SummaryIn this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo-or comparator-controlled

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World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision

The basic framework of the cognitive theory of psychopathology and cognitive therapy of specific psychiatric disorders was developed more than 40 years ago. Since that time, there has been continuing progress in the development of cognitive theory and therapy and in the empirical testing of both. A substantial body of research supports the cognitive model of depression and, to a somewhat lesser extent, the various anxiety disorders. Cognitive therapy (CT), often labeled as the generic term cognitive behavior therapy , has been shown to be effective in reducing symptoms and relapse rates, with or without medication, in a wide variety of psychiatric disorders. Suggestions for future research and applications are presented.

https://jamanetwork.com/journals/PSYCH/articlepdf/1108411/yps40003.pdf

The current state of cognitive therapy: a 40-year retrospective.

To date, few studies have been published on the doseresponse relationship, but there is general consensus that between 13 and 18 sessions of therapy are required for 50% of patients to improve. Reviewing the clinical trials literature reveals that in carefully controlled and implemented treatments, between 57.6% and 67.2% of patients improve within an average of 12.7 sessions. Using naturalistic data, however, revealed that the average number of sessions received in a national database of over 6,000 patients was less than five. The rate of improvement in this sample was only about 20%. These results suggest that patients, on average, do not get adequate exposure to psychotherapy, nor do they recover from illness at rates observed in clinical trials research.

http://dunx1.irt.drexel.edu/~emf27/Lab%20Group/Publications%20and%20Presentations_files/Hansen%20Lambert%20and%20Forman%202002.pdf

The Psychotherapy Dose‐Response Effect and Its Implications for Treatment Delivery Services

The authors report a meta-analysis of high-quality studies published from 1990-1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects: that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals: and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and meta-analyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples.

A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies.

The efficacy of cognitive behavioral treatments (CBT) for anxiety in adults has been supported by multiple meta-analyses. However, most have focused on only 1 diagnosis, thereby disallowing diagnostic comparisons. This study examined the efficacy of CBT across the anxiety disorders. One hundred eight trials of CBT for an anxiety disorder met study criteria. Cognitive therapy and exposure therapy alone, in combination, or combined with relaxation training, were efficacious across the anxiety disorders, with no differential efficacy for any treatment components for any specific diagnoses. However, when comparing across diagnoses, outcomes for generalized anxiety disorder and posttraumatic stress disorder were superior to those for social anxiety disorder, but no other differences emerged. CBT effects were superior to those for no-treatment and expectancy control treatments, although tentative evidence suggested equal effects of CBT when compared with relaxation-only treatments.

A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders.

BACKGROUND We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8-10 sessions of therapy is as effective as 16-20 sessions, and (c) brief therapist training is as effective as intensive training.

METHOD Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM-III-R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up.

RESULTS Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change.

CONCLUSIONS Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16-20 sessions of treatment is more effective, on average, than 8-10 sessions.

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder.

This paper concerns an investigation of outcome predictors in a clinical trial of psychological therapies for generalized anxiety disorder. A variety of information of potential predictive value was obtained at three stages of patient contact: the initial referral, a screening interview and early sessions of therapy. Three measures of the clinical significance of change over a 12-month follow-up period were used to construct a composite measure which categorized outcome in terms of sustained improvement, relapse and no consistent change. Logistic regression was used to examine the validity of predictors identified in previous research and the relative importance of data obtained from the three different stages. Seventy-one per cent of patients were correctly classified as improved or not from initial data with a significant increase in accuracy with information from the screening interview (77 per cent) and early sessions (82 per cent). Patients who relapsed or not were predicted with considerable accuracy from initial data (90 per cent) and there was no significant increase in predictive power with additional information. The most powerful and robust predictors were: type of treatment received, marital status, marital tension and complexity of clinical presentation in terms of axis 1 co-morbidity. A conceptual framework for prediction is outlined.

On predicting improvement and relapse in generalized anxiety disorder following psychotherapy.

Comparative outcome studies of generalised anxiety disorder suggest that psychological therapy is a potentially valuable alternative to anxiolytic medication. However, on average psychological therapy results in modest improvements in symptoms, with about 50% of patients achieving normal functioning. Limited follow-up data indicate that these changes are maintained over six months. Cognitive therapy appears to be most effective, although comparisons with other therapies are limited and non-specific factors are clearly important. There is also evidence of considerable variability in outcome between studies, with the best results obtained with patients who are free of anxiolytic medication and recruited directly from primary care or other non-psychiatric settings. The effects on outcome of patient characteristics known to be associated with more severe illness and complexity of clinical presentation have yet to be explored. A balanced appraisal of the value of psychological therapy with this common condition requires a fuller description of sample characteristics and more systematic investigation of the clinical significance of treatment effects over the long term.

Thérèse Allan

Papers

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder.

On predicting improvement and relapse in generalized anxiety disorder following psychotherapy.

Psychological treatment of generalised anxiety disorder. A review of the clinical significance of results in outcome studies since 1980.