Cognitive Behavior Therapy Is the Most Effective Psychotherapy for Generalized Anxiety Disorder

Credit: ResearchGate

Cognitive behavior therapy (CBT) is the most effective psychotherapy for generalized anxiety disorder (GAD), according to a new study led by Davide Papola, MD, PhD, of the department of global health and social medicine at Harvard Medical School.¹

“While our findings support other research showing that traditional CBT itself is the leading psychotherapy for generalized anxiety disorder, as well as for other anxiety disorders, third-wave CBTs have recently emerged as solid alternatives,” the team wrote. “In recent times, there has been growing interest in testing third wave CBTs across mood and anxiety disorders.”

Previous research already found that psychotherapies effectively treat GAD, but those prior studies only used pairwise meta-analyses and therefore did not compare all types of treatment side-by-side.^2,3

The new study included a systematic review and network meta-analyses, comparing 8 psychotherapy nodes—CBT; behavior therapy; cognitive restructuring; psychoeducation; psychodynamic therapy; relaxation therapy; supportive psychotherapy; and third-wave CBTs. The investigators used this method to rank treatment options in order of effectiveness. The team examined 2 primary outcomes: GAD symptoms and discontinuation of psychotherapies.¹

Papola and colleagues examined databases to identify randomized controlled trials (RCTs) that observed the effects of psychotherapy for any anxiety disorder compared with any other psychotherapy. RCTs needed to have samples of participants >18 years old with a primary diagnosis of GAD.

The investigators viewed 66 studies, which comprised of 5597 participants. The mean age was 42.2 years, and 70.9% of the sample was female. The studies, lasting from 1 – 12 weeks with follow-up observations a year later, were published from 1980 – 2022. The average number of therapy sessions was 11.

Concerning study accuracy, 35% (n = 23) of the studies were at high risk of bias, 48% (n = 32) of the studies had “some concerns,” and 17% (n = 11) of the studies were at a low risk of bias.

In the investigator’s initial analyses, they found that CBT (–0.68; 95% CI, –1.05 to –0.32), third-wave CBTs (–0.78; 95% CI, –1.19 to –0.37), and relaxion therapy (–0.54; 95% CI, –1.04 to –0.05) exceeded other treatments for effectiveness. But after examining high risk for bias, only CBT and third-wave CBTs remained the superior form of treatment. Except, only CBT was linked with long-term effectiveness, making it the leading psychotherapy for GAD.

At the follow-up (3 – 12 months), CBT performed better than other treatment (SMD, −0.58; 95% CI, −0.93 to −0.23).

The investigators discussed the implications of using network meta-analyses in their report.

“Although network meta-analyses are more specific than pairwise meta-analyses in disentangling and systematizing the different psychotherapy protocols, the boundaries between different kinds of psychotherapies are often blurred, and 1 standalone intervention can also be a component of a more structured psychotherapy,” the investigators wrote.

The investigators gave the example how a “standard package of CBT” for GAD often included both cognitive restructuring, applied relaxation, education about anxiety, guidance in the “recognition and monitoring of situational, physiological, cognitive, and behavior cues associated with anxious responding,” and “imaginal exposure to anxiety cues” with “coping skill rehearsal.”

Even though CBT incorporates various treatment methods, CBT is still the more effective treatment method than, for example, relaxation therapy.

Despite the relaxation therapy performing well in the initial analysis, its high risk of bias cannot be dismissed. The investigators pointed out while clinical guidelines “unanimously recommend CBT” to treat adults with GAD, the National Institute for Health and Care Excellence guidelines recommend relaxing as a “first-line choice.”

“While our results largely confirm these indications, caution is needed when recommending relaxation techniques as stand-alone interventions,” the investigators wrote. “Relaxation techniques may be best valued when considered embedded in CBT protocols.”

References

1. ^{Papola D, Miguel C, Mazzaglia M, et al. Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials [published online ahead of print, 2023 Oct 18]. JAMA Psychiatry. 2023;10.1001/jamapsychiatry.2023.3971. doi:10.1001/jamapsychiatry.2023.3971}
2. ^{Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJ. How effective are cognitive behavior therapies for major depression and anxiety disorders? ameta-analytic update of the evidence. World Psychiatry. 2016;15(3):245-258. doi:10.1002/wps.20346}
3. ^{Bandelow B, Sagebiel A, Belz M, Görlich Y, Michaelis S,Wedekind D. Enduring effects of psychological treatments for anxiety disorders: meta-analysis of follow-up studies. Br J Psychiatry. 2018;212(6):333-338. doi:10.1192/bjp.2018.49}