Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Psychiatry
Published in: BMC Psychiatry 1/2024

Open Access 01-12-2024 | Anxiety | Research

A meta-analysis on the efficacy of low-intensity cognitive behavioural therapy for generalised anxiety disorder

Authors: Candice L. Y. M. Powell, Chun Yuen Chiu, Xiaoqi Sun, Suzanne Ho-wai So

Published in: BMC Psychiatry | Issue 1/2024

Login to get access

Abstract

Background

Low-intensity cognitive behavioural therapy (LICBT) has been recommended as a primary intervention in the tiered care for mild to moderate generalised anxiety disorder. However, LICBT for generalised anxiety disorder are markedly diverse and efficacy data on various outcomes have not been systematically reviewed. This meta-analysis aimed to synthesise effect sizes of three NICE-recommended LICBT for generalised anxiety disorder: non-facilitated self-help, guided self-help, and psychoeducational groups.

Methods

A systematic literature review of randomised controlled trials (RCTs) examining LICBT for generalised anxiety disorder in the last 23 years (2000–2023) was conducted. Efficacy data for anxiety, depression, and worry outcomes were separately meta-analysed. The study was reported following the PRISMA guidelines.

Results

The systematic review identified 12 RCTs out of 1205 papers. The three meta-analyses consisted of 12 (anxiety), 11 (depression), and 9 (worry) effect sizes respectively, including total sample sizes of 1201 (anxiety), 1164 (depression), and 908 (worry). The adjusted effect sizes for reductions in anxiety (g = -0.63), depression (g = -0.48), and worry (g = -0.64) were all in the medium range, favouring LICBT over control conditions. Between-study heterogeneity was significant on anxiety and worry, with no specific moderators identified by meta-regression.

Conclusions

LICBT has shown promise as an effective and efficient treatment modality for individuals with generalised anxiety disorder. Future research comparing various LICBT subtypes and treatment components will further inform clinical practice.

Trial registration

This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; record ID CRD42021285590).
Appendix
Available only for authorised users
Literature
1.
Ruscio AM, Hallion LS, Lim CCW, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Andrade LH, Borges G, Bromet EJ, Bunting B, et al. Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA Psychiat. 2017;74(5):465–75.CrossRef
2.
Ter Meulen WG, Draisma S, van Hemert AM, Schoevers RA, Kupka RW, Beekman ATF, Penninx B. Depressive and anxiety disorders in concert-a synthesis of findings on comorbidity in the NESDA study. J Affect Disord. 2021;284:85–97.PubMedCrossRef
3.
Zbozinek TD, Rose RD, Wolitzky-Taylor KB, Sherbourne C, Sullivan G, Stein MB, Roy-Byrne PP, Craske MG. Diagnostic overlap of generalized anxiety disorder and major depressive disorder in a primary care sample. Depress Anxiety. 2012;29(12):1065–71.PubMedPubMedCentralCrossRef
4.
Bjornsson AS, Sibrava NJ, Beard C, Moitra E, Weisberg RB, Benitez CI, Keller MB. Two-year course of generalized anxiety disorder, social anxiety disorder, and panic disorder with agoraphobia in a sample of Latino adults. J Consult Clin Psychol. 2014;82(6):1186–92.PubMedPubMedCentralCrossRef
5.
Sibrava NJ, Beard C, Bjornsson AS, Moitra E, Weisberg RB, Keller MB. Two-year course of generalized anxiety disorder, social anxiety disorder, and panic disorder in a longitudinal sample of African American adults. J Consult Clin Psychol. 2013;81(6):1052–62.PubMedPubMedCentralCrossRef
6.
Yonkers KA, Dyck IR, Warshaw M, Keller MB. Factors predicting the clinical course of generalised anxiety disorder. Br J Psychiatry. 2000;176(6):544–9.PubMedCrossRef
7.
Rodriguez BF, Weisberg RB, Pagano ME, Bruce SE, Spencer MA, Culpepper L, Keller MB. Characteristics and predictors of full and partial recovery from generalized anxiety disorder in primary care patients. J Nerv Ment Dis. 2006;194(2):91.PubMedPubMedCentralCrossRef
8.
Tully PJ, Winefield HR, Baker RA, Denollet J, Pedersen SS, Wittert GA, Turnbull DA. Depression, anxiety and major adverse cardiovascular and cerebrovascular events in patients following coronary artery bypass graft surgery: a five year longitudinal cohort study. BioPsychoSoc Med. 2015;9:14.PubMedPubMedCentralCrossRef
9.
Celano CM, Daunis DJ, Lokko HN, Campbell KA, Huffman JC. Anxiety Disorders and Cardiovascular Disease. Curr Psychiat Rep. 2016;18(11):101.CrossRef
10.
Comer JS, Blanco C, Hasin DS, Liu S-M, Grant BF, Turner JB, Olfson M. Health-related quality of life across the anxiety disorders. J Clin Psychiatry. 2011;72(01):43–50.PubMedCrossRef
11.
Romera I, Fernández-Pérez S, Montejo AL, Caballero F, Caballero L, Arbesú JÁ, Delgado-cohen H, Desaiah D, Polavieja PGD, Gilaberte I. Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: prevalence of painful somatic symptoms, functioning and health status. J Affect Disord. 2010;127(1–3):160–8.PubMedCrossRef
12.
Revicki DA, Travers K, Wyrwich KW, Svedsäter H, Locklear JC, Mattera MS, Sheehan DV, Montgomery S. Humanistic and economic burden of generalized anxiety disorder in North America and Europe. J Affect Disorders. 2012;140(2):103–12.PubMedCrossRef
13.
Zhu B, Zhao Z, Ye W, Marciniak MD, Swindle RWJ. The cost of comorbid depression and pain for individuals diagnosed with generalized anxiety disorder. J Ner Ment Dis. 2009;197:136–9.CrossRef
14.
15.
National Institute for Health and Care Excellence [NICE]: Common mental health disorders: identification and pathways to care. NICE guideline (CG123) 2011.
16.
The National Collaborating Centre for Mental Health. Improving Access to Psychological Therapies Manual. 2021.
17.
Powell CLYM, Lo AP-K, Yeung GTY, Leung NTY, Mak WWS, So SH-w, et al. A pilot study on the effectiveness of low-intensity cognitive behavioural therapy (LiCBT) for common mental disorders in Hong Kong. Behav Cogn Psychoth. 2021;49(6):758–63.
18.
Baigent M, Smith D, Battersby M, Lawn S, Redpath P, McCoy A. The Australian version of IAPT: clinical outcomes of the multi-site cohort study of NewAccess. J Ment Health. 2020;32(1):341–50.PubMedCrossRef
19.
NHS England: Psychological Therapies: reports on the use of IAPT services, England, June 2018 Final, including a report on the IAPT Employment Advisers pilot. In Psychological Therapies, Reports on the use of IAPT services 2018.
20.
National Institute for Health and Care Excellence [NICE]: Generalised anxiety disorder and panic disorder in adults: management. NICE guideline (CG113) 2011.
21.
LeBlanc NJ, Bartuska AD, Blanchard L, Baker AW, Bui E. Cognitive-behavioral treatment for generalized anxiety disorder: theoretical foundations and empirically supported strategies. Psychiatr Ann. 2021;51:210–5.CrossRef
22.
Newman MG, Zainal NH, Hoyer J. Cognitive-Behavioral Therapy (CBT) for Generalized Anxiety Disorder (GAD). In: Generalized Anxiety Disorder and Worrying. edn. 2020. p. 203–30.CrossRef
23.
Siev J, Chambless DL. Specificity of treatment effects: cognitive therapy and relaxation for generalized anxiety and panic disorders. J Consult Clin Psych. 2007;75(4):513–22.CrossRef
24.
Dugas MJ, Marchand A, Ladouceur R. Further validation of a cognitive-behavioral model of generalized anxiety disorder: Diagnostic and symptom specificity. J Anxiety Disord. 2005;19(3):329–43.PubMedCrossRef
25.
Covin R, Ouimet AJ, Seeds PM, Dozois DJA. A meta-analysis of CBT for pathological worry among clients with GAD. J Anxiety Disord. 2008;22(1):108–16.PubMedCrossRef
26.
Cuijpers P, Sijbrandij M, Koole SL, Huibers MJH, Berking M, Andersson G. Psychological treatment of generalized anxiety disorder: a meta-analysis. Clin Psychol Rev. 2014;34(2):130–40.PubMedCrossRef
27.
Hanrahan F, Field AP, Jones FW, Davey GCL. A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clin Psychol Rev. 2013;33(1):120–32.PubMedCrossRef
28.
Carpenter JK, Andrews LA, Witcraft SM, Powers MB, Smits JA, Hofmann SG. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018;35(6):502–14.PubMedPubMedCentralCrossRef
29.
Cromarty P, Drummond A, Francis T, Watson J, Battersby MW. NewAccess for depression and anxiety: adapting the UK Improving Access to Psychological Therapies Program across Australia. Australas Psychiatry. 2016;24:489–92.PubMedCrossRef
30.
Shafran R, Myles-Hooton P, Bennett SD, Öst L-G. The concept and definition of low intensity cognitive behaviour therapy. Behav Res Ther. 2021;138:103803.PubMedCrossRef
31.
Eilert N, Enrique Á, Wogan R, Mooney O, Timulak L, Richards D. The effectiveness of Internet-delivered treatment for generalized anxiety disorder: an updated systematic review and meta-analysis. Depress Anxiety. 2020;38:196–219.PubMedPubMedCentralCrossRef
32.
Richards D, Timulak L, O’Brien E, Hayes C, Viganó N, Sharry J, Doherty G. A randomized controlled trial of an internet-delivered treatment: Its potential as a low-intensity community intervention for adults with symptoms of depression. Eur Psychiat. 2015;33:S112–S112.CrossRef
33.
Andersson G, Carlbring P, Titov N, Lindefors N. Internet interventions for adults with anxiety and mood disorders: a narrative umbrella review of recent meta-analyses. Can J Psychiatry. 2019;64(7):465–70.PubMedPubMedCentralCrossRef
34.
Haug T, Nordgreen T, Öst L-G, Havik OE. Self-help treatment of anxiety disorders: a meta-analysis and meta-regression of effects and potential moderators. Clin Psychol Rev. 2012;32(5):425–45.PubMedCrossRef
35.
Hunot V, Churchill R, de SilvaLima M, Teixeira VB. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;1:CD001848.
36.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.PubMedPubMedCentralCrossRef
37.
* Al-Alawi M, McCall RK, Sultan A, Al Balushi N, Al-Mahrouqi T, Al Ghailani A, Al Sabti H, Al-Maniri A, Panchatcharam SM, Al Sinawi H. Efficacy of a six-week-long therapist-guided online therapy versus self-help internet-based therapy for COVID-19–induced anxiety and depression: open-label, pragmatic, randomized controlled trial. JMIR Ment Health. 2021;8(2):e26683.
38.
* Andersson G, Paxling B, Roch-Norlund P, Östman G, Norgren A, Almlöv J, Georén L, Breitholtz E, Dahlin M, Cuijpers P. Internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: a randomized controlled trial. Psychother Psychosom. 2012;81(6):344–55.
39.
* Carl JR, Miller CB, Henry AL, Davis ML, Stott R, Smits JA, Emsley R, Gu J, Shin O, Otto MW. Efficacy of digital cognitive behavioral therapy for moderate-to-severe symptoms of generalized anxiety disorder: a randomized controlled trial. Depress Anxiety. 2020;37(12):1168–78.
40.
* Dahlin M, Andersson G, Magnusson K, Johansson T, Sjögren J, Håkansson A, Pettersson M, Kadowaki Å, Cuijpers P, Carlbring P. Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: a randomized controlled trial. Behav Res Ther. 2016;77:86–95.
41.
* Jones SL, Hadjistavropoulos HD, Soucy JN. A randomized controlled trial of guided internet-delivered cognitive behaviour therapy for older adults with generalized anxiety. J Anx Disord. 2016;37:1–9.
42.
* Newman MG, Przeworski A, Consoli AJ, Taylor CB. A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder. Psychotherapy. 2014;51(2):198–206.
43.
* Paxling B, Almlöv J, Dahlin M, Carlbring P, Breitholtz E, Eriksson T, Andersson G. Guided Internet-delivered cognitive behavior therapy for generalized anxiety disorder: a randomized controlled trial. Cogn Behav Therapy. 2011;40:159–73.
44.
* Richards D, Timulak L, Rashleigh C, McLoughlin O, Colla A, Joyce C, Doherty G, Sharry J, Duffy D, Anderson-Gibbons M. Effectiveness of an internet-delivered intervention for generalized anxiety disorder in routine care: a randomised controlled trial in a student population. Internet Interv. 2016;6:80–8.
45.
* Robinson E, Titov N, Andrews G, McIntyre K, Schwencke G, Solley K. Internet treatment for generalized anxiety disorder: a randomized controlled trial Comparing Clinician vs. Technician Assistance. PLoS One. 2010;5:e10942.
46.
* Rollman BL, Herbeck Belnap B, Abebe KZ, Spring MB, Rotondi AJ, Rothenberger SD, Karp JF. Effectiveness of online collaborative care for treating mood and anxiety disorders in primary care. JAMA Psychiatry. 2017;75:56–64.
47.
* Terides MD, Dear BF, Fogliati VJ, Gandy M, Karin E, Jones MP, et al. Increased skillsusage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy fordepression and anxiety: a randomised controlled trial. Cogn Behav Ther. 2017;47(1):43–61. https://​doi.​org/​10.​1080/​16506073.​2017.​1347195.
48.
* Titov N, Andrews G, Robinson E, Schwencke G, Johnston L, Solley K, Choi I. Clinician-assisted internet-based treatment is effective for generalized anxiety disorder: randomized controlled trial. Aust NZ J Psychiat. 2009;43:905–12.
49.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7.PubMedCrossRef
50.
Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consul Clin Psych. 1988;56(6):893–7.CrossRef
51.
Cella D, Yount S, Rothrock N, Gershon R, Cook K, Reeve B, Ader D, Fries JF, Bruce B, Rose M. The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years. Med Care. 2007;45(5 Suppl 1):S3.PubMedPubMedCentralCrossRef
52.
Hamilton M. The assessment of anxiety states by rating. Bri J Med Psychol. 1959;32(1):50–5.CrossRef
53.
Newman MG, Zuellig AR, Kachin KE, Constantino MJ, Przeworski A, Erickson T, Cashman-McGrath L. Preliminary reliability and validity of the Generalized Anxiety Disorder Questionnaire-IV: a revised self-report diagnostic measure of generalized anxiety disorder. Behav Ther. 2002;33(2):215–33.CrossRef
54.
Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists; 1983.
55.
Pachana NA, Byrne GJ, Siddle H, Koloski NA, Harley E, Arnold E. Development and validation of the geriatric anxiety inventory. Int Psychogeriatr. 2006;19:103–14.CrossRef
56.
57.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiat. 1961;4(6):561–71.PubMedCrossRef
58.
Beck AT, Steer RA, Brown G: Beck depression inventory–II. Psychol Assessment 1996.
59.
Montgomery S, Åsberg M. A New Depression Scale Designed to be Sensitive to Change. Bri J Psychiatry. 1979;134:382–9.CrossRef
60.
Sheikh J, Yesavage JA. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clin Gerontologist. 1986;5:165–73.CrossRef
61.
Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the Penn State Worry Questionnaire. Behav Res Ther. 1990;28(6):487–95.PubMedCrossRef
62.
Hopko DR, Reas DL, Beck JG, Stanley MA, Wetherell JL, Novy DM, Averill PM. Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychol Assessment. 2003;15(2):173–83.CrossRef
63.
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge S, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.PubMedCrossRef
64.
65.
66.
Duval S, Tweedie R. Trim and fill: a simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–63.PubMedCrossRef
67.
Cooper H, Hedges LV, Valentine JC: The handbook of research synthesis and meta-analysis: Russell Sage Foundation; 2019.
68.
Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive meta-analysis version 3. Englewood, NJ. Biostatistics. 2005;2005:104.
69.
Borenstein M, Hedges L, Higgins J, Rothstein H: Introduction to meta-analysis: John Wiley & Sons; 2009.
70.
Riley RD, Higgins JPT, Deeks JJ. Interpretation of random effects meta-analyses. BMJ. 2011;342:d549.PubMedCrossRef
71.
Viechtbauer W, Cheung MWL. Outlier and influence diagnostics for meta-analysis. Res Synth Methods. 2010;1:112–25.PubMedCrossRef
72.
National Collaborating Centre for Mental Health (UK). Generalised Anxiety Disorder in Adults: Management in Primary, Secondary and Community Care. Leicester: British Psychological Society; 2011.
73.
van der Heiden C, Muris P, van der Molen HT. Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder. Behav Res Ther. 2012;50(2):100–9.PubMedCrossRef
74.
Linden AH, Hönekopp J. Heterogeneity of research results: A new perspective from which to assess and promote progress in psychological science. Perspect Psychol Sci. 2021;16:358–76.PubMedPubMedCentralCrossRef
75.
76.
Cuijpers P, Griffin JW, Furukawa TA. The lack of statistical power of subgroup analyses in meta-analyses: a cautionary note. Epidemiol Psychiatr Sci. 2021;31:e78.CrossRef
77.
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. Bri J Psychiatry. 2018;212(6):333–8.CrossRef
Metadata
Title
A meta-analysis on the efficacy of low-intensity cognitive behavioural therapy for generalised anxiety disorder
Authors
Candice L. Y. M. Powell
Chun Yuen Chiu
Xiaoqi Sun
Suzanne Ho-wai So
Publication date
01-12-2024
Publisher
BioMed Central
Published in
BMC Psychiatry / Issue 1/2024
Electronic ISSN: 1471-244X
DOI
https://doi.org/10.1186/s12888-023-05306-6

Other articles of this Issue 1/2024

BMC Psychiatry 1/2024 Go to the issue

Research

Social media addiction: associations with attachment style, mental distress, and personality

Research

‘Fear, uncertain, tired…...’ psychological distress among pulmonary hypertension patients: a qualitative interview study

Study Protocol

Evaluating the effect of action-like video game play and of casual video game play on anxiety in adolescents with elevated anxiety: protocol for a multi-center, parallel group, assessor-blind, randomized controlled trial

Research

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study

Research

Are social pressure, bullying and low social support associated with depressive symptoms, self-harm and self-directed violence among adolescents? A cross-sectional study using a structural equation modeling approach

Research

Why do patients want medication free treatment for psychosis? An explorative study on reasons for applying to medication free programs