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Scholten W, Seldenrijk A, Hoogendoorn A, Bosman R, Muntingh A, Karyotaki E, Andersson G, Berger T, Carlbring P, Furmark T, Bouchard S, Goldin P, Kampmann I, Morina N, Kocovski N, Leibing E, Leichsenring F, Stolz T, van Balkom A, Batelaan N. Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis. JAMA Psychiatry 2023:2805367. [PMID: 37256597 PMCID: PMC10233456 DOI: 10.1001/jamapsychiatry.2023.1291] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Importance Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD. Objective To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD. Data Sources For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial. Study Selection Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD. Data Extraction and Synthesis Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models. Main Outcomes and Measures The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS. Results A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD). Conclusions and Relevance In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.
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Affiliation(s)
- Willemijn Scholten
- GGZ inGeest, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
| | - Adrie Seldenrijk
- GGZ inGeest, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
| | - Adriaan Hoogendoorn
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
| | - Renske Bosman
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
| | - Anna Muntingh
- GGZ inGeest, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
| | - Eirini Karyotaki
- Faculty of Behavioural and Movement Sciences, Department of Clinical, Neuro- and Developmental Psychology, VU Amsterdam, Amsterdam, the Netherlands
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Tomas Furmark
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Stéphane Bouchard
- Departement de Psychoéducation et Psychologie, Université du Québec en Outaouais, Gatineau, Quebec, Canada
- Centre de Recherche, Centre Intégré de Santé et des Services Sociaux de l'Outaouais, Gatineau, Quebec, Canada
| | - Philippe Goldin
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento
| | - Isabel Kampmann
- Institute of Psychology, University of Münster, Münster, Germany
| | - Nexhmedin Morina
- Institute of Psychology, University of Münster, Münster, Germany
| | - Nancy Kocovski
- Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Eric Leibing
- Clinic of Psychosomatic Medicine and Psychotherapy, University Medicine Goettingen, Georg-August-Universität Goettingen, Goettingen, Germany
| | - Falk Leichsenring
- Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Timo Stolz
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Anton van Balkom
- GGZ inGeest, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
| | - Neeltje Batelaan
- GGZ inGeest, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
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Abstract
The study was designed to determine which formats for displaying quantities, such as probabilities of treatment risks and benefits, are perceived most accurately and easily by patients. Accuracy and speed of processing were compared for six different presentation formats: pie charts, vertical bars, horizontal bars, numbers, systematic ovals, and random ovals. Quantities were used in two tasks: a choice task that required larger/smaller judgments and an estimate task that required more precise evaluation. The impacts of blue-yellow color and of a treatment-decision context on performance in the two tasks were also investigated. The study included four experiments. Taken together the results suggest that the formats best for making a choice differ from those best for estimating the size of an amount. For making a choice, vertical bars, horizontal bars, numbers, and systematic ovals were equally well perceived; pie charts and random ovals caused slower and less accurate performances. For estimating, numbers led to the most accurate estimates, followed by systematic ovals. The other four formats led to the least accurate estimates. Color and context did not alter which formats were best.
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Affiliation(s)
- D Feldman-Stewart
- Department of Oncology, Queen's University, Kingston, Ontario, Canada.
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