Anxiety management for persistent generalised anxiety

Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

Importance

Generalized anxiety disorder (GAD) is one of the most common mental disorders in adults. Psychotherapies are among the most recommended treatments for GAD, but which should be considered as first-line treatment needs to be clarified.

Objective

To use a network meta-analysis to examine the short- and long-term associations of different psychotherapies with outcomes of effectiveness and acceptability in adults with GAD.

Data Sources

MEDLINE, Embase, PsycINFO, and the Cochrane Register of Controlled Trials were searched from database inception to January 1, 2023, to identify randomized clinical trials (RCTs) of psychotherapies for adults with GAD.

Study Selection

RCTs comparing any type of psychotherapy against another or with a control condition for the treatment of adults (≥18 years, both sexes) with a primary diagnosis of GAD were eligible for inclusion.

Data Extraction and Synthesis

This study followed Cochrane standards for extracting data and assessing data quality and used the PRISMA guideline for reporting. Risk of bias of individual studies was assessed using the second version of the Cochrane risk of bias tool, and the Confidence in Network Meta-Analysis was used to rate the certainty of evidence for meta-analytical results.

Main Outcomes and Measures

Eight psychotherapies were compared against one another and with 2 control conditions. Primary outcomes were severity of GAD symptoms and acceptability of the psychotherapies. Random-effects model pairwise and network meta-analyses were conducted. For effectiveness, standardized mean differences (SMDs) were pooled, and for acceptability, relative risks with 95% CIs were calculated.

Results

Data from 65 RCTs were included. Effect size estimates on data from 5048 participants (mean [SD], 70.9% [11.9%] women; mean [SD] age, 42.2 [12.5] years) suggested that third-wave cognitive behavior therapies (CBTs) (SMD, -0.76 [95% CI, -1.15 to -0.36]; certainty, moderate), CBT (SMD, -0.74 [95% CI, -1.09 to -0.38]; certainty, moderate), and relaxation therapy (SMD, -0.59 [95% CI, -1.07 to -0.11]; certainty, low) were associated with reduced GAD symptoms vs treatment as usual. Relative risks for all-cause discontinuation (indication of acceptability) signaled no differences compared with treatment as usual for all psychotherapies (eg, relative risk, 1.04 [95% CI, 0.64-1.67] for CBT vs treatment as usual). When excluding studies at high risk of bias, relaxation therapy lost its superiority over treatment as usual (SMD, -0.47; 95% CI, -1.18 to 0.23). When considering anxiety severity at 3 to 12 months after completion of the intervention, only CBT remained significantly associated with greater effectiveness than treatment as usual (SMD, -0.60; 95% CI, -0.99 to -0.21).

Conclusions and Relevance

Given the evidence in this systematic review and network meta-analysis for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

Remote cognitive-behavioral therapy for generalized anxiety disorder: A preliminary meta-analysis

BACKGROUND

Generalized anxiety disorder (GAD) is a chronic mental health condition that results in significant individual, societal, and economic burden. While cognitive behavioral therapy (CBT) is well established as an efficacious treatment for GAD, individuals have identified several logistical barriers to accessing face-to-face CBT. Remotely delivered treatments address many of these treatment barriers.

METHODS

The aim of the current study was to synthesize the current literature on the efficacy of remote CBT for GAD using a meta-analytic approach. Relevant articles were identified through an electronic database search and 10 studies (with 11 remote conditions and 1071 participants) were included in the meta-analysis.

RESULTS

Within-group findings indicate that remote CBT for GAD results in large effect sizes from pretreatment to posttreatment (g = 1.30; 95% confidence interval [CI]: 1.03-1.58). Both low intensity and high intensity remote CBT interventions were found to result in large effect sizes (g = 1.36; 95% CI: 1.11-1.61 and g = 0.83; 95% CI: 0.20-1.47, respectively), with no significant differences between the treatment formats (Q₁  = 2.28, p = 0.13). Between-group effect sizes were medium in size at posttreatment (g = 0.76; 95% CI: 0.47-1.06).

CONCLUSIONS

These findings have potential implications for the delivery of evidence-based treatment for GAD and the inclusion of remote methods in stepped care treatment approaches.

Long term therapy of generalized anxiety disorder

Generalized anxiety disorder (GAD) is a common (lifetime prevalence: 5.1%), recurrent condition, which often heralds other psychiatric disorders, notably depression. As by definition it is a disorder progressing over months, treatment should be designed on a long term basis. And yet, few studies have been conducted beyond the classical 6–8 weeks characterizing the acute treatment phase. This is especially true of anxiolytics, but also of antidepressants, with the exception of paroxetine and venlafaxine, which are the only drugs approved in this indication in Western countries. The efficacy of psychotherapy, notably relaxation and cognitive-behavioral therapy, is established in the treatment of GAD, but its preferred indications and possible combination with antidepressants are still to be specified. Long term, not to say very long term studies of GAD, as well as depression, will still be required in the future to improve its management and specify therapeutic modalities (combination treatment, optimal duration, continuous or intermittent therapy, choice of psychotherapeutic techniques or agents, …). Early and adequately prolonged treatment should not only result in more numerous remission periods, but also in decreased frequency of co-morbidities whether depressive, addictive, or of another nature, and should also reduce the social impact of GAD.

The Institute of Psychiatry cognitive behaviour therapy course

Cognitive behaviour therapy is now widely accepted clinically as a treatment for depression and anxiety, and there is increasing research evidence to confirm its efficacy (Rush et al, 1977; Blackburn et al, 1981; Murphy et al, 1984; Butler et al, 1987; Beck, 1988). Of the various short term psychotherapies currently available, it is probably the most widely known and best researched. Despite this, and the recommendation of the Royal College of Psychiatrists (1986) that trainees receive training in cognitive therapy, there is little opportunity to gain a formal training in this psychotherapy. Short workshops are often available through the British Association for Behavioural Psychotherapy and from other sources, and ad hoc supervision from interested psychologists and psychiatrists may be available in some centres. Scott et al (1985) described a workshop and peer supervision training scheme in Newcastle. Macaskill (1986) reported a course for psychiatrists in training in Sheffield which extended over 20 weeks and combined Beck's cognitive therapy and Ellis' Rational Emotive Therapy.

Safety Seeking Behaviours

People react to threatening situations by employing behaviours that they perceive will help them to cope with the difficulties confronting them. In cognitive therapy (CT), these behaviours, which can be either physical or mental activities, are termed ‘safety-seeking behaviours’. This article discusses the use of such behaviours by people with cognitive confusion. It suggests that the employment of safety behaviours may have a major impact on the presentation of the person. Indeed, in some situations the behaviour may either mimic the effects of cognitive impairment or exacerbate the impact of the person’s cognitive difficulties. Further, it is observed that the onset of dementia is likely both to lead to the emergence of safety behaviours, and reinforce any coping strategies used by the person in the past. Hence, this article suggests that clinicians and staff should pay particular care when developing both their conceptualizations and care plans in order to ensure that they have an appreciation of the forms of safety seeking behaviours the confused person may be using.

The cost-effectiveness of psychotherapy for the major psychiatric diagnoses

Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions. Psychotherapy can also lead to savings in other medical and societal costs. It is at times the firstline and most important treatment and at other times augments the efficacy of psychotropic medication. Many patients are in need of more prolonged and intensive psychotherapy, including those with personality disorders and those with chronic complex psychiatric conditions often with severe anxiety and depression. Many patients with serious and complex psychiatric illness have experienced severe early life trauma in an atmosphere in which family members or caretakers themselves have serious psychiatric disorders. Children and adolescents with learning disabilities and those with severe psychiatric disorders can also require more than brief treatment. Other diagnostic groups for whom psychotherapy is effective and cost-effective include patients with schizophrenia, anxiety disorders (including posttraumatic stress disorder), depression, and substance abuse. In addition, psychotherapy for the medically ill with concomitant psychiatric illness often lowers medical costs, improves recovery from medical illness, and at times even prolongs life compared to similar patients not given psychotherapy. While "cost-effective" treatments can yield savings in healthcare costs, disability claims, and other societal costs, "cost-effective" by no means translates to "cheap" but instead describes treatments that are clinically effective and provided at a cost that is considered reasonable given the benefit they provide, even if the treatments increase direct expenses. In the current insurance climate in which Mental Health Parity is the law, insurers nonetheless often use their own non-research and non-clinically based medical necessity guidelines to subvert it and limit access to appropriate psychotherapeutic treatments. Many patients, especially those who need extended and intensive psychotherapy, are at risk of receiving substandard care due to inadequate insurance reimbursement. These patients remain vulnerable to residual illness and the concomitant sequelae in lost productivity, dysfunctional interpersonal and family relationships, comorbidity including increased medical and surgical services, and increased mortality.

An outcome study of a brief anxiety management programme: Anxiety Control Training

Objective: Anxiety management techniques may all be expected to produce immediate therapeutic effect; more information is required on long term outcome after contact with the therapist ceases. The study is an independently monitored enquiry into the outcome of a brief technique, Anxiety Control Training. Following eight ten-minute instructional sessions with the therapist, assessments were made by a person who had not been involved with the treatment. Medication was withheld throughout the whole period of the study and ‘booster’ sessions were not given in order that an estimate may be made of the degree of subsequent improvement which may be attributed to the patient's own resources and continued practice of the technique. Method: The study was conducted on a sample of patients referred to an anxiety management service suffering from a phobic disorder. Assessments of the severity of the phobia and of generalized anxiety were made at commencement of treatment, at the end of the eight sessions and thereafter at three month and nine month intervals. Follow up assessment of all patients included in the sample was achieved. Results: At inception into the treatment phase seven of the 22 patients suffered from a moderate to severe degree of generalized anxiety in addition to phobia. As expected a significant (p<0.001) degree of improvement in phobic severity occurred during the period of therapy. Following termination of therapy further significant (p<0.01) improvement occurred up to the final assessment. The number of patients suffering from generalized anxiety was too small to allow confident conclusion but the results suggest improvement in generalized as well as phobic anxiety. Conclusions: The instructional sessions of the ACT procedure provide skill in mastery over anxiety. The subject may continue to use this skill without further aid from the therapist; with regular practice of the technique progressive improvement is likely to occur.

The temporal course of the influence of anxiety on fairness considerations

This study investigated the potential causes of anxious people's social avoidance. The classic ultimatum game was utilized in concert with electroencephalogram recording. Participants were divided into two groups according to levels of trait anxiety as identified by a self-report scale. The behavioral results indicate that high-anxious participants were more prone to reject human-proposed than computer-proposed unequal offers compared to their low-anxious counterparts. The event-related potential results indicate that the high-anxious group showed a larger feedback-related negativity when receiving unequal monetary offers than equal ones, and a larger P3 when receiving human-proposed offers than computer-proposed ones, but these effects were absent in the low-anxious group. We suggest anxious people's social avoidance results from hypersensitivity to unequal distributions during interpersonal interactions.

Generalizability of clinical trial results for generalized anxiety disorder to community samples

BACKGROUND

There has been little research on the generalizability of clinical trials for generalized anxiety disorder (GAD). The present study examines the generalizability of pharmacological and psychotherapy clinical trials' results of individuals with DSM-IV GAD to a large community sample.

METHODS

Data were drawn from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a large national representative face-to-face sample of 43,093 adults of the United States population. We applied a standard set of eligibility criteria representative of GAD pharmacological and psychotherapy clinical trials to all adults with past 12 months GAD (n = 894), and to a subgroup of participants seeking treatment (n = 329). Our aim was to assess how many participants with GAD would fulfil typical eligibility criteria.

RESULTS

We found that more than seven out of 10 participants with GAD were excluded by at least one criterion. In the subgroup of GAD participants who sought treatment, the exclusion rate by at least one criterion raised to more than eight out of 10 participants with GAD. For the overall sample and the treatment-seeking subsample, having a current depression was the criterion excluding the highest percentage of individuals. Having a lifetime history of bipolar disorder, a current significant medical condition, a current diagnosis of alcohol abuse or dependence, and a social or specific phobia also excluded a substantial proportion of individuals in both samples.

CONCLUSIONS

Clinical trials exclude a majority of adults with GAD. Clinical trials should carefully consider the impact of eligibility criteria on the generalizability of their results.

The Importance of Behaviour in the Maintenance of Anxiety and Panic: A Cognitive Account

The theoretical and empirical basis of commonly accepted propositions concerning the role of behaviour in the practice of behavioural psychotherapy for anxiety problems is considered. A number of problems are identified, and an alternative, more explicitly cognitive hypothesis is described. According to this cognitive account, there is both a close relationship and specific interactions between “threat cognitions” and “safety seeking behaviour”. For any individual, safety seeking behaviour arises out of, and is logically linked to, the perception of serious threat. Such behaviour may be anticipatory (avoidant) or consequent (escape). Because safety seeking behaviour is perceived to be preventative, and focused on especially negative consequences (e.g. death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety seeking behaviours. By preventing disconfirmation of threat-related cognitions, safety seeking behaviour may be a crucial factor in the maintenance of anxiety disorders. The implications of this view for the understanding and treatment of anxiety disorders are discussed.

A Controlled Comparison of Cognitive—Behaviour Therapy, Diazepam and Placebo in the Management of Generalized Anxiety

Generalized anxiety patients were randomly allocated to Cognitive-Behaviour Therapy, Diazepam or Placebo and managed in a primary care setting. Treatments were balanced for degree of psychologist/patient contact. A range of outcome measures, including patient self report, psychologist assessor and general practitioner ratings were used. Large variations within group response to treatment emerged. At the end of active treatment the superiority of Cognitive-Behaviour Therapy was suggested. Post-study psychotropic prescription and psychological treatment was assessed at a 12-month follow-up. The Cognitive-Behaviour group revealed the lowest incidence of subsequent treatment interventions.

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

One hundred and nine patients with a primary diagnosis of GAD were allocated to either cognitive, behavioural, cognitive-behavioural or placebo versions of “Stress Control” large group didactic therapy or to a waiting list condition. Each group was run by two therapists and, with the exception of the placebo, contained between 20 and 24 patients. A wide range of measures were administered at pre-, mid- and post-therapy and at six month follow-up. At post-therapy, all therapy conditions showed highly significant change on almost all measures, with the active therapies, and to a slightly lesser degree, the placebo, being significantly different to the waiting list on most measures. At follow-up, the active treatment conditions enhanced post-therapy improvements, while the placebo condition maintained progress. No significant differences existed between the four treatment conditions at post-therapy and, with the exception of one measure, at follow-up. However, a trend at both points favours the cognitive and behavioural conditions.

Generalized anxiety disorder: connections with self-reported attachment

Even though generalized anxiety disorder (GAD) is one of the most common of the anxiety disorders, relatively little is known about its precursors. Bowlby's attachment theory provides a framework within which these precursors can be considered. According to Bowlby, adult anxiety may be rooted in childhood experiences that leave a child uncertain of the availability of a protective figure in times of trouble.Furthermore, adult "current state of mind with respect to attachment" is thought to relate to adult anxiety. Both attachment-related components were assessed with 8 subscales of the Perceptions of Adult Attachment Questionnaire(PAAQ). Clinically severe GAD clients who were about to begin therapy reported experiencing less maternal love in childhood, greater maternal rejection/neglect, and more maternal role-reversal/enmeshment than did control participants.In keeping with a cumulative risk model, risk for GAD increased as indices of poor childhood attachment experience increased. GAD clients, in contrast to controls,also reported greater current vulnerability in relation to their mothers as well as more difficulty accessing childhood memories. Logistic regression analyses revealed that elevations on PAAQ subscales could significantly predict GAD vs.non-GAD status. Results and the implications for advancing the theory and treatment of GAD are discussed.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

AUTHORS' CONCLUSIONS

This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Muscle tension in generalized anxiety disorder: a critical review of the literature

BACKGROUND

Generalized anxiety disorder (GAD) is a prevalent, disabling, and often chronic disorder. With a typical recovery rate of only about 40% with current psychological treatments a better understanding of potential psychophysiological mechanisms is vital.

METHODS

Since the most discriminative somatic symptom of GAD compared to other anxiety disorders is muscle tension this review qualitatively examines the literature on muscle tension as it relates to GAD and muscle relaxation therapy for GAD patients.

RESULTS

Muscle tension in GAD is poorly understood. Experimental studies refute the often-assumed direct relationship between anxiety and muscle tension. However, muscle relaxation therapies have been as effective as cognitive interventions directly addressing the defining symptom worry.

CONCLUSIONS

Muscle tension in its objective and subjective representations may play a role in GAD through various pathways that are testable. Future research needs to better examine the different aspects and functions of muscle tension in GAD.

Cognitive-behavioral therapy for anxiety in the elderly

Anxiety is a significant problem among the elderly. Due to complexities in the medical management of elderly patients, researchers and clinicians have sought psychosocial alternatives to pharmacotherapy in order to treat anxiety in the elderly. Cognitive-behavioral therapy (CBT) in particular has been investigated as a promising treatment. Research conducted to date has established that CBT produces significant improvement in anxiety symptoms among the elderly. However, there is some concern that CBT does not benefit elderly anxiety patients as much as it does younger patients. Investigators are seeking methods of augmenting or supplementing CBT in order to develop more effective treatments for anxiety in the elderly.

Well-being therapy of generalized anxiety disorder

BACKGROUND

There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD.

METHODS

Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel's Clinical Interview for Depression, Ryff's Psychological Well-being Scales and Kellner's Symptom Questionnaire. A one-year follow-up was undertaken.

RESULTS

Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up.

CONCLUSIONS

These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

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.

Can the Randomized Controlled Trial Literature Generalize to Nonrandomized Patients?

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.

Are samples in randomized controlled trials of psychotherapy representative of community outpatients? A new methodology and initial findings

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of community outpatients, the authors used a method of matching information obtained from outpatient charts to inclusion and exclusion criteria from published RCT studies. They found that 80% of the patients in their sample who had diagnoses represented in the RCT literature were judged eligible for at least 1 published RCT; however, 58% of the patients had primary diagnoses such as adjustment disorder or dysthymia, which were not represented in the existing psychotherapy outcome literature. The most common reasons that patients in their sample did not match with published RCTs for psychotherapy are listed, and the implications of these findings for research and practice are discussed.

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.

Treatment of generalised anxiety disorder with a short course of psychological therapy, combined with buspirone or placebo

BACKGROUND

Very few studies have examined the combination of drug and psychological treatment in generalised anxiety disorder (GAD). Theoretically, buspirone should be a useful drug to combine with a learning-based therapy.

METHODS

Sixty patients with GAD were randomly assigned to treatment with buspirone or placebo, combined with anxiety management training or non-directive therapy for a period of 8 weeks.

RESULTS

Forty-four patients with a mean Hamilton Anxiety Scale score of 28 completed treatment. There were no significant differences between treatment groups. All groups showed significant improvement after 8 weeks compared to baseline. There were no baseline differences between those who completed the trial and those who did not but patients given buspirone were more likely to drop out.

CONCLUSIONS

A short course of psychological therapy, whether or not accompanied by active medication, was an effective treatment for patients diagnosed as having quite severe symptoms of GAD. CLINICAL IMPLICATIONS AND LIMITATIONS: Dropouts led to a sample size which may have been too small to detect group differences. Cognitive therapy may have been more effective.

Issues of measurement and mechanism in meta-analyses: comment on Westen and Morrison (2001)

The authors suggest that D. Westen and K. Morrison's (2001) meta-analysis of treatment is critically limited in the consideration of measurement and mechanisms of therapeutic change. The measures included in the analysis fail to represent a comprehensive coverage of the domains within which change is expected. Moreover, they do not measure the theoretically derived constructs currently conceived as being central to each disorder. Further, the particular meta-analytical approach taken prohibits evaluation of the treatment components responsible for change. The authors reviewed the most recent data on comorbidity as an issue of treatment efficacy and generalizability, proffer an interpretation for the difference in outcome results across the 3 diagnostic groups, and discuss internally valid methodologies for the bridging from research to clinical practice.

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.

Sleep disturbance in generalized anxiety disorder and its treatment

Sleep laboratory and epidemiological studies indicate that insomnia is a frequent finding in patients with psychiatric disorders. In this respect, insomnia associated with a major depression or an anxiety disorder, mainly generalized anxiety disorder (GAD), is the most prevalent diagnosis. According to available evidence, the sleep disturbance associated with mild-to-moderate GAD is a sleep-maintenance insomnia, and to a lesser extent a sleep-onset insomnia. Insomnia associated with mild-to-moderate GAD generally responds to psychological treatments and anxiolytic benzodiazepines. Moreover, concomitant administration of hypnotic medication can be contemplated in patients with severe GAD.

On-site mental health workers in primary care: effects on professional practice

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting. In addition to treating patients, the introduction of on-site MHWs may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (18-22 June 1998), the Cochrane Controlled Trials Register (18-22 June 1998), MEDLINE (1966 to 1998), EMBASE (1980 to 1998), PsychInfo (1984 to 1998), CounselLit (18-22 June 1998), NPCRDC skill-mix in primary care bibliography, and reference lists of articles.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series analyses of MHWs either replacing PCPs as providers of mental health care ('replacement' models) or providing collaborative care/support to PCPs in managing patients' mental health problems ('consultation-liaison' models). The participants were primary care providers. The outcomes included objective PCP behaviours such as diagnosis, prescribing and referral.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Thirty-eight studies were included involving more than 460 PCPs and more than 3880 patients. There was some evidence that 'replacement' model MHWs achieved significant short-term reductions in PCP psychotropic prescribing and mental health referral, but the effects were not reliable. Consultation rates were also reduced, but with even less evidence of a consistent effect. There were no indirect effects in prescribing behaviour on the wider population and no consistent pattern to the impact on referrals. 'Indirect' effects on PCP consultation rates were not assessed. There was some evidence that 'consultation-liaison' model MHWs had a direct effect on PCP prescribing behaviour when used as part of complex, multifaceted interventions. Few studies examined the 'indirect' effects of such interventions, and those that did failed to provide evidence that 'direct' effects were generalisable to the wider population or endured once the 'consultation-liaison' intervention was removed.

REVIEWER'S CONCLUSIONS

This review does not support the hypothesis that adding MHWs to primary care provider organisations in 'replacement' models causes a significant or enduring change in PCP behaviour. 'Consultation-liaison' interventions may cause changes in psychotropic prescribing, but these seem short-term and limited to patients under the direct care of the MHW. Longer-term studies are needed to assess the degree to which demonstrated effects endure over time.

A cognitive model of generalized anxiety disorder

A cognitive model of generalized anxiety disorder (GAD) is described. The model asserts that generalized anxiety is an abnormal worry state. In this model, GAD results from the usage of worrying as a coping strategy and subsequent negative evaluation of worrying. The use of worry as a strategy is supported by positive metabeliefs concerning worry, whereas the negative appraisal of worrying (worry about worry) is linked to negative metabeliefs developed out of previous experience. These beliefs center on the themes of uncontrollability of worries and the dangerous consequences of worrying. Negative appraisal of worrying is associated with behavioral and cognitive responses that serve to maintain unwanted thoughts, and preserve dysfunctional beliefs. A review of the literature indicates that the model is consistent with existing data. Predictions and treatment implications of the model are discussed.

Description of a group Cognitive Behaviour Therapy programme with cancer patients

Cognitive Behaviour Therapy (CBT) has already been shown to be highly effective in the treatment of various psychological disorders within mental health populations; however, it has not been widely tested in the treatment of cancer patients. In the last decade there has been growing interest in the application of CBT interventions within psycho-oncology, and some studies have reported on its efficacy, both with individuals and in group-therapy contexts. To date there have been few descriptions of how a CBT programme for cancer patient groups can be structured and delivered. We present a description of a 12-session CBT programme that has been developed by our centre, for delivery to cancer patient groups.

A group cognitive behaviour therapy programme with metastatic breast cancer patients

One-hundred and twenty-four patients with metastatic breast cancer were randomised to either a group Cognitive Behaviour Therapy (CBT) intervention, or to a no-therapy control group condition. Both groups received standard oncological care; however, therapy recipients also attended eight weekly sessions of group CBT, followed by a family night, and three further monthly sessions. Patients completed the 'Profile of Mood States' (POMS) and the Coopersmith Self-esteem Inventory (CSI) before and after therapy, and at 3 and 6 month follow-up periods. Outcome data in the period following therapy showed reduced depression and total mood disturbance, as well as improved self-esteem amongst therapy participants, relative to a no-therapy control group. These improvements were no longer evident at the 3 or 6 month follow-up assessments. We also report on the difficulties associated with conducting a group intervention with this patient cohort.

Preliminary tests of a cognitive model of generalized anxiety disorder

Although worry is the central feature of Generalised Anxiety Disorder (GAD), little is known about the factors that contribute to pathological or problematic worry. In a recent cognitive model of GAD, Wells, A. (1995) proposed that negative appraisal of worrying itself (meta-worry or type 2 worry) should be distinguished from other types of worrying (type 1 worry). A central feature of this model is the idea that individuals with GAD hold rigid positive beliefs about the usefulness of worrying as a coping strategy. However, these individuals also hold negative beliefs and appraise worrying as uncontrollable and dangerous. This combination of cognitions and associated responses leads to an increased frequency and generality of worrying, and thus to the pathological worry characteristic of GAD. This paper reports a preliminary test of the hypothesis that meta-worry contributes to problematic and pathological worrying, and this relationship is independent of the frequency of other types of worry. In testing for associations between worry dimensions we controlled for overlaps with Trait anxiety, and the controllability of worrying. Results of a series of regression analyses support the hypothesis that pathological worry is associated with meta-worry and this association is independent of Trait-anxiety and type 1 worry. The clinical implications of these data are briefly discussed.

The nature and duration of treatment for GAD

It is becoming increasingly evident that GAD is a chronic condition with repeated acute-on-chronic episodes. Treatment in the short term relies on the benzodiazepines, which are rapid in action, providing substantial symptomatic relief with a low incidence of side-effects and low toxicity in overdose. The risk of more serious unwanted effects in the long term, including some risk of physical dependence, has led to a move towards alternative treatments both pharmacological and psychotherapeutic. Antidepressants are being used on a long-term basis, but data are sparse to confirm their efficacy in GAD. Anxiety management and cognitive-behavioural techniques are rivalling pharmacotherapy in popularity. None the less, research seeking optimal ways of combining therapies remains an urgent priority.

Psychotherapy integration: its implications for psychiatry

BACKGROUND

The proliferation of psychotherapies has been balanced by an equal and opposite tendency towards integration. Integrative approaches are particularly relevant to psychotherapy in psychiatric settings.

METHOD

MEDLINE and manual literature searches yielded over 250 articles on psychotherapy integration, which are reviewed in the light of the authors' experience in a district psychotherapy service.

RESULTS

Psychotherapy integration is an umbrella term covering a wide range of meanings: rapprochement between different theoretical positions; convergence of ideas and techniques; eclectic selection from many different methods; and integration proper in specifically integrative therapies. Many effective psychotherapeutic treatments for psychiatric disorders are integrative, including those for depression, schizophrenia, bulimia nervosa and borderline personality disorder.

CONCLUSIONS

Integration at the level of practice is common and desirable. At the level of theory, clarification and creative conflict are essential. Different therapeutic approaches should work closely together but retain their separate identities.

Benzodiazepine dependence. Avoidance and withdrawal

Benzodiazepine dependence is a frequent complication of regular prescriptions for 4 weeks or longer, occurring in almost one-third of patients. Although it is also manifested by tolerance to drug effects and occasional drug seeking behaviour, particularly in those prone to drug abuse, most dependence is characterised by a withdrawal syndrome on stopping treatment. The withdrawal syndrome includes symptoms of anxiety and those of perceptual disturbance such as depersonalisation, hypersensitivity of all major senses, dysphoria and (rarely) epileptic seizures and psychotic episodes. Risk factors for dependence include high dosage, use of more potent and short acting benzodiazepines, long duration of therapy and dependent premorbid personality characteristics. If none of these apply, benzodiazepines can be prescribed with safety.

Psychological treatment of generalised anxiety disorder. A review of the clinical significance of results in outcome studies since 1980

Comparative outcome studies of generalised anxiety disorder suggest that psychological therapy is a potentially valuable alternative to anxiolytic medication. However, on average psychological therapy results in modest improvements in symptoms, with about 50% of patients achieving normal functioning. Limited follow-up data indicate that these changes are maintained over six months. Cognitive therapy appears to be most effective, although comparisons with other therapies are limited and non-specific factors are clearly important. There is also evidence of considerable variability in outcome between studies, with the best results obtained with patients who are free of anxiolytic medication and recruited directly from primary care or other non-psychiatric settings. The effects on outcome of patient characteristics known to be associated with more severe illness and complexity of clinical presentation have yet to be explored. A balanced appraisal of the value of psychological therapy with this common condition requires a fuller description of sample characteristics and more systematic investigation of the clinical significance of treatment effects over the long term.

Behavioural approaches to anxiety disorders

Powerful behavioural treatments for many patients with anxiety disorders have been widely available since the 1970s. Despite this, the majority of such patients have continued to be treated with psychotrophic drugs. Recent litigation against the manufacturers of benzodiazepine drugs has made the public increasingly concerned about the prescription of anxiolytic agents. In parallel with the fall in popularity of drug treatment, advances have been made which increase the availability and applicability of behavioural treatments for these patients. This paper examines the impact of the development of self-exposure and cognitive methods on a number of common anxiety syndromes. Clinical examples of self-exposure are given to demonstrate the simplicity of the technique.

Can psychotherapy help patients with psoriasis?

Two groups of people with psoriasis attended a short series of meetings conducted by a clinical psychologist. During these sessions the patients were given the opportunity to discuss between themselves problems created by their skin complaint and they were taught specific relaxation techniques for use whenever they felt under stress. Psychological tests showed that the participants were a noticeably anxious group compared to the general population. However, their levels of anxiety were significantly reduced by the end of the study. There was also a modest trend towards physical improvement. No such changes were seen in a matched control group.

Psychological treatment for atypical non-cardiac chest pain: a controlled evaluation

Thirty-one patients with atypical non-cardiac chest pain which had persisted despite negative medical investigation were treated in a controlled trial of cognitive-behavioural therapy. The average duration of pain was 4.7 years. Patients were randomized to either immediate treatment or as a control to assessment only. Treatment involved teaching patients how to anticipate and control symptoms, and modification of inappropriate health beliefs. The average number of sessions given was 7.2. There were significant reductions in chest pain. limitations and disruption of daily life, autonomic symptoms, distress and psychological morbidity in the treated group as compared with the control group who were unchanged. The assessment-only group were treated subsequently and showed comparable changes. Improvements were fully maintained by both treated groups at four- to six-months follow-up.

The diagnosis and management of pathological anxiety

The anxiety disorders are common reasons for patients approaching their doctors for help. While benzodiazepines used to be the treatments most commonly used, increasing concern about the wisdom of prescribing these drugs means that other treatments have to be considered. A differential diagnostic schema for patients who complain of anxiety is presented and an outline for counselling these patients is described. Treatment of the four major anxiety disorders is evaluated, and the efficacy of drug treatment compared to various levels of behaviour therapy. Cognitive behaviour therapy is recommended for all four disorders on the grounds of a short-term effectiveness comparable to drug therapy and evidence for stability of improvement after treatment has concluded, evidence that is lacking for the drug therapies.

Behaviour therapy and benzodiazepines: allies or antagonists?

Behaviour therapy and benzodiazepines are directed towards common problems and are often used in combination. At present we know little about the beneficial or adverse interactions of these two treatments. This paper reviews the available literature and suggests that there are important theoretical and clinical issues to be resolved.

The Nottingham study of neurotic disorder: comparison of drug and psychological treatments

210 psychiatric outpatients with generalised anxiety disorder (71), or panic disorder (74), or dysthymic disorder (65) diagnosed by an interview schedule for DSM-III were allocated by constrained randomisation to one of five treatments: diazepam (28), dothiepin (28), placebo (28), cognitive and behaviour therapy (84), and a self-help treatment programme (42). All treatments were given for 6 weeks and then withdrawn by 10 weeks. Ratings of psychopathology were made by psychiatric assessors blind to both treatment and diagnosis before treatment and at 2, 4, 6, and 10 weeks after randomisation. 18 patients had insufficient data for analysis because of early drop-out. There were no important differences in treatment response between the diagnostic groups, but diazepam was less effective than dothiepin, cognitive and behaviour therapy, or self-help, these three treatments being of similar efficacy. Significantly more patients in the placebo group took additional psychotropic drugs in the 10 week period, and those allocated to dothiepin and cognitive and behaviour therapy took the least.