Generalized Anxiety Disorder: 8 Studies of Psychosocial Interventions

Sy Atezaz Saeed, MD, MS; Daniel John Majarwitz, MD

Curr Psychiatr. 2022;21(10):33-45.

Abstract and Introduction

Introduction

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 al^[2] 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] page 34 ).

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Table. Psychosocial interventions for generalized anxiety disorder: 8 studies
Study	Design	Outcomes
Simon et al⁵	Adults age ≥18 who met DSM-5 criteria for GAD were randomized to receive Kundalini yoga (n = 93), stress education (n = 43), or CBT (n = 90)	CBT and Kundalini yoga were both more effective than stress education in short-term response rates. CBT appeared to have better long-term response outcomes compared to stress education, while Kundalini yoga did not show benefit in the long-term analyses
Gould et al⁶	Adults age ≥65 (N = 37) who met MINI and DSM-IV criteria for GAD and experienced resistance to first-line treatment received up to 16 1-on-1 sessions of ACT	Although the study was not powered to assess clinical effectiveness, there was some evidence of ACT reducing anxiety and depression, and increasing psychological flexibility
Stefan et al⁷	Adults age 20 to 51 who met DSM-IV and Structured Clinical Interview criteria for GAD were randomized to receive CT/BTP (n = 23), REBT (n = 24), or ACT/ABBT (n = 24)	CT/BTP, REBT, and ACT/ABBT each appeared to be efficacious in reducing GAD symptoms. There were no statistically significant differences among the 3 versions of CBT
Plag et al⁸	German adults age ≥18 (N = 33) who met DSM-5 criteria for GAD were randomized to a high-intensity exercise group or a control group of lower-intensity exercise	Both groups experienced reduced worrying, though the high-intensity exercise group had a larger decrease. The high-intensity exercise group also experienced greater reductions in anxiety and depression scores
Amir et al⁹	Adults age 18 to 65 (N = 169) who met DSM-IV criteria for GAD were randomized to receive ABM followed by AR-pe, AR-pe followed by ABM, simultaneous ABM and AR-pe, or a control group	Both the ABM followed by AR-pe group and the AR-pe followed by ABM group had significant reductions in HAM-A scores compared to the control group. The simultaneous ABM and AR-pe group did not experience significantly different outcomes compared to the control group
Burke et al¹⁰	Adults age 18 to 45 (N = 36) from an Irish university who scored ≥10 on the GAD-7 were randomized to an immediate iCBT group or a delayed access to treatment/waiting list control group	iCBT may be a useful and accessible approach in the treatment of GAD, although there are still hindrances to its use
Miller et al¹¹	Adults age ≥18 (N = 21) who scored ≥10 on the GAD-7 accessed a digital CBT smartphone program called Daylight	Daily and weekly outcomes provided preliminary evidence of efficacy of the program for improving GAD symptoms
Hirsch et al¹²	Patients with GAD or GAD plus MDD who scored ≥62 on the PSWQ and ≥10 on the GAD-7 were randomized to an internet-delivered cognitive bias modification for interpretation group (n = 115) or a control group (n = 115)	Internet-delivered cognitive bias modification for interpretation appears to promote a positive interpretation bias, reduce negative intrusions, and reduce levels of worrying, anxiety, repetitive negative thinking, and ruminations

ABM: attention bias modification; ACT: acceptance and commitment therapy; ACT/ABBT: acceptance and commitment therapy/acceptance-based behavioral therapy; AR-pe: applied relaxation psychoeducation; CBT: cognitive-behavioral therapy; CT/BTP: cognitive therapy/Borkovec's treatment package; GAD: generalized anxiety disorder; GAD-7: Generalized Anxiety Disorder 7-item scale; HAM-A: Hamilton Anxiety Rating Scale; iCBT: internet-based cognitive-behavioral therapy; MDD: major depressive disorder; MINI: Mini-International Neuropsychiatric Interview; PSWQ: Penn State Worry Questionnaire; REBT: rational emotive behavior therapy