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

Conclusions/limitations

iCBT may be a useful and accessible approach for treating GAD, although there are still hindrances to its use.
This study was qualitative and did not comment on the efficacy of the applied intervention.
The benefits of iCBT may differ depending on the patient’s level of computer literacy.

7. 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

Access to CBT is limited due to cost, dearth of trained therapists, scheduling availability, stigma, and transportation. Digital CBT may help overcome these obstacles. Miller et al¹¹ studied the feasibility and efficacy of a new automated, digital CBT intervention named Daylight.

Study design

This randomized, multiple-baseline, single-case, experimental trial included 21 adults (20 women) age ≥18 who scored ≥10 on the GAD-7 and screened positive for GAD on MINI version 7 for DSM-5.
Participants were not taking psychotropic medications or had been on a stable medication regimen for ≥4 weeks.
Exclusion criteria included past or present psychosis, schizophrenia, BD, seizure disorder, substance use disorder, trauma to the head or brain damage, severe cognitive impairment, serious physical health concerns necessitating surgery or with prognosis <6 months, and pregnancy.
Participants were randomized to 1 of 3 baseline durations: 2 weeks, 4 weeks, or 6 weeks. They then could access the smartphone program Daylight. The trial lasted for 12 to 16 weeks.
Primary anxiety outcomes were assessed daily and weekly, while secondary outcomes (depressive symptoms, sleep) were measured weekly.
Postintervention was defined as 6 weeks after the start of the intervention and follow-up was 10 weeks after the start of the intervention.
Participants were deemed not to have clinically significant anxiety if they scored <10 on GAD-7; not to have significant depressive symptoms if they scored <10 on the Patient Health Questionnaire-9 (PHQ-9); and not to have sleep difficulty if they scored >16 on the Sleep Condition Indicator (SCI-8). The change was considered reliable if patients scored below the previously discussed thresholds and showed a difference in score greater than the known unreliability of the questionnaire (GAD-7 reductions ≥5, PHQ-9 reductions ≥6, SCI-8 increases ≥7).

Outcomes

In terms of feasibility, 76% of participants completed all 4 modules, 81% completed 3 modules, 86% completed 2 modules, and all participants completed at least 1 module.
No serious adverse events were observed, but 43% of participants reported unwanted symptoms such as agitation, fatigue, low mood, or reduced motivation.
As evaluated by the Credibility/Expectancy Questionnaire, the program received moderate to high credibility scores. Participants indicated they were mostly satisfied with the program, although some expressed technical difficulties and a lack of specificity to their anxiety symptoms.
Overall daily anxiety scores significantly decreased from baseline to postintervention (P < .001). Weekly anxiety scores significantly decreased from baseline to postintervention (P = .024), and follow-up (P = .017) as measured by the GAD-7.
For participants with anxiety, 70% no longer had clinically significant anxiety symptoms postintervention, and 65% had both clinically significant and reliable change at postintervention. Eighty percent had clinically significant and reliable change at follow-up.
For participants with depressive symptoms, 61% had clinical and reliable change at postintervention and 44% maintained both at follow-up.
For participants with sleep disturbances, 35% had clinical and reliable improvement at postintervention and 40% had clinical and reliable change at follow-up.

Conclusions/limitations

Daylight appears to be a feasible program with regards to acceptability, engagement, credibility, satisfaction, and safety.
The daily and weekly outcomes support preliminary evidence of program efficacy in improving GAD symptoms.
Most participants identified as female and were recruited online, which limits generalizability, and the study had a small sample size.

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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

Conclusions/limitations

7. 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

Study design

Outcomes

Conclusions/limitations

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