be conducted to assess the processes involved in implementing the intervention. Interviews will be conducted to explore acceptability and framework analysis will be used to analyse the data.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by NHS Research and Ethics Committee: NW-Greater Manchester East. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, the internet and community engagement activities.

TRIAL REGISTRATION NUMBER

ISRCTN23278208;Pre-results.

Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials

The purpose of this meta-analysis was to provide updated pooled effect sizes of evidence-based psychotherapies and medications for generalized anxiety disorder (GAD) and to investigate potential moderators of outcomes. Seventy-nine randomized controlled trials (RCT) including 11,002 participants with a diagnosis of GAD were included in a meta-analysis that tested the efficacy of psychotherapies or medications for GAD. Psychotherapy showed a medium to large effect size (g = 0.76) and medication showed a small effect size (g = 0.38) on GAD outcomes. Psychotherapy also showed a medium effect on depression outcomes (g = 0.64) as did medications (g = 0.59). Younger age was associated with a larger effect size for psychotherapy (p < 0.05). There was evidence of publication bias in psychotherapy studies. This analysis found a medium to large effect for empirically supported psychotherapy interventions on GAD outcomes and a small effect for medications on GAD outcomes. Both groups showed a medium effect on depression outcomes. Because medication studies had more placebo control conditions than inactive conditions compared to psychotherapy studies, effect sizes between the domains should not be compared directly. Patient age should be further investigated as a potential moderator in psychotherapy outcomes in GAD.

Experiences of a transdiagnostic group, the Take Control Course, for clients with common mental health problems: A qualitative study

OBJECTIVES

Despite the promising effectiveness findings for transdiagnostic groups, studies have not explored clients' experiences. There is a risk that clients could perceive that the content of transdiagnostic groups is not sufficiently tailored to their specific problems. Our aims were to examine whether a brief transdiagnostic group, the Take Control Course (TCC), was acceptable to participants and to explore participants' perceptions of psychological change.

METHODS

Qualitative data were collected via 12 semistructured, in-depth interviews. Data collection and thematic analysis were concurrent and iterative.

RESULTS

Three superordinate themes were identified: "Style and format," "Control and flexibility," and "Change." The flexible group format was appreciated, as participants felt able to engage at their own pace and adapt relevant aspects. Greater clarity regarding what was within participants' control reduced distress and enabled effective pursuit of valued goals. Participants described significant (predominantly gradual) changes, including substantial improvements within relationships.

CONCLUSIONS

The transdiagnostic format did not prevent participants experiencing the TCC as individually relevant. The flexibility and consistent theoretical framework seemed to contribute to this. The results indicated that greater consideration of control and mindfulness allowed greater cognitive flexibility, an ability to reprioritize and let go of unhelpful habits, which better enabled participants to meet their goals. Implications for group therapy include (a) clearly explaining the format of such groups to clients and (b) providing flexibility in the way the group is delivered where possible. Additional qualitative studies of transdiagnostic groups are required to establish if themes generalize to other transdiagnostic groups.

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership.

Group cognitive–behavioural therapy for anxiety and depression

Cognitive–behavioural therapy (CBT) is a psychological treatment approach that can be delivered not only on a one-to-one basis but also to groups and in self-help formats. However, the evidence base supporting individual CBT is more extensive than the research regarding group CBT. This is likely to influence the choice of services that develop in the Improving Access to Psychological Therapies (IAPT) programme for the treatment of depression and anxiety disorders in primary care in England. This article outlines the different forms that group CBT takes, the way in which it may benefit people and the current evidence base supporting its use for anxiety and depression. It also outlines the advantages of group or individual CBT and describes those patients who appear to be best suited to a specific delivery.

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck's cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.

Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis

Although cognitive and behavioral therapies are effective in the treatment of anxiety disorders, it is not clear what the relative effects of these treatments are. We conducted a meta-analysis of trials comparing cognitive and behavioral therapies with a control condition, in patients with social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder. We included 42 studies in which generic measures of anxiety were used (BAI, HAMA, STAI-State and Trait). Only the effects of treatment for panic disorder as measured on the BAI (13.33 points; 95% CI: 10.58-16.07) were significantly (p=0.001) larger than the effect sizes on GAD (6.06 points; 95% CI: 3.96-8.16) and SAD (5.92 points; 95% CI: 4.64-7.20). The effects remained significant after adjusting for baseline severity and other major characteristics of the trials. The results should be considered with caution because of the small number of studies in many subgroups and the high risk of bias in most studies.

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

We report the current best estimate of the effects of cognitive behavior therapy (CBT) in the treatment of major depression (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD), taking into account publication bias, the quality of trials, and the influence of waiting list control groups on the outcomes. In our meta-analyses, we included randomized trials comparing CBT with a control condition (waiting list, care-as-usual or pill placebo) in the acute treatment of MDD, GAD, PAD or SAD, diagnosed on the basis of a structured interview. We found that the overall effects in the 144 included trials (184 comparisons) for all four disorders were large, ranging from g=0.75 for MDD to g=0.80 for GAD, g=0.81 for PAD, and g=0.88 for SAD. Publication bias mostly affected the outcomes of CBT in GAD (adjusted g=0.59) and MDD (adjusted g=0.65), but not those in PAD and SAD. Only 17.4% of the included trials were considered to be high-quality, and this mostly affected the outcomes for PAD (g=0.61) and SAD (g=0.76). More than 80% of trials in anxiety disorders used waiting list control groups, and the few studies using other control groups pointed at much smaller effect sizes for CBT. We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution.

“Stress Control” as a Large Group Psychoeducational Intervention at Step 2 of IAPT Services: Acceptability of the Approach and Moderators of Effectiveness

Background:“Stress Control” (SC) has been adopted as a core intervention in step 2 of Improving Access to Psychological Therapies (IAPT) services, but contemporary evidence of effectiveness has lagged behind service uptake.Aims:To investigate the acceptability and effectiveness of SC and to explore moderators of outcome.Method:Analysis of acceptability (via attendance rates) and effectiveness (via IAPT minimum dataset).Results:SC was well tolerated with 73.3% of all patients and 75.4% of “clinical cases” attending three or more sessions. Of the 546 “clinical cases” attending SC and not in receipt of other interventions, 37% moved to recovery. Attendance improved outcome; for those patients attending all SC sessions the recovery rate rose to 59.2%.Conclusion:SC appears a well-tolerated and effective intervention that enables large numbers to gain access to treatment in an organizationally efficient manner. Attendance is important in facilitating SC outcomes and research evaluating attendance interventions are needed.

One-day cognitive-behavioural therapy self-confidence workshops for people with depression: randomised controlled trial

BACKGROUND

Despite its high prevalence, help-seeking for depression is low.

AIMS

To assess the effectiveness and cost-effectiveness of 1-day cognitive-behavioural therapy (CBT) self-confidence workshops in reducing depression. Anxiety, self-esteem, prognostic indicators as well as access were also assessed.

METHOD

An open randomised controlled trial (RCT) waiting list control design with 12-week follow-up was used (trial registration: ISRCTN26634837). A total of 459 adult participants with depression (Beck Depression Inventory (BDI) scores of ≥ 14) self-referred and 382 participants (83%) were followed up.

RESULTS

At follow-up, experimental and control participants differed significantly on the BDI, with an effect size of 0.55. Anxiety and self-esteem also differed. Of those who participated, 25% were GP non-consulters and 32% were from Black and minority ethnic groups. Women benefited more than men on depression scores. The intervention has a 90% chance of being considered cost-effective if a depression-free day is valued at £14.

CONCLUSIONS

Self-confidence workshops appear promising in terms of clinical effectiveness, cost-effectiveness and access by difficult-to-engage groups.

Psychological treatment of generalized anxiety disorder: a meta-analysis

Recent years have seen a near-doubling of the number of studies examining the effects of psychotherapies for generalized anxiety disorder (GAD) in adults. The present article integrates this new evidence with the older literature through a quantitative meta-analysis. A total of 41 studies (with 2132 patients meeting diagnostic criteria for GAD) were identified through systematic searches in bibliographical databases, and were included in the meta-analysis. Most studies examined the effects of cognitive behavior therapy (CBT). The majority of studies used waiting lists as control condition. The pooled effect of the 38 comparisons (from 28 studies) of psychotherapy versus a control group was large (g=0.84; 95% CI: 0.71-0.97) with low to moderate heterogeneity. The effects based on self-report measures were somewhat lower than those based on clinician-rated instruments. The effects on depression were also large (g=0.71; 95% CI: 0.59-0.82). There were some indications for publication bias. The number of studies comparing CBT with other psychotherapies (e.g., applied relaxation) or pharmacotherapy was too small to draw conclusions about comparative effectiveness or the long-term effects. There were some indications that CBT was also effective at follow-up and that CBT was more effective than applied relaxation in the longer term.

Study protocol: evaluation of a parenting and stress management programme: a randomised controlled trial of Triple P Discussion Groups and Stress Control

BACKGROUND

Children displaying psychosocial problems are at an increased risk of negative developmental outcomes. Parenting practices are closely linked with child development and behaviour, and parenting programmes have been recommended in the treatment of child psychosocial problems. However, parental mental health also needs to be addressed when delivering parenting programmes as it is linked with parenting practices, child outcomes, and treatment outcomes of parenting programmes. This paper describes the protocol of a study examining the effects of a combined intervention of a parenting programme and a cognitive behavioural intervention for mental health problems.

METHODS/DESIGN

The effects of a combined intervention of Triple P Discussion Groups and Stress Control will be examined using a randomised controlled trial design. Parents with a child aged 3-8 years will be recruited to take part in the study. After obtaining informed consent and pre-intervention measures, participants will be randomly assigned to either an intervention or a waitlist condition. The two primary outcomes for this study are change in dysfunctional/ineffective parenting practices and change in symptoms of depression, anxiety, and stress. Secondary outcomes are child behaviour problems, parenting experiences, parental self-efficacy, family relationships, and positive parental mental health. Demographic information, participant satisfaction with the intervention, and treatment fidelity data will also be collected. Data will be collected at pre-intervention, mid-intervention, post-intervention, and 3-month follow-up.

DISCUSSION

The aim of this paper is to describe the study protocol of a randomised controlled trial evaluating the effects of a combined intervention of Triple P Discussion Groups and Stress Control in comparison to a waitlist condition. This study is important because it will provide evidence about the effects of this combined intervention for parents with 3-8 year old children. The results of the study could be used to inform policy about parenting support and support for parents with mental health problems.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT01777724, UTN: U1111-1137-1053.

Nonpharmacological treatments for anxiety disorders

An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.

Delivering group psychoeducational CBT in Primary Care: Comparing outcomes with individual CBT and individual psychodynamic-interpersonal psychotherapy

Within psychological services in Primary Care, service providers are expected and required to deliver clinical services that are prompt, safe and effective. However, long wait-times for treatment are common, with attendant clinical chronicity and risk issues. Evaluations of group-based treatments in Primary Care, which are clinically more efficient than individual treatments, are extremely scarce. The current evaluation attempted to appraise the effectiveness of a service innovation of introducing group-based psychoeducational cognitive-behaviour therapy (CBT; N=43), by comparing outcomes with clients treated in individual CBT (N=68) and individual psychodynamic-interpersonal psychotherapy (N=65). Group psychoeducational participants completed validated scales of psychological functioning (Beck Depression Inventory - 2, BDI-2; Brief Symptom Inventory, BSI; Inventory of Interpersonal Problems, IIP-32; and General Health Questionnaire, GHQ-12) at assessment, start of group, termination of group and 3-month follow-up, whereas participants in the individual therapies completed measures only at initiation and termination of treatment. The results indicate broad similarities between the outcomes achieved by the three services, with rates of clinically significant improvements and deteriorations comparable in the main across services. The results are discussed in terms of identified methodological limitations, service implications and models of service delivery for the psychological therapies in Primary Care.

Efficacy of self-administered treatments for pathological academic worry: A randomized controlled trial

Research on treatments for reducing pathological worry is limited. In particular, academic worry is a common theme in generalized anxiety disorder (GAD) samples as well as non-clinical student samples. Given the high cost of anxiety disorders to society, research is needed to examine the efficacy of self-administered treatments designed to reduce pathological worry. The primary goal of this study was to investigate the benefits of three self-administered interventions for reducing academic worry. College students (N = 113) experiencing clinically significant academic worry were randomized to either: (a) worry exposure (WE); (b) expressive writing (EW); (c) relaxation consisting of pulsed audio-photic stimulation (APS); or (d) waitlist control (WLC). Participants were instructed to practice their interventions three times per week for one month and completed home practice logs online to track treatment adherence. Academic worry, general anxiety, and perceived stress were assessed at baseline and post-treatment. Academic worry and general anxiety were also assessed at a three-month follow-up. Those assigned to the WE and APS conditions showed significant improvement relative to EW and WLC at post-treatment. All treatment conditions showed continued improvement by follow-up, with no between-group differences. Treatment and public health implications are discussed.

An evaluation of the impact of a large group psycho-education programme (Stress Control) on patient outcome: does empathy make a difference?

Large psycho-education groups are being increasingly used in mental-health promotion and the treatment of common mental-health problems. In individual therapy there is a well-established link between therapist empathy, therapeutic relationship and patient outcome but the role of empathy within large psycho-educational groups is unknown. This service evaluation investigated the impact of a 6-week large psycho-education group on patient outcome and the role of perceived therapist empathy on outcome. Within a before–after experimental design, 66 participants completed baseline and endpoint measures; Clinical Outcome Routine Evaluation (CORE), Patient Enablement Instrument (PEI), and the modified Consultation and Relational Empathy (CARE) measure. The results showed that the intervention had a positive impact on patient outcome; the CORE score reduced significantly over the 6 weeks by 0.63 (95% CI 0.82–1.14) (t= 9.18, d.f. = 55,p= <0.001) and attendees felt highly enabled. Attendees perceived the course leader as highly empathetic. However, the relationship between perceived empathy and attendee outcome was less clear; no significant relationship was found with the main outcome measure (the change in CORE score). Factors that influenced the main outcome included age, symptom severity at baseline, having a long-term illness or disability, and whether attendees tried the techniques at home (homework). These findings suggest that large group psycho-education is an effective treatment for mild to moderate mental-health problems, at least in the short term. The role of therapist empathy remains ambiguous but may be important for some patient outcomes.

Who Attends and Who Benefits from CBT “Self-Confidence” Workshops Run in Routine Practice? A Pilot Study

Background:This study examined characteristics of members of the public who self-referred and the effectiveness of psycho-educational CBT self-confidence workshops when run in routine practice.Method:Repeated measures were employed at pre- and post-workshop stages.Results:Of the 56 members of the general public who self-referred to the workshops, 70% were above the clinical cut-offs for Global Distress (CORE OM) and 86% were above the clinical cut offs for depression symptomatology (CES-D). Follow up data (n= 31) showed significant reduction in self-reported distress and depression at 4-week follow-up. A further analysis showed that those whose scores were above the clinical threshold at initial presentation benefited most but those with scores below the threshold did not seem to benefit.Conclusions:This study demonstrates that psycho-educational CBT workshops attract those with high levels of distress and depression, and have potential as a cost effective means of disseminating psychological interventions.

Stresspac: A Controlled Trial of a Self-Help Package for the Anxiety Disorders

In order to test the efficacy of a self-help anxiety management package, sixty-two individuals meeting DSM-III-R criteria for an anxiety disorder were randomly allocated to one of three conditions: Stresspac patients were given a self-help/information package. Advice only patients were offered verbal advice on ways of coping with anxiety. Patients in both conditions were seen on one occasion shortly after referral for assessment and management advice. They were then placed back on the waiting list for a three month period. Patients in the No intervention condition also completed measures during this time. They were not seen until the end of this period when formal assessment took place. All patients were then followed through individual therapy and to 12 month follow-up. Results clearly support the superiority of the Stresspac condition after the waiting period, at post therapy and at follow-up on a range of measures. Possible explanations for the results are discussed.

Short and Long-Term Effectiveness of Group Anxiety Management Training

This study explored both the short-term and long-term effectiveness of group anxiety management training. The treatment package employed ran along cognitive-behavioural principles. Consistent with previous evaluations the groups had a significant effect on levels of anxiety and depression as measured by self-report instruments. Participants rated “meeting people with similar problems” and “learning about anxiety” as the two most important therapeutic ingredients. At a follow-up period of greater than two years therapeutic gains, at least in part, seemed to have been maintained.

Psychological therapies for generalised anxiety disorder

BACKGROUND

Generalised anxiety disorder (GAD) is a highly prevalent condition, characterised by excessive worry or anxiety about everyday events and problems. The effectiveness and effectiveness of psychological therapies as a group has not yet been evaluated in the treatment of GAD.

OBJECTIVES

To examine the efficacy and acceptability of psychological therapies, categorised as cognitive behavioural therapy (CBT), psychodynamic therapy and supportive therapy, compared with treatment as usual/waiting list (TAU/WL) and compared with one another, for patients with GAD.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, LILACS and controlledtrials.com in February 2006. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials conducted in non-inpatient settings, involving adults aged 18-75 years with a primary diagnosis of GAD, assigned to a psychological therapy condition compared with TAU/WL or another psychological therapy.

DATA COLLECTION AND ANALYSIS

Data on patients, interventions and outcomes were extracted by two review authors independently, and the methodological quality of each study was assessed. The primary outcome was anxiety reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of symptom reduction, using the standardised mean difference (SMD), with 95% confidence intervals.

MAIN RESULTS

Twenty five studies (1305 participants) were included in the review, of which 22 studies (1060 participants) contributed data to meta-analyses. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.63, 95%CI 0.55 to 0.73), and also in reducing anxiety, worry and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however significant heterogeneity was indicated, which was partly explained by the number of therapy sessions.

AUTHORS' CONCLUSIONS

Psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective. Further studies examining non-CBT models are required to inform health care policy on the most appropriate forms of psychological therapy in treating GAD.

Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome

OBJECTIVE

To determine which factors impact on the efficacy of cognitive behavioural therapy (CBT) for depression and anxiety. Factors considered include those related to clinical practice: disorder, treatment type, duration and intensity of treatment, mode of therapy, type and training of therapist and severity of patients. Factors related to the conduct of the trial were also considered, including: year of study, country of study, type of control group, language, number of patients and percentage of dropouts from the trial.

METHOD

We used the technique of meta-analysis to determine an overall effect size (standardized mean difference calculated using Hedges' g) and meta-regression to determine the factors that impact on this effect size. We included randomized controlled trials with a wait list, pill placebo or attention/psychological placebo control group. Study participants had to be 18 years or older and all have diagnosed depression, panic disorder (with or without agoraphobia) or generalized anxiety disorder (GAD). Outcomes of interest included symptom, functioning and health-related quality of life measures, reported as continuous variables at post-treatment.

RESULTS

Cognitive behavioural therapy for depression, panic disorder and GAD had an effect size of 0.68 (95% CI=0.51-0.84, n=33 studies, 52 comparisons). The heterogeneity in the effect sizes was fully explained by treatment, duration of therapy, inclusion of severe patients in the trial, year of study, country of study, control group, language and number of dropouts from the control group. Disorder was not a significant predictor of the effect size.

CONCLUSIONS

Cognitive behavioural therapy is significantly less effective for severe patients and trials that compared CBT to a wait-list control group found significantly larger effect sizes than those comparing CBT to an attention placebo, but not to a pill placebo. Further research is needed to determine whether CBT is effective when provided by others than psychologists and whether it is effective for non-English-speaking patient groups.

Experimental analysis of specific treatment factors: efficacy and practice implications

Interest in the empirical demonstration of the clinical efficacy of psychosocial treatments has been rekindled by societal concerns over accountability and cost effectiveness of mental health services. The result has been the identification of specific treatments for specific disorders. The prescription of treatment content should be based on the theory of therapeutic action and/or the disorder to which it is applied. The demonstration of specific treatment efficacy requires experimental evidence showing the influence of specific procedures beyond nonspecific factors of treatment. We provide an analysis of these factors and their effects in evaluating the specific efficacy of prescriptive psychosocial treatments. Experimental procedures and designs that test the validity of specific treatments are described and applied to cognitive-behavioral treatments of generalized anxiety disorder. The empirical and professional implications of specific treatment efficacy in evidence-based practice are discussed.

Psychological interventions for late-life anxiety: a review and early lessons from the CALM study

The authors review the literature on psychological treatment for anxiety in older adults, focusing on randomized, controlled trials. Evidence exists for the efficacy of relaxation training for subjective anxiety symptoms and cognitive-behavioral therapy for generalized anxiety disorder and miscellaneous anxiety syndromes, including panic disorder. The authors also present the rationale for the CALM Study (Controlling Anxiety in Later-life Medical Patients), an ongoing randomized trial in which a modular psychotherapeutic intervention for anxiety in older primary care patients is compared with treatment as usual. Data are presented from 2 pilot patients in the CALM Study, and preliminary lessons are discussed.

Experience of implementing an adult educational approach to treating anxiety disorders

This paper describes the background to the development and delivery of a self-help package for anxiety disorders. Evidence of effectiveness is summarized. The paper outlines the intervention and describes the experience of two mental health nurses, who set out to assess its acceptability, evaluate its outcomes in routine clinical practice and assess the feasibility of its delivery by mental health nurses. Acceptability of the intervention was high, judged by retention and attendance rates. The pilot study produced promising clinical outcomes, especially for people with depression secondary to anxiety. Clinical measures showed significant improvements from pre-course to 6-month follow-up in anxiety, psychological well-being and depression. The outcomes suggest that appropriately trained mental health nurses could deliver the intervention as a routine treatment. The paper concludes by discussing future plans, including a randomized controlled trial and implementation in primary care.

Meta-Analysis of Cognitive-Behavioral Treatments for Generalized Anxiety Disorder: A Comparison With Pharmacotherapy

The efficacy of (cognitive) behavioral therapy ([C]BT) for generalized anxiety disorder was investigated and compared with the efficacy of pharmacological therapy using meta-analytic techniques. A total of 65 (C)BT studies and pharmacological studies were included. (C)BT was more effective than control conditions. The results of the comparison between (C)BT and pharmacotherapy varied according to the meta-analytic methods used. Conclusions about differences in efficacy between therapy approaches are limited when all available studies are included owing to a number of factors that influence effect sizes. When only those studies that directly compared both therapies were included in the analysis, there were no significant differences in efficacy. Attrition rates were lower for (C)BT, indicating that it is better tolerated by patients.

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder

OBJECTIVE

To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]).

METHOD

The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater.

CONCLUSIONS

Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

Specific and nonspecific treatment factors in the experimental analysis of behavioral treatment efficacy

Interest in the empirical demonstration of the clinical efficacy of psychosocial treatments has been rekindled by societal concerns over accountability and cost-effectiveness in the delivery of mental health services. Behavior therapy has had a long history of experimental research on treatment efficacy and enjoys a visible presence in contemporary mental health practice. The demonstration of behavioral treatment efficacy, however, requires experimental evidence that shows the efficacy of prescriptive structured procedures beyond nonspecific factors in delivery of such procedures. The authors provide an analysis of the nature of nonspecific treatment factors and nonspecific effects and suggest experimental procedures testing the incremental validity of specific treatments. They examine two widely promoted, prescriptive structured treatments to analyze the specificity of their clinical efficacy: eye movement desensitization and reprocessing for anxiety disorders and cognitive-behavioral treatment of generalized anxiety disorder. They conclude that the treatments show different levels of efficacy and different degrees of specificity.

Cognitive-behavioral therapy for generalized anxiety disorder with integrations from interpersonal and experiential therapies

After providing background information on the definition and nature of generalized anxiety disorder, this article describes cognitive-behavioral therapy (CBT) methods that have been empirically supported in the treatment of this disorder. Subsequent to this description, relevant outcome literature is briefly reviewed, along with evidence that the addition of other techniques beyond traditional CBT methods may be necessary to maximize clinical outcome. A description is then provided of an integrated interpersonal/emotional processing therapy that the authors have recently added to their CBT protocol. CBT with and without this integrated treatment is currently being evaluated in an experimental trial.

Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy?

Self-help materials, brief therapies, and treatments involving minimal therapist contact have all been proposed as effective and low-cost interventions for anxiety disorders. However, research also suggests that the therapeutic alliance is a central predictor of therapy outcome. Interestingly, amounts of therapist contact within and across "self-help" interventions vary greatly. It is therefore unclear how much therapist contact is necessary for a positive anxiety disorder treatment outcome. The present article reviews the literature on anxiety disorder treatments using self-help, self-administered, and decreased therapist-contact interventions. Treatment studies are grouped together by anxiety diagnosis as well as amount of therapist contact. It is concluded that self-administered treatments are most effective for motivated clients seeking treatment for simple phobias. Predominantly self-help therapies are efficacious for panic disorder and mixed anxiety samples. On the other hand, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses.

Treatment of generalized anxiety disorder in older adults

Older adults with generalized anxiety disorder (GAD; N = 75; M age = 67.1 years) were randomly assigned to cognitive-behavioral therapy (CBT), a discussion group (DG) organized around worry-provoking topics, or a waiting period. Participants in both active conditions improved relative to the waiting list. Although CBT participants improved on more measures than DG participants, the authors found only I significant difference immediately after treatment and no differences at 6-month follow-up. Effect sizes were smaller than in younger samples, but CBT showed large effects and DG showed medium-sized effects Overall, results indicate that brief treatment of late-life GAD is beneficial, but they provide only limited support for the superiority of CBT to a credible comparison intervention.

[The generalized anxiety disorder--disease pattern, diagnostics and therapy]

OBJECTIVES AND METHODS

The Generalized Anxiety Disorder (GAD) is probably the most frequent anxiety disorder, demonstrating a chronic course and severe psychosocial impairments. GAD is seldom diagnosed in practice and research on GAD has in the past been sparse. This may be linked to the less dramatic symptomatology and the diagnostic criteria which were first clearly defined by DSM-IIIR and ICD-10. This article reviews diagnostics, epidemiology and current research on psychotherapy in GAD.

RESULTS AND CONCLUSIONS

Whereas cognitive-behavioral therapy (CBT) is regarded as empirically supported treatment, controlled and manualized studies of psychodynamic therapy in GAD do not exist. However, the results obtained thus far are promising. There is a definite need for further research in this area. Finally, we present an ongoing randomized controlled trial which compares manualized psychodynamic therapy and CBT in GAD. In this trial, efficacy and mechanisms of change (fearful cognitions vs. Core Conflictual Relationship Theme) in both therapies are being evaluated.

The nonpharmacologic treatment of generalized anxiety disorder

This article describes the latest nonpharmacologic therapies for generalized anxiety disorder. In addition, a review of available nonpharmacologic treatment outcome studies and studies that compare the efficacy of pharmacologic and nonpharmacologic treatment is presented. The authors conclude that, of the nonpharmacologic therapies available, cognitive-behavioral therapy may be the preferred first-line treatment. Results of comparison studies have suggested that medication acts more quickly than does therapy in reducing symptoms, whereas therapy has more long-lasting effects. The authors recommend that further research be conducted in identifying the essential components of treatment and the most efficacious treatment combinations.

Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder

The present study investigated the efficacy of a coping-technique, applied relaxation (AR) and cognitive therapy (CT), in the treatment of generalized anxiety disorder. Thirty-six outpatients fulfilling the DSM-III-R criteria for generalized anxiety were assessed with independent assessor ratings and self-report scales before and after treatment and at a 1 yr follow-up. The patients were randomized and treated individually for 12 weekly sessions. The results showed that both treatments yielded large improvements, which were maintained, or furthered at follow-up. There was no difference between AR and CT on any measure. The drop-out rate was 12% for AR and 5% for CT. The proportions of clinically significantly improved patients were 53 and 62% at post-treatment and 67 and 56% at follow-up for AR and CT, respectively. Besides affecting generalized anxiety the treatments also yielded marked and lasting changes on ratings of worry, cognitive and somatic anxiety and depression. The conclusion that can be drawn is that both AR and CT have potential as treatments for generalized anxiety disorder but they have to be developed further in order to increase the efficacy to the level usually seen in panic disorder, 80-85% clinically improved.

One-session group therapy of spider phobia: direct versus indirect treatments

Forty-six patients with spider phobia, fulfilling the DSM-IV criteria for specific phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to three group treatment conditions: (1) direct treatment; (2) direct observation; and (3) indirect observation. All treatments were carried out in large groups of eight patients, and consisted of one 3 hr session of massed exposure and modelling. The results showed that on the behavioral test, measures and the specific self-report measures of spider phobia the direct treatment was significantly better than direct observation and indirect observation, which did not differ. On the physiological measures and the psychopathology self-report measures there were significant pre-post improvements, but no differences between the groups. The effects were maintained or furthered at the one year follow-up assessment. The proportion of clinically significantly improved patients were, at post-treatment, 75% in the direct treatment, 7% in the direct observation, and 31% in the indirect observation group. At follow-up, the corresponding figures were 75, 14, and 44%, respectively. The conclusion that can be drawn is that direct treatment is the treatment of choice.

One-session group treatment of spider phobia

Forty-two patients with spider phobia, fulfilling the DSM-III-R criteria for simple phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to two group treatment conditions: (1) small groups of three to four patients, and (2) large groups of seven to eight patients. They received one 3-hr session consisting of exposure and modeling. The results showed that both conditions yielded significant improvements on almost all measures, and these were maintained or furthered at the 1-yr follow-up. With one exception, there was no difference between the conditions, but on most measures there was a trend for the small group condition to yield better effects. The proportions of clinically significantly improved patients at post-treatment were 82% in the small group and 70% in the large group. At follow-up the corresponding figures were 95% and 75%, respectively. The conclusion that can be drawn is that one-session group treatment is a feasible alternative to individual treatment, yielding almost as good effects.

A follow-up study of cognitive bias in generalized anxiety disorder

Patients with generalized anxiety disorder (GAD) without concurrent depression (n = 11) and normal controls (n = 17) were tested twice, about 2 months apart, on a modified Stroop colour-naming task, which presented anxiety-related, depression-related and neutral words in masked and unmasked exposure conditions. GAD patients received cognitive behaviour therapy in the test-retest interval, and were also retested at follow-up, about 20 months after initial testing. GAD patients showed interference in colour-naming negative words across both masked and unmasked conditions before treatment, but not post-treatment, compared with controls. Reduced interference effects of masked threat words over time correlated with reduced ratings of anxious thoughts at post-treatment, and at follow-up, in GAD patients. Thus, the preconscious bias for threat information in GAD appears to vary over time in association with changes in anxious thoughts and worries.