A Critical Evaluation of Three Different Methods for Treating Generalised Anxiety Disorder

By

 


 Generalised anxiety disorder (GAD) is a psychiatric illness comprised of mental and physical symptoms dovetailing from an overarching presentation of uncontrollable worry (Salzer et al., 2011)). Other symptoms include disturbed sleep, inability to concentrate, tense muscles, irritable mood, fatigue, and restlessness. With a lifetime prevalence of 4.3–5.9%, GAD is common and is rarely sufficiently treated in primary care settings, such as general practice, resulting in significant medical costs. These include specialist fees, medication, therapies, and hospital admissions. Additional societal and individual costs include loss of productivity, sick leave, and government benefits. Due to its chronic nature and high recurrence rate (Cuijpers et al., 2014)), an evaluation of the efficacy of current treatment options is necessary. Three treatments will be analysed to determine the most advantageous option for patients with GAD. The selected treatments are intensive short-term dynamic psychotherapy (ISTDP); cognitive behaviour therapy (CBT); and pharmacological treatment, specifically venlafaxine XR. It will be argued that venlafaxine XR is the most effective, convenient, and expeditious of these treatment options.


ISTDP is a psychotherapy based on the theory that anxiety and depression are products of adverse life experiences, such as childhood traumas (Lilliengren et. al. 2017). The theory holds that this leads to generalised anxiety and maladaptive defence mechanisms in response to unprocessed emotions reactivating in new, and seemingly unrelated, situations. Lilliengren et. al. undertook a study on ISTPP in 2017 to evaluate its clinical and cost-effectiveness in treating GAD. Additionally, this study examined one of the key processes within the treatment known as the mobilisation of unprocessed complex emotions (MUCE) and its links to outcome. The sample was comprised of 215 patients, 60.9% of which were females. It is thus unknown whether this predominantly female sample influenced outcome. Age was another potential influencing factor, with 80% aged 19–35, 11.2% 36–60 years, and only 8.8% aged over 60 years. In addition, the study included conditions comorbid with GAD (Lilliengren et. al., 2017) and it therefore cannot be concluded that this, did not influence the results. The study occurred at the Centre for Emotions and Health (CEH) at Dalhousie University and all participants fit diagnostic criteria for GAD in the DSM-IV. Diagnoses were confirmed by each patient’s treating therapist at CEH, as well as by their supervising psychiatrist, using information gleaned from the patient’s referral, initial interview, and observation throughout treatment. The study was approved by its local hospital ethics review board and was a registered clinical trial with identifier number NCT01924715. Treatment commenced with an interview of 2–3 hours, focussed on identifying patients’ problematic areas, as well as assessing capacity for intense emotion-focussed therapy, or whether a graded format of ISTPP would be more suitable. Patients’ self-reported symptoms were assessed using the Brief Symptom Inventory. The Inventory of Interpersonal Problems was utilised at these same points. MUCE levels were monitored by a 5-point scale addressing emotional expressiveness and arousal, and activation of unconscious anxieties, defence mechanisms and other indications of the unconscious therapeutic alliance. Each patient attended an average of 8.3 sessions.  

            Treatment was administered by 38 therapists: 22 were psychiatry residents based at CEH, 11 were licensed health professionals, and 5 were trainees learning ISTDP at CEH (Lilliengren et. al., 2017). All therapists took part in weekly supervision and didactic courses in which reviews of filmed sessions were led by an ISTDP trainer. Reliability of data was impacted by the absence of a control group and the inclusion of patients’ self-reported data. Missing data was another issue. This could be attributed to the longitudinal nature of the study which took place over a 9-year period. This included follow-up of participants’ changing healthcare costs over time. Costs decreased each year for 4 years but were significantly lower in the first-year post-treatment. The average reduction per patient, over the 4-year period, was $16,205. This indicates that ISTDP is beneficial in treating GAD. Moreover, effects are optimised in relation to high levels of emotional activation during treatment sessions. The results should nevertheless be interpreted with caution in the absence of a control group and complete data. It is unknown whether combining ISTDP with psychopharmacological treatment could enhance positive outcomes and further research on this in the imminent future would be clinically relevant.


CBT is a group of scientifically evidenced interventions targeting dysfunctional thought patterns to reduce anxiety (Carpenter et al., 2018). In 2018, Carpenter et al. conducted a meta-analysis of the effectiveness of CBT using randomised placebo-controlled trials. Researchers reviewed 41 studies, totalling 2,843 patients aged 18–65 years with GAD or other similar conditions. GAD was represented in two of these studies, totalling 57 patients. Each patient was randomly assigned CBT; a psychological placebo, such as counselling; or a pill placebo (Carpenter et al., 2018). The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement and was registered with the International Prospective Register of Systematic Reviews under the number, CRD42016050841. Eligible studies were sourced from PubMed and PsycINFO and risk of bias was combatted with the Cochrane Collaboration’s tool.

            Most patients randomly assigned CBT were guided through a combination of exposure and cognitive strategies throughout an average of 11 sessions (Carpenter et al., 2018). The mean age was 36, 58.9% were female, and 73% were Caucasian. The possibility a more racially and/or gender diverse sample would alter results can thus not be ruled out. Outcomes may also have been influenced by including patients treated with various psychiatric medications. Interestingly, CBT had a drop-out rate 6.8% higher (24% compared to 17.2%) than its placebo counterpart (Carpenter et al., 2018). Despite this, results yielded significant improvement in the CBT sample, as opposed to the placebo; however, researchers warn due diligence should be exercised when examining outcomes. Analysis was limited in that many included studies had not properly accounted for missing data. Likewise, varying control conditions may have swayed outcomes. “Despite these limitations, the present results provide strong evidence that CBT is an efficacious treatment for anxiety and related disorders in adults, and its effects meaningfully exceed that of placebo” (Carpenter et al., 2018, p. 7). It can thus be assumed that CBT is an effective treatment option for GAD.

 

Crits-Christoph et al. (2011) conducted a study on the efficacy of combined medication and CBT for treating GAD. The medication was Venlafaxine XR, a prescription drug used to treat anxiety and depressive disorders. Research psychiatrists recruited participants from four primary care practices, while a fifth group were enrolled in a university psychopharmacology clinic. Expressions of interest were screened using the Anxiety Screening Questionnaire (ASQ-15). Those with comorbid conditions were excluded, as were those treated with buspirone, anticonvulsants, neuroleptics, or any other antidepressants in the 14 days prior to the trial’s start date. This may have influenced outcomes due to the high prevalence of comorbid conditions occurring alongside GAD. This limits generalisability of results, particularly for those with dual diagnoses.

            Participants commenced a long-term venlafaxine XR trial during which randomly selected patients were offered 12 CBT sessions, administered weekly (Crits-Christoph et al., 2011). 33% agreed and participated in at least one session. The venlafaxine XR trial was approved and overseen by the local Institutional Review Board and the randomised CBT combined therapy was approved by this same board. Further, the combined study was funded by the National Institute of Mental Health with grant R34-MH072678 and the venlafaxine XR parent study, with grant R01-065963.

            CBT sessions were carried out by five doctoral-level licensed psychologists: two females and three males (Crits-Christoph et al., 2011). All were experienced in treating anxiety disorders using CBT and were, on average, 10 years post-doctoral. The HAM-A was implemented to assess anxiety and the 17-item version of the HAM-D, to monitor depression. The Clinical Global Impressions Severity and Improvement scales (CGI-S and CGI-I) assessed severity of illness and improvement. Self-report methods for patients included the quality-of-life subscale of the General Health Questionnaire (GHQ/12-QL), Penn State Worry Questionnaire, and Hospital Anxiety and Depression scale. Ultimately, no evidence of added benefit in the combined therapy sample was identified and, contrarily, improvement was swifter in patients treated with venlafaxine XR alone. It should, however, be noted that two thirds of patients offered combined treatment declined, potentially indicating a preference for the convenience of medication. While further studies of combined therapy across different settings, using various inclusion criteria are warranted, for patients with a standalone diagnosis of GAD, treatment with venlafaxine XR is fast, effective, and convenient.  

 

Three treatment methods for GAD were compared with the aim of determining the most efficacious option. The first treatment explored was ISTDP which was found to significantly decrease healthcare costs associated with GAD over a 4-year period. This study was limited by the absence of a control group and the presence of missing data. Secondly, CBT was investigated, and results of a placebo-controlled study revealed substantial positive effects on GAD symptoms. Again, missing data posed a problem and varying placebo may have impacted outcomes. Finally, venlafaxine XR as a pharmacological treatment of GAD was compared with a package of venlafaxine XR and CBT. Combined treatment was not more beneficial. It is acknowledged that exclusion criteria limited generalisability, though for patients with a diagnosis of GAD alone, venlafaxine XR is proven to be effective, and is an important treatment option for those unable to commit to psychotherapy. For patients desiring combined treatment, venlafaxine XR with ISTDP may be preferable, given that combined CBT provided no added benefits. Further studies are required to confirm the efficacy of combined venlafaxine XR and ISTDP in the treatment of GAD.

 

References

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A. J., & Hofmann, S. G.          (2018). Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of            randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514. http://doi-      org.ezproxy.usq.edu.au/10.1002/da.22728.


Crits-Christoph, P., Newman, M. G., Rickels, K., Gallop, R., Gibbons, M. B. C., Hamilton, J. L., Ring-Kurtz, S., & Pastva, A. M. (2011). Combined medication and cognitive therapy for     generalized anxiety disorder. Journal of Anxiety Disorders, 25(8), 1087–1094.    http://doi.org/10.1016/j.janxdis.2011.07.007


Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014).           Psychological treatment of generalized anxiety disorder: a meta-analysis. Clinical Psychology   Review, 34(2014), 130–140. http://dx.doi.org/10.1016/j.cpr.2014.01.002


Lilliengren, P., Johansson, R., Town, J. M., Kisely, S., & Abbass, A. (2017). Intensive short-term dynamic psychotherapy for generalized anxiety disorder: a pilot effectiveness and process- outcome study. Clinical Psychology & Psychotherapy, 24(6), 1313–1321. http://doi-     org.ezproxy.usq.edu.au/10.1002/cpp.2101.


Salzer, S., Winkelbach, C., Leweke, F., Leibing, E., & Leichsenring, F. (2011). Long-term effects of        short-term psychodynamic psychotherapy and cognitive-behavioural therapy in generalized anxiety disorder: 12-month follow-up. Canadian Journal of Psychiatry, 56(8), 503–508. 














google.com, pub-5896944412523933, DIRECT, f08c47fec0942fa0   

 

Comments

Post a Comment

Popular posts from this blog

'Til Death, did we Part

By
Image
TRIGGER WARNING: this post contains very graphic detail, which some may find distressing My eldest son, Lachlan, did not ever meet his biological father, Dean.  Their entire father/son relationship amounted to approximately 3 telephone calls throughout the time between Lachlan's birth in 2010, and Dean's untimely death.  This aside, Lachlan and I were both lucky enough to find an amazing man, who not only loved me more fiercely and passionately than I had ever known, but also loved my son as though he were his own—Chris—the first man I ever truly loved.   When Chris and I discovered I was pregnant, we were surprised but thrilled.  We had our first ultrasound at 6 weeks and I will never forget the look of sheer wonder, delight and adoration on Chris's face as he watched the screen and listened to our baby's heartbeat.   I recall thinking, this is how it's supposed to be —i t's going to be so different this time around — it's going to be perfect... how
Read more

Confessions of a Pro-life Mother: there but for the grace of God go I

By
Image
I have always been open about being pro-life. I know this is a sensitive topic but please hold off on lugging out the torches and pitchforks just yet. There is a heartfelt story behind my steadfast view. A few months ago an acquaintance accused me of unfairly judging my fellow women by being pro-life, rather than pro-choice.  I responded, 'I don't judge women who make that choice because, there but for the grace of God, go I.' She replied, 'So, you're pro-life but don't judge a woman for making a choice? I don't understand.' Well, what led me to be pro-life? That is the story that needs telling to answer her question. I was 20 years old when I learned I was pregnant for the first time. A few months prior, I fled from a toxic 2 year, on again/off again relationship, riddled with domestic violence and drug dependence. He was what I thought at the time was my first love. How wrong I was. I had no idea what love was then, but he was all I knew. I was dy
Read more

Jimmy Crow of Crow's Nest, Queensland

By
Image
Crow, Jim (c. 1825—c. 1884) by C M Wormington Jim ‘Jimmy’ Crow (c. 1825—c. 1884), camp operator and Indigenous guide, was born in the 1820s, in the Darling Downs, Queensland (Kerkhove 2020). His exact birth and death dates remain unknown and, in addition, it is unclear whether Crow's surname was associated with his crow-like appearance or his moiety (Kerkhove 2020); in fact, many aspects of Crow's early life are disputed. This can most likely be attributed to his younger years having occurred in early Aboriginal times. Written history from these times is ‘…almost non-existent’ (McGreevy 2003, para. 1) and, because of this, there is a large gap in the documented facts of Crow’s life. This gap ranges from his birth, up until approximately his early 20s. Popular belief holds that the entire name ‘Jim Crow’ was given to him by the early settlers (Watson 2020), with his traditional birth name remaining a mystery; however, Kerkhove (2020) did not acknowledge this theory in hi
Read more

Best Friends Forever

By
Image
People say, " you don't know what you've got until it's gone" but the truth is, with Brad, I always knew.  The statement,  "True friends are like diamonds, precious but rare..." is so, so very true and it was never lost on me, that Brad was one of my diamonds.    2012 was, undoubtedly, the worst year of my life and the final kick in the guts, just one day before it ended, was a phone call during which I learned my best friend had left this world.  I will never forget the crashing in my ears, the sinking pit in my stomach, my knees hitting the floor as my legs gave way, the unshakeable belief that every person I loved seemed cursed to die.  Life seemed hell bent on slamming me back to the floor again, every time I found my feet. ~ To go back to where it all began, Brad was originally close mates with Dean, the biological father of my eldest son.  Early on in my pregnancy, when Dean and I were still together, Brad often looked out for me, ensuring
Read more

Tales of a VBAC Hypnobirth

By
Image
Parts of this birth story are written in 'Hypnobirthing Language' which changes a lot of medical terms to gentler words. The medical terms are added in brackets the first time each is used. This story begins with the events that shaped my views of birth. In 2010 I gave birth to my first child. At two weeks overdue, I was induced and my labour was horrific, as were my postpartum complications. I now attribute this to the fact my labour was artificially induced. In December 2011, I fell pregnant with my second child. During the first trimester, my loving partner tragically passed away in our home during an epileptic seizure. Remembering how traumatic my first birth was, I didn't believe I'd cope, especially given the dark place I was already in. Instead, I opted for an elective C-section. Early in my final pregnancy, I discovered a place I now view as The Gold Standard in prenatal and postnatal care: My Midwives . I cannot speak highly enough of My Midwives and the
Read more

The Day the Virus Came

By
Image
We will never forget the year 2020.Countries shut down, children were pulled from schools, the stock market crashed, and unemployment hit a record high of 14.7%, the highest it has been since 1948 (Thompson 2020).  With this new world, birthed by a foreign virus, so too, came a surge in mental health and domestic violence crises. The global death toll is currently at 382,412 (Worldometer 3 June 2020) but the true statistics are likely much higher. The forgotten numbers are found in suicides of isolated depression sufferers, murdered children and partners forcibly quarantined in violent homes, and people with chronic illnesses, too afraid to attend critical medical appointments for fear of contracting the deadly Coronavirus.  Additionally, drug overdoses from relapses that may never have occurred had the addicts had access to their support networks and meetings, would further inflate the tally. Indeed, we will never forget the year 2020; the year the COVID-19 pandemic came.
Read more

For the Love of Difficult Children

By
Image
No parent signs up for children with behavioural or emotional disabilities. Heck, if it worked that way, none of us would. But oh, what a gift would be lost to this world. Difficult children grow into strong willed adults, champions of the causes they believe in; dream chasers, peacemakers, and driven entrepreneurs.  They are worth all the tears, sleepless nights, judgemental stares, and specialist appointments.   I was a difficult child; now I am raising one. I know you are exhausted, Mumma, but to your little boy, you are Wonder Woman , battling his demons and bringing calm to the chaos of his overwhelmed mind. Breathe—you've got this.   Dad, I see you struggling with the weight of working hard, only to come home to World War III in your living room, when all you want is peace and quiet.   To the single parent weeping in your car, after your daughter threw the mother of all tantrums in the supermarket, I think you are a rock star. ~    These children see the world in
Read more

An Open Letter to my Father

By
Image
Dear Dad, It’s been years since we last spoke. I was pregnant with my first child; you were sectioned in a psychiatric hospital again. I’d visited you there many times over the years, as a child and as an adult. I feel I owe you an explanation as to why I had to walk away.   My childhood seems like a good place to begin. I vividly recall you telling me at Family Court, right before you were stripped your parental responsibility and visitation rights, that I was strong like you. You told me this strength was what enabled me to endure and withstand all of the pain. That day was the first and only time I saw you cry. I remember how hard you hugged me; how tightly you clung to me. Your exact final words as I was escorted from the room were: 'God, I love you, kiddo.' What you may not know is that it wasn’t any perceived strength that allowed me to speak to you that day when my brother refused. It was the panic button located beneath the Family Report Writer's desk. That discr
Read more