Robert C. Durham

Recovery rates in generalized anxiety disorder following psychological therapy: an analysis of clinically significant change in the STAI-T across outcome studies since 1990

BACKGROUND There have been six randomized controlled trials of psychological therapy with generalized anxiety disorder (GAD) using DSM-III-R and DSM-IV. All have used the Trait version of the Spielberger State-Trait Anxiety Inventory (STAI-T) as one of several outcome measures. Each study, however, employed different methods of calculating the clinical significance of outcomes making it difficult to reach a balanced appraisal of the efficacy of psychological treatment. METHODS Raw data on STAI-T scores at pre-, post- and follow-up were obtained for each of the six studies (total N = 404). Jacobson methodology for defining clinically significant change (criterion c, reliable change index = 8, cut-off point = 46) was used to allocate each patient to one of four outcomes: worse, unchanged, improved and recovered. The proportion of patients in each category was calculated for treatment conditions in each study and also for aggregate data across types of treatment. RESULTS A recovery rate of 40% was found for the sample as a whole with 12 of the 20 treatment conditions obtaining very modest recovery rates of 30% or less. Two treatment approaches--individual cognitive behavioural therapy and applied relaxation--do relatively well with overall recovery rates at 6-month follow-up of 50-60%. CONCLUSIONS Jacobson methodology, in distinguishing between improvement and recovery on a standardized measure of general vulnerability to anxiety, provides a stringent but clinically more meaningful evaluation of the efficacy of psychological therapies with GAD than has been available hitherto. Systematic focus on either excessive worry or physiological arousal gives worthwhile results.

Does cognitive-behavioural therapy influence the long-term outcome of generalized anxiety disorder? An 8–14 year follow-up of two clinical trials

BACKGROUND Generalized anxiety disorder is a common condition of excessive worry and tension which tends to run a chronic course associated with significant psychiatric and medical problems. Cognitive behaviour therapy (CBT) has been shown to be of clinical value in about 50% of cases with treatment gains maintained over follow-up periods ranging from 6 to 12 months. The potential value of CBT over the longer term has not been subject to rigorous investigation. METHOD Results are reported of 8-14 year follow-up of two randomized controlled trials of cognitive-behaviour therapy for generalized anxiety disorder employing structured interview with an assessor blind to initial treatment condition. Comparison groups included medication and placebo in one study based in primary care, and analytical psychotherapy in the other based in secondary care. Follow-up samples (30% and 55% of trial entrants) were broadly representative of the original cohorts. RESULTS Overall, 50% of participants were markedly improved of whom 30-40% were recovered (i.e. free of symptoms). Outcome was significantly worse for the study based in secondary care in which the clinical presentation of participants was more complex and severe. For a minority (30-40%), mainly from the secondary care study, outcome was poor. Treatment with CBT was associated with significantly lower overall severity of symptomatology and less interim treatment, in comparison with non-CBT conditions, but there was no evidence that CBT influenced diagnostic status, probability of recovery or patient perceptions of overall improvement. CONCLUSIONS Both CBT and the complexity and severity of presenting problems appear to influence the long-term outcome of GAD.

Cognitive therapy vs behaviour therapy in the treatment of chronic general anxiety

Abstract Psychiatric outpatients with a diagnosis of chronic anxiety of at least one years duration were randomly assigned to either behaviour therapy or Becks cognitive therapy, and to one of two experienced therapists. Both treatment conditions followed the therapeutic processes described in Becks treatment manual for anxiety states, but the behaviour therapy condition excluded any attempt to modify automatic thoughts, thinking errors, or underlying assumptions. However, it did include the use of positive self-statements. Treatment consisted of a maximum of 16 1-hour sessions. Several outcome measures were administered before treatment, during treatment, at discharge, and at 6 month follow-up. At the end of treatment there was no difference between the cognitive and behavioural treatments in the amount of improvement observed. By the 6 month follow-up, however, there was a trend, which was significant on a number of outcome measures, for the cognitive therapy patients to maintain or improve upon their progress and for the behaviour therapy patients to revert toward their pre-treatment scores.

Complexity and collaboration in routine practice of CBT: What doesn't work with whom and how might it work better?

There is compelling evidence from specialist research centres for the efficacy of cognitive-behavioural therapy (CBT) with a variety of psychiatric disorders but effectiveness in routine clinical practice has yet to be established. The complex tasks confronting those generalist practitioners who see a broad range of referrals are analysed in terms of the breadth of treatable disorders, the variable nature of patient characteristics and the pressures of work. This analysis suggests that effectiveness and efficiency in routine practice of CBT will be compromised unless therapists work in small teams and adopt some of the rigours and objectivity of the research context. In particular, it is suggested that clinical practice should include routine assessment of complexity and severity of problems at a screening interview and quality of collaboration after a trial period of treatment. Therapy for those cases with high complexity and poor collaboration should incorporate peer-aided clinical supervision and periodic review.