Psychotherapies for Generalized Anxiety Disorder in Adults

Summary & key facts

Researchers combined results from 65 carefully controlled studies that tested different kinds of talk therapy for adults with generalized anxiety. The analysis used data from about 5,000 people, most of them women, with an average age of about 42. They found that standard cognitive behavioral therapy, and a group of newer 'third-wave' CBT approaches, were linked with bigger short-term drops in anxiety than usual care. Relaxation training also helped in the short term, but its benefit was less certain after removing weaker studies. Only standard CBT showed a clear advantage that lasted three to twelve months. There were no clear differences in how many people stopped treatment early across the therapies. These results suggest CBT is a strong first choice, but the quality of some studies and shorter follow-up for many therapies mean the findings are not without limits.

Key facts:

• The review pooled 65 carefully controlled studies that compared different psychotherapies for adults with generalized anxiety disorder.
• The pooled data came from about 5,000 people. Around 71% were women and the average age was about 42.
• Standard cognitive behavioral therapy was linked with a meaningful reduction in anxiety symptoms compared with usual care in both the short term and three to twelve months after treatment.
• A group of treatments called third-wave CBTs were also linked with a clear short-term improvement in anxiety symptoms compared with usual care.
• Relaxation therapy showed short-term benefit compared with usual care, but that advantage became unclear when studies at high risk of bias were removed.
• There were no clear differences between therapies in how often people stopped treatment early, which is one way researchers checked if treatments were acceptable.
• The certainty of the evidence varied. For standard CBT and third-wave CBT the certainty was moderate. For relaxation therapy the certainty was lower.
• Because some studies had a higher risk of bias and not all therapies had long-term follow-up, the results should be viewed as informative but not definitive.

Abstract

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.

Topics

Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes Child and Adolescent Psychosocial and Emotional Development Treatment of Major Depression

Categories

Experimental and Cognitive Psychology Psychology Social Sciences

Tags

Anxiety Clinical psychology Confidence interval Generalized anxiety disorder Internal medicine Law Medicine MEDLINE Meta-analysis Political science Psychiatry Psychology PsycINFO Randomized controlled trial Relative risk

Conditions & symptoms

Anxiety Anxiety or worry