Anxiety -- CBT

Children

James, A. C., James, G., Cowdrey, F. A., Soler, A., & Choke, A. (2013). Cognitive behavioural therapy for anxiety disorders in children and adolescents. The Cochrane Library 2013, Issue 6.

• Meta-analysis. 
• Forty-one studies consisting of 1806 participants were included in the analyses. The studies involved children and adolescents with anxiety of mild to moderate severity in university and community clinics and school settings. 
• CBT is significantly more effective than no therapy in reducing symptoms of anxiety in children and young people. No clear evidence indicates that one way of providing CBT is more effective than another (e.g. in a group, individually, with parents). CBT is no more effective than other 'active therapies’ such as self-help books. The small number of studies meant the review authors could not compare CBT with medication. Only four studies looked at longer-term outcomes after CBT. No clear evidence showed maintained improvement in symptoms of anxiety among children and young people. 
• Cognitive behavioural therapy is an effective treatment for childhood and adolescent anxiety disorders; however, the evidence suggesting that CBT is more effective than active controls or TAU or medication at follow-up, is limited and inconclusive.
• Cognitive behavioural therapy (CBT) is an important therapy for the treatment of anxiety disorders in children and adolescents. This review alongside those in adults (Otte 2011) and older adults (Gould 2012) suggests that CBT is effective across the age range, and CBT can, therefore, be recommended more generally for the treatment of anxiety disorders.The number of studies and reviews is now reasonably large; however, studies are confined to community or outpatient samples with mild to moderate cases only. Evidence derived from this review indicates that CBT is effective in 59% of cases compared with a natural remission rate of 16.1% in waiting list controls, and with an NNT of 6, CBT is associated with a clinically robust effect (Laupacis 1988). 

Davis, R., Souza, M. A. M. D., Rigatti, R., & Heldt, E. (2014). Cognitive-behavioral therapy for anxiety disorders in children and adolescents: a systematic review of follow-up studies. Jornal Brasileiro de Psiquiatria, 63(4), 373-378.

• [T]his study aims to carry out a systematic review of follow-up studies assessing CBT for ADs [Anxiety Disorders] in children and adolescents. 
• 10 studies. 
• It can be observed that the follow-up period in the study ranged from 12 months to 13 years after CBT.
• in most studies, the benefits of therapy regarding anxiety and depression symptoms were maintained over time; in three of them, improvement was greater at the follow-up in five there was an improvement compared to the baseline, but no significant difference regarding the evaluation after the end of the sessions, and in two studies no difference in the anxiety symptoms was observed at the follow-up. 
• It was also found that CBT can have a positive impact on the diagnosis of ADs over time, i.e., in eight of the studies, most patients no longer met the diagnostic criteria for the ADs, excepting two studies, in which no significant difference was found
• Among the studies that compared CBT + Family and CBT only with the children, the results of more recent studies found that interventions including the family were more favorable. On the other hand, in two studies, no differences was found between the groups, even though these are older studies.
• This review was conducted with scientific rigor and it has confirmed that there are very few follow-up studies of CBT for ADs in children and adolescents covering a period over 12 months. The main finding of the studies included is that the benefits of therapy are maintained over time, even for the cases in which the difference was in relation to the baseline

Brief, intensive and concentrated CBT for anxiety disorders in children

• Currently, “standard” 11-18 session Cognitive Behavioural Therapy (CBT) is the only treatment with an adequate evidence base for effectively treating anxiety disorders in children and adolescents (Reynolds et al, 2012).
• The authors aim here is to compare BIC treatments to the “standard” CBT treatment and see if there are similar outcomes. In order to do this, Öst & Ollendick carefully define BIC treatments:
• Brief: a total number of sessions at least 50% or less compared to standard CBT, (it could be carried out over the same number of weeks, or a shorter period of time)
• Intensive: both total number of sessions are 50% or less and the duration of treatment is greatly reduced compared to standard
• Concentrated: the total number of sessions is the same as “standard” CBT but completed in less time, e.g. daily sessions over 3 weeks.
• BIC yielded very large effect sizes compared to wait list and placebo
• There was no significant difference between outcomes of BIC and standard length CBT
• Both the effects of BIC and standard CBT were maintained at follow up

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Adults

Carpenter JK, Andrews LA, Witcraft SM. et al (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6): 502 – 514.

• To properly test the efficacy of a treatment like CBT, randomised controlled trials (RCTs) using a psychological or pill placebo comparison should be used, as they are considered the ‘gold-standard’ tool for assessment. Nonetheless, evidence for the efficacy of CBT as a treatment for anxiety disorders mainly comes from meta-analyses that have compared CBT to a range of control conditions, including wait-list control and treatment-as-usual. These conditions cannot be considered as robust as a placebo comparison; wait-list comparisons do not control for patient expectations whereas treatment-as-usual can be highly variable and inappropriately monitored.
• Thus, the purpose of this study was to update the only meta-analysis ever published on randomised placebo-controlled trials of CBT for anxiety and related disorders (Hofmann & Smiths, 2008), by including data from RCTs published since 2008. 
• The 41 RCTs included in the final analysis of this study represented a total of 2,843 patients randomly assigned to either CBT or a placebo condition: Findings revealed that overall, people randomised to CBT, as opposed to placebo, demonstrated significant improvements to target disorder symptoms (Hedges’ g = 0.56, p < 0.0001); CBT was also found to significantly improve anxiety symptoms, depression, and quality of life, although the effect sizes were reportedly smaller (Hedges’ g = 0.56, 0.38 and 0.31, respectively)
• At follow-up, individuals treated with CBT also showed improvements in: disorder specific symptoms (Hedges’ g = 0.47, p < 0.0001),anxiety symptoms (Hedges’ g = 0.42, p < 0.0001), depression (Hedges’ g = 0.29, p < 0.0001), and quality of life (Hedges’ g = 0.15, p < 0.05).
• Interestingly, the greatest effect sizes were reported for OCD, GAD, and acute stress disorder (Hedges’ g = 0.87–1.13), with smaller effects identified for PTSD, SAD, and PD (Hedges’ g = 0.39–0.48).