Evidence-Based Reviews

Generalized anxiety disorder: 8 studies of psychosocial interventions

Current Psychiatry. 2022 October;21(10):33-41,45 | doi: 10.12788/cp.0294

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. American Psychiatric Association; 2022.

2. Carl E, Witcraft SM, Kauffman BY, et al. Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cogn Behav Ther. 2020;49(1):1-21. doi:10.1080/16506073.2018.1560358

3. Cuijpers P, Cristea IA, Karyotaki E, et al. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta‐analytic update of the evidence. World Psychiatry. 2016;15(3):245-258. doi:10.1002/wps.20346

4. Saeed SA, Majarwitz DJ. Generalized anxiety disorder: 8 studies of biological interventions. Current Psychiatry. 2022;21(7):10-12,20,22-27. doi:10.12788/cp.02645

5. Simon NM, Hofmann SG, Rosenfield D, et al. Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: a randomized clinical trial. JAMA Psychiatry. 2021;78(1):13-20. doi:10.1001/jamapsychiatry.2020.2496

6. Gould RL, Wetherell JL, Serfaty MA, et al. Acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder: the FACTOID feasibility study. Health Technol Assess. 2021;25(54):1-150. doi:10.3310/hta25540

7. Stefan S, Cristea IA, Szentagotai Tatar A, et al. Cognitive-behavioral therapy (CBT) for generalized anxiety disorder: contrasting various CBT approaches in a randomized clinical trial. J Clin Psychol. 2019;75(7):1188-1202. doi:10.1002/jclp.22779

8. Plag J, Schmidt-Hellinger P, Klippstein T, et al. Working out the worries: a randomized controlled trial of high intensity interval training in generalized anxiety disorder. J Anxiety Disord. 2020;76:102311. doi:10.1016/j.janxdis.2020.102311

9. Amir N, Taboas W, Montero M. Feasibility and dissemination of a computerized home-based treatment for generalized anxiety disorder: a randomized clinical trial. Behav Res Ther. 2019;120:103446. doi:10.1016/j.brat.2019.103446

10. Burke J, Richards D, Timulak L. Helpful and hindering events in internet-delivered cognitive behavioural treatment for generalized anxiety. Behav Cogn Psychother. 2019;47(3):386-399. doi:10.1017/S1352465818000504

11. Miller CB, Gu J, Henry AL, et al. Feasibility and efficacy of a digital CBT intervention for symptoms of generalized anxiety disorder: a randomized multiple-baseline study. J Behav Ther Exp Psychiatry. 2021;70:101609. doi:10.1016/j.jbtep.2020.101609

12. Hirsch CR, Krahé C, Whyte J, et al. Internet-delivered interpretation training reduces worry and anxiety in individuals with generalized anxiety disorder: a randomized controlled experiment. J Consult Clin Psychol. 2021;89(7):575-589. doi:10.1037/ccp0000660

13. Hofmann SG, Smits JAJ. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69(4):621-632. doi:10.4088/jcp.v69n0415

14. Clarke TC, Barnes PM, Black LI, et al. Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and over. NCHS Data Brief. 2018;(325):1-8.

15. Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018;35(6):502-514. doi:10.1002/da.22728

16. Covin R, Ouimet AJ, Seeds PM, et al. A meta-analysis of CBT for pathological worry among clients with GAD. J Anxiety Disord. 2008;22(1):108-116. doi:10.1016/j.janxdis.2007.01.002

17. Merom D, Phongsavan P, Wagner R, et al. Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders--a pilot group randomized trial. J Anxiety Disord. 2008;22(6):959-968. doi:10.1016/j.janxdis.2007.09.010

18. Herring MP, Jacob ML, Suveg C, et al. Feasibility of exercise training for the short-term treatment of generalized anxiety disorder: a randomized controlled trial. Psychother Psychosom. 2012;81(1):21-28. doi:10.1159/000327898

19. Bischoff S, Wieder G, Einsle F, et al. Running for extinction? Aerobic exercise as an augmentation of exposure therapy in panic disorder with agoraphobia. J Psychiatr Res. 2018;101:34-41. doi:10.1016/j.jpsychires.2018.03.001

20. Korman N, Armour M, Chapman J, et al. High Intensity Interval training (HIIT) for people with severe mental illness: a systematic review & meta-analysis of intervention studies- considering diverse approaches for mental and physical recovery. Psychiatry Res. 2020;284:112601. doi:10.1016/j.psychres.2019.112601

21. Amir N, Beard C, Cobb M, et al. Attention modification program in individuals with generalized anxiety disorder. J Abnorm Psychol. 2009;118(1):28-33. doi:10.1037/a0012589

22. Hirsh CR, Mathews A. A cognitive model of pathological worry. Behav Res Ther. 2012;50(10):636-646. doi:10.1016/j.brat.2012.007

SECOND OF 2 PARTS

For patients with generalized anxiety disorder (GAD), the intensity, duration, and frequency of an individual’s anxiety and worry are out of proportion to the actual likelihood or impact of an anticipated event, and they often find it difficult to prevent worrisome thoughts from interfering with daily life.¹ Successful treatment for GAD is patient-specific and requires clinicians to consider all available psychotherapeutic and pharmacologic options.

In a 2020 meta-analysis of 79 randomized controlled trials (RCTs) with 11,002 participants diagnosed with GAD, Carl et al² focused on pooled effect sizes of evidence-based psychotherapies and medications for GAD. Their analysis showed a medium to large effect size (Hedges g = 0.76) for psychotherapy, compared to a small effect size (Hedges g = 0.38) for medication on GAD outcomes. Other meta-analyses have shown that evidence-based psychotherapies have large effect sizes on GAD outcomes.³

However, in most of the studies included in these meta-analyses, the 2 treatment modalities—psychotherapy and pharmacotherapy—use different control types. The pharmacotherapy trials used a placebo, while psychotherapy studies often had a waitlist control. Thus, the findings of these meta-analyses should not lead to the conclusion that psychotherapy is necessarily more effective for GAD symptoms than pharmacotherapy. However, there is clear evidence that psychosocial interventions are at least as effective as medications for treating GAD. Also, patients often prefer psychosocial treatment over medication.

Part 1 (Current Psychiatry, July 2022) of this 2-part article reviewed 8 RCTs of biological interventions for GAD published within the last 5 years.⁴ Part 2 discusses RCTs published in the last 3 years that studied psychosocial interventions (Table^5-12).

1. Simon NM, Hofmann SG, Rosenfield D, et al. Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: a randomized clinical trial. JAMA Psychiatry. 2021;78(1):13-20. doi:10.1001/jamapsychiatry.2020.2496

Cognitive-behavioral therapy (CBT) is a first-line therapy for GAD.¹³ However, patients may not pursue CBT due to fiscal and logistical constraints, as well as the stigma associated with it. Yoga is a common complementary health practice used by adults in the United States,¹⁴ although evidence has been inconclusive for its use in treating anxiety. Simon et al⁵ examined the efficacy of Kundalini yoga (KY) vs stress education (SE) and CBT for treating GAD.

Study design

A prospective, parallel-group, randomized-controlled, single-blind trial in 2 academic centers evaluated 226 adults age ≥18 who met DSM-5 criteria for GAD.
Participants were randomized into 3 groups: KY (n = 93), SE (n = 43), or CBT (n = 90), and monitored for 12 weeks to determine the efficacy of each therapy.
Exclusion criteria included current posttraumatic stress disorder, eating disorders, substance use disorders, significant suicidal ideation, mental disorder due to a medical or neurocognitive condition, lifetime psychosis, bipolar disorder (BD), developmental disorders, and having completed more than 5 yoga or CBT sessions in the past 5 years. Additionally, patients were either not taking medication for ≥2 weeks prior to the trial or had a stable regimen for ≥6 weeks.
Each therapy was guided by 2 instructors during 12 120-minute sessions with 20 minutes of daily assignments and presented in cohorts of 4 to 6 participants.
The primary outcome was an improvement in score on the Clinical Global Impression–Improvement scale from baseline at Week 12. Secondary measures included scores on the Meta-Cognitions Questionnaire and the Five Facet Mindfulness Questionnaire.

Outcomes

A total of 155 participants finished the posttreatment assessment, with similar completion rates between the groups, and 123 participants completed the 6-month follow-up assessment.
The KY group had a significantly higher response rate (54.2%) than the SE group (33%) at posttreatment, with a number needed to treat (NNT) of 4.59. At 6-month follow-up, the response rate in the KY group was not significantly higher than that of the SE group.
The CBT group had a significantly higher response rate (70.8%) than the SE group (33%) at posttreatment, with a NNT of 2.62. At 6-month follow-up, the CBT response rate (76.7%) was significantly higher than the SE group (48%), with a NNT of 3.51.
KY was not found to be as effective as CBT on noninferiority testing.

Continue to: Conclusions/limitations

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. American Psychiatric Association; 2022.

4. Saeed SA, Majarwitz DJ. Generalized anxiety disorder: 8 studies of biological interventions. Current Psychiatry. 2022;21(7):10-12,20,22-27. doi:10.12788/cp.02645

14. Clarke TC, Barnes PM, Black LI, et al. Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and over. NCHS Data Brief. 2018;(325):1-8.

16. Covin R, Ouimet AJ, Seeds PM, et al. A meta-analysis of CBT for pathological worry among clients with GAD. J Anxiety Disord. 2008;22(1):108-116. doi:10.1016/j.janxdis.2007.01.002

21. Amir N, Beard C, Cobb M, et al. Attention modification program in individuals with generalized anxiety disorder. J Abnorm Psychol. 2009;118(1):28-33. doi:10.1037/a0012589

22. Hirsh CR, Mathews A. A cognitive model of pathological worry. Behav Res Ther. 2012;50(10):636-646. doi:10.1016/j.brat.2012.007

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Generalized anxiety disorder: 8 studies of psychosocial interventions

References

SECOND OF 2 PARTS

1. Simon NM, Hofmann SG, Rosenfield D, et al. Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: a randomized clinical trial. JAMA Psychiatry. 2021;78(1):13-20. doi:10.1001/jamapsychiatry.2020.2496

Study design

Outcomes

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