Describing the Framework for AI Tool Assessment in Mental Health and Applying It to a Generative AI Obsessive-Compulsive Disorder Platform: Tutorial.

As artificial intelligence (AI) technologies occupy a bigger role in psychiatric and psychological care and become the object of increased research attention, industry investment, and public scrutiny, tools for evaluating their clinical, ethical, and user-centricity standards have become essential. In this paper, we first review the history of rating systems used to evaluate AI mental health interventions. We then describe the recently introduced Framework for AI Tool Assessment in Mental Health (FAITA-Mental Health), whose scoring system allows users to grade AI mental health platforms on key domains, including credibility, user experience, crisis management, user agency, health equity, and transparency. Finally, we demonstrate the use of FAITA-Mental Health scale by systematically applying it to OCD Coach, a generative AI tool readily available on the ChatGPT store and designed to help manage the symptoms of obsessive-compulsive disorder. The results offer insights into the utility and limitations of FAITA-Mental Health when applied to "real-world" generative AI platforms in the mental health space, suggesting that the framework effectively identifies key strengths and gaps in AI-driven mental health tools, particularly in areas such as credibility, user experience, and acute crisis management. The results also highlight the need for stringent standards to guide AI integration into mental health care in a manner that is not only effective but also safe and protective of the users' rights and welfare.

Diagnosis and Management of Obsessive-Compulsive Disorder in the Primary Care Setting.

Obsessive-compulsive disorder is a common neuropsychiatric disorder that is often underdiagnosed or misdiagnosed. It is characterized by obsessions, which are intrusive and include unwanted thoughts, images, or urges that cause marked anxiety or distress. Obsessions also drive patients to engage in repetitive actions or thoughts, known as compulsions. The condition has a high prevalence of comorbid disorders and can be associated with functional impairment. Early recognition and treatment can lead to improved outcomes, and complete remission is possible. Validated tools, such as the Yale-Brown Obsessive-Compulsive Scale, are effective in diagnosing and monitoring obsessive-compulsive disorder and determining the severity of the condition. Severity varies among cases, and proper diagnosis and education about this condition are important for determining a treatment plan, which can include psychotherapy, pharmacotherapy, or both. Exposure and response prevention is the most effective form of psychotherapy, and selective serotonin reuptake inhibitors are the most effective pharmacotherapy. If monotherapy is not effective, psychotherapy and pharmacotherapy can be combined. Treatment of obsessive-compulsive disorder is typically recommended for at least 12 months for maintenance and prevention of relapse. In patients requiring augmentation, higher-risk or novel adjunctive treatments or investigational therapies should be managed by an experienced multidisciplinary team.

Deep brain stimulation for obsessive compulsive disorder: the functional neurosurgeon armamentarium.

Deep brain stimulation (DBS) is a neurosurgical procedure that utilizes implanted electrodes and electrical stimulation for the treatment of neurological disorders. In cases where patients present with severe functional impairment while being refractory to less invasive treatment options, DBS is considered "gold standard." Still, DBS-related work is still widely under investigation, with ethical issues arising that may impact a patient's physical and psycho-social status. These include patient selection, informed consent, patient autonomy, pre-operation counseling and professional psycho-social preparation and follow-up support. Bioethicists and philosophers have increasingly worked together with in clinicians and researchers to identify, address and present ethical consideration in both clinical practice and research to balance the risk-benefit ratio in DBS treatment for obsessive-compulsive disorder.

Repetitive transcranial magnetic stimulation for major depression and obsessive-compulsive disorders in Singapore.

Introduction: Repetitive transcranial magnetic stimulation (rTMS) is used for treatment-resistant major depressive disorder (MDD) and obsessive-compulsive disorder (OCD), but there are few studies on patient outcomes in Southeast Asia. In this study, we describe the clinical profile and outcome of patients with MDD and OCD treated with rTMS in Singapore. Method: A naturalistic retrospective study of 71 patients (inpatient and outpatient) who received rTMS treatment between June 2018 and April 2023 was conducted. The depressive and obsessive outcome rating scales used were clinician-rated Montgomery-Åsberg Depression Rating Scale (MADRS), Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Clinical Global Impressions-Severity (CGI-S) and self-rated Depression Anxiety and Stress Scale-21 (DASS-21). Results: Clinician-rated and self-rated mood and general condition improved significantly. MADRS mean score improved from 28.1 (standard deviation [SD] 7.3) to 20.7 (SD 10.1) (P<0.0001) (20.8% response rate/17% remission rate). CGI-S mean 4.6 (SD 0.8) improved to 3.3 (SD 1.2) (P<0.0001). DASS-21 total mean improved from 67.3 (SD 24.6) to 49.6 (SD 28.0) (P<0.0001). Y-BOCS mean score displayed a trend towards improvement from 30.1 (SD 7.5) to 27.2 (SD 6.9) (P=0.799). However, 44.4% of patients with OCD responded with a minimal 20% reduction in baseline Y-BOCS. Moreover, the subgroup of 35.8% of patients with less than 30 rTMS sessions had contributed disproportionately to nonresponse (85.7%). Patients who received rTMS treatment (>30 sessions) had a trend of larger improvement of MADRS score when compared to patients with (≤30 sessions) (9.4 [SD 9.7] versus 3.8 [SD 12.3] [P=0.078]). Conclusion: Response and remission rates for MDD and OCD suggest patients have a good response to rTMS treatment. Dosing longer rTMS sessions after an acute course helps to maximise effectiveness. Further research to determine predictors of outcome and characterise clinical features of late responders to target treatment more effectively is recommended.

A systematic review of focused ultrasound for psychiatric disorders: current applications, opportunities, and challenges.

OBJECTIVE: Advancements in MRI-guided focused ultrasound (MRgFUS) technology have led to the successful treatment of select movement disorders. Based on the comparative success between ablation and deep brain stimulation, interest arises in focused ultrasound (FUS) as a promising treatment modality for psychiatric illnesses. In this systematic review, the authors examined current applications of FUS for psychiatric conditions and explored its potential opportunities and challenges. METHODS: The authors performed a comprehensive review using the PRISMA guidelines of studies investigating psychiatric applications for FUS. Articles indexed on PubMed between 2014 to 2024 were included. The authors synthesized the psychiatric conditions treated, neural targets, outcomes, study design, and sonication parameters, and they reviewed important considerations for the treatment of psychiatric disorders with FUS. They also discussed active clinical trials in this research domain. RESULTS: Of 250 articles, 10 met the inclusion criteria. Eight articles investigated the clinical, safety, and imaging correlates of MRgFUS in obsessive-compulsive disorder (OCD), whereas 3 examined treatment-resistant depression. Bilateral anterior capsulotomy resulted in a full responder rate of 67% (≥ 35% reduction in the Yale-Brown Obsessive-Compulsive Scale score) and 33% (≥ 50% reduction in the score on the Hamilton Rating Scale for Depression) in OCD and treatment-resistant depression, respectively. Sonications ranged from 8 to 36 with targeted lesional temperatures of 51°C-56°C. Lesions in the anterodorsal aspect of the anterior limb of the internal capsule (ALIC) and increased functional connectivity to the left dorsolateral prefrontal cortex and dorsal anterior cingulate cortex significantly predicted reduction in symptoms among patients with OCD, with decreases in beta-band activity in the frontocentral and temporal regions associated with reductions in depression and anxiety. Treatment of the nucleus accumbens with low-intensity FUS (LIFU) in patients with opioid-use disorders resulted in significant reductions in cue-reactive cravings, lasting up to 90 days. No serious adverse events were reported, including cognitive decline. Side effects were generally mild and transient, consisting of headaches, pin-site swelling, and nausea. Fourteen active clinical trials were identified, primarily targeting depression with LIFU. CONCLUSIONS: Currently, FUS for psychiatric conditions is centered on OCD, with early pilot studies demonstrating promising safety and efficacy. Further research expanding on defining optimal patient selection, study design, intensity, and sonication parameters is warranted, particularly as FUS expands to other psychiatric illnesses and incorporates LIFU paradigms. Ethical considerations such as patient consent and equitable access also remain paramount.

Unveiling the neurolipidome of obsessive-compulsive disorder: A scoping review navigating future diagnostic and therapeutic applications.

Obsessive-Compulsive Disorder (OCD) poses a multifaceted challenge in psychiatry, with various subtypes and severities greatly impacting well-being. Recent scientific attention has turned towards lipid metabolism, particularly the neurolipidome, in response to clinical demands for cost-effective diagnostics and therapies. This scoping review integrates recent animal, translational, and clinical studies to explore impaired neurolipid metabolism mechanisms in OCD's pathogenesis, aiming to enhance future diagnostics and therapeutics. Five key neurolipids - endocannabinoids, lipid peroxidation, phospholipids, cholesterol, and fatty acids - were identified as relevant. While the endocannabinoid system shows promise in animal models, its clinical application remains limited. Conversely, lipid peroxidation and disruptions in phospholipid metabolism exhibit significant impacts on OCD's pathophysiology based on robust clinical data. However, the role of cholesterol and fatty acids remains inconclusive. The review emphasises the importance of translational research in linking preclinical findings to real-world applications, highlighting the potential of the neurolipidome as a potential biomarker for OCD detection and monitoring. Further research is essential for advancing OCD understanding and treatment modalities.

Effect of deep brain stimulation on postoperative body mass index: A systematic review and meta-analysis.

BACKGROUND: Deep Brain Stimulation (DBS) is FDA-approved for several movement disorders; such as Parkinson's disease, dystonia, and neuropsychiatric disorders. There are various reports of Body mass index (BMI) changes following different DBS targets in various disorders. AIM: A comprehensive systematic review and meta-analysis were conducted to investigate the impact of DBS on patients' Body Mass Index (BMI) and provide an in-depth overview of its underlying mechanisms. MATERIALS AND METHODS: We conducted research according to PRISMA guidelines. Our study assessed comprehensively electronic databases, including Pubmed, Scopus, Embase, web of science, and the Cochrane Library, up to May 2024. The random-effect model analysis was performed by the Comprehensive Meta-analysis software (CMA) version 3.0. As well, Cochran's Q test was used to determine the statistical heterogeneity of included studies. RESULT: This systematic review ultimately included 49 studies, 46 of which entered the meta-analysis. The total number of patients was 1478, consisting of Parkinson's disease (PD), dystonia, and the obsessive compulsive disorder (OCD) patients. The most common DBS target was subthalamic nucleus, followed by globus pallidus internus (GPi). Our meta-analysis depicted the BMI of participants significantly mount after DBS electrode implantation (SMD = -0.542, 95%CI: -0.678 to -0.406, and P-value < 0.001). However, moderate to high heterogeneity was detected among the studies (I2 = 67.566%). Additionally, the Daily energy intake (DEI) of patients significantly decreased after DBS (SMD: 0.457, 95%CI; 0.205 to 0.709, and P-value < 0.001). CONCLUSION: STN and GPi DBS can lead to weight gain through distinct central pathways in various movement and neuropsychiatric disorders, posing a potential risk for obesity, insulin resistance, and metabolic syndrome.

A Multicomponent Cognitive-Behavioral Hypnotic Approach for Obsessive-Compulsive Disorder Treatment: A Case Study.

This article proposes a multicomponent hypnotherapeutic approach for obsessive-compulsive disorder (OCD) treatment. This new approach combines hypnosis with exposure and response prevention, cognitive reappraisal, principles of acceptance and commitment therapy, and other components. In the presented case study, the patient was treated for four months with both biological and psychological first-line therapy with minor effects; the patient was then treated with hypnotherapy. The patient listened to a recorded hypnosis session, which was constructed according to the new proposed principle. After three weeks of near-daily listening to the session, the patient's Yale-Brown Obsessive-Compulsive Scale score decreased by 38.5%, which helped achieve a 51.5% reduction from the initial score, suggesting that this method might have significantly contributed to the therapeutic outcome. In addition, this article discusses the differences between the proposed approach and previously published hypnotherapeutic methods for OCD treatment and the hypothetical use of such an approach for other disorders characterized by compulsive behavior. Further randomized controlled studies are needed to confirm the efficacy of hypnotic approaches for treating OCD.

A systematic review and meta-analysis for the efficacy of transcranial direct current stimulation (tDCS) in OCD treatment: A non-pharmacological approach to clinical interventions.

Obsessive-compulsive disorder (OCD) is a prevalent mental condition characterized by recurrent, unwanted thoughts (obsessions) and repetitive behaviors (compulsions), significantly disrupting daily functioning and social interactions. Transcranial direct current stimulation (tDCS) presents a promising non-invasive treatment modality aimed at alleviating symptoms. However, the evidence regarding its effectiveness remains inconclusive. This study seeks to address this gap by conducting a systematic review and meta-analysis of clinical trials, offering improved guidance for clinical intervention. A comprehensive search strategy was implemented across multiple databases, including PubMed, Cochrane CENTRAL, Embase, Scopus, and Web of Science. This search focused strictly on randomized controlled trials (RCTs) involving 147 patients. These trials evaluated the efficacy of tDCS in OCD patients. Subsequent data extraction, risk of bias assessment, and statistical analysis using Review Manager software revealed the potential efficacy of tDCS in reducing OCD symptoms. The meta-analysis not only fails to demonstrate significant superiority of active tDCS over sham tDCS but also suggests that sham tDCS may be more effective than active tDCS in reducing OCD symptoms. This finding diminishes the promise of tDCS as an effective treatment for OCD. Larger trials are warranted to further elucidate these findings.

Utilising activity patterns of a complex biophysical network model to optimise intra-striatal deep brain stimulation.

A large-scale biophysical network model for the isolated striatal body is developed to optimise potential intrastriatal deep brain stimulation applied to, e.g. obsessive-compulsive disorder. The model is based on modified Hodgkin-Huxley equations with small-world connectivity, while the spatial information about the positions of the neurons is taken from a detailed human atlas. The model produces neuronal spatiotemporal activity patterns segregating healthy from pathological conditions. Three biomarkers were used for the optimisation of stimulation protocols regarding stimulation frequency, amplitude and localisation: the mean activity of the entire network, the frequency spectrum of the entire network (rhythmicity) and a combination of the above two. By minimising the deviation of the aforementioned biomarkers from the normal state, we compute the optimal deep brain stimulation parameters, regarding position, amplitude and frequency. Our results suggest that in the DBS optimisation process, there is a clear trade-off between frequency synchronisation and overall network activity, which has also been observed during in vivo studies.

Ethics of deep brain stimulation for neuropsychiatric disorders.

Deep Brain Stimulation (DBS) has emerged as a revolutionary neurosurgical technique with significant implications for the treatment of various neuropsychiatric disorders. Initially developed for movement disorders like Parkinson's disease, DBS has expanded to psychiatric conditions such as obsessive-compulsive disorder, depression, anorexia nervosa, dystonia, essential tremor, and Tourette's syndrome. This paper explores the clinical efficacy and ethical considerations of DBS in treating these disorders. While DBS has shown substantial promise in alleviating symptoms and improving quality of life, it raises ethical challenges, including issues of informed consent, patient selection, long-term management, and equitable access to treatment. The irreversible nature of DBS, potential adverse effects, and the high cost of the procedure necessitate a rigorous ethical framework to guide its application. The ongoing evolution of neuromodulation requires continuous ethical analysis and the development of guidelines to ensure that DBS is used responsibly and equitably across different patient populations. This paper underscores the need for a balanced approach that integrates clinical efficacy with ethical considerations to optimize patient outcomes and ensure sustainable practice.

Continuous theta burst stimulation to relieve symptoms in patients with moderate obsessive-compulsive disorder: a preliminary study with an external validation.

Obsessive-compulsive disorder (OCD) is a clinically challenging and refractory psychiatric disorder characterized by pathologically hyperactivated brain activity. Continuous theta burst stimulation (cTBS) is considered a potentially non-invasive treatment for inducing inhibitory effects on the underlying cortex. Numerous studies showed an unsatisfactory efficacy of cTBS for OCD. Accordingly, it seems that cTBS is ineffective for OCD. However, the neglect of varying OCD severities, modest sample size, absence of a multicenter design incorporating inpatients and outpatients, and lack of personalized imaging-guided targeting may constrain the conclusive findings of cTBS efficacy for OCD. In the preliminary experiment, 50 inpatients with OCD were enrolled to receive cTBS (10 sessions/day for five continuous days) or sham over the personalized right pre-supplementary motor area determined by the highest functional connectivity with the subthalamic nucleus according to our prior study. In the extension experiment, 32 outpatients with OCD received cTBS to generalize the treatment effects. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was assessed before and after treatment. In the preliminary experiment, the response rates in the cTBS group were 56.52%, respectively, significantly higher than those in the sham group. Further analysis revealed significant YBOCS improvement in patients with moderate OCD symptoms than those with severe OCD symptoms. In the extension experiment, the response rates were 50.00%. Additionally, a significant decrease in YBOCS scores was only found in patients with moderate OCD symptoms. This is the first study with an external validation design across two centers to identify OCD symptoms as playing an important role in cTBS treatment effects, especially in patients with moderate OCD symptoms.

Immediate and long-term efficacy of transcranial direct current stimulation (tCDS) in obsessive-compulsive disorder, posttraumatic stress disorder and anxiety disorders: a systematic review and meta-analysis.

Currently, there is still debate over the effectiveness of transcranial direct current stimulation (tDCS) in treating obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD) and anxiety disorders (ADs). To investigate the immediate and long-term effectiveness of tDCS in these diseases, we conducted a systematic review and quantitative analysis of existing literature on the treatment of OCD, PTSD, and ADs with tDCS. Following the PRISMA guidelines, we searched seven electronic databases and systematically retrieved articles published from May 2012 to June 2024 that compared the effects of active tDCS with sham stimulation in the treatment of these disorders. We included primary outcome measures such as the change scores in disorder-specific and general anxiety symptoms before and after treatment, as well as secondary outcomes such as changes in disorder-specific and general anxiety symptoms at follow-up. We also assessed the impact of tDCS on depressive symptoms. Fifteen papers met the eligibility criteria. Overall, the results of meta-analysis indicated that tDCS had a high effect in improving specific symptoms (SMD = -0.73, 95% CI: -1.09 to -0.37) and general anxiety symptoms (SMD = -0.75; 95% CI: -1.23 to -0.26) in OCD, PTSD and ADs, with effects lasting up to 1 month and showing a moderate effect size. Furthermore, tDCS demonstrated immediate and significant alleviation of depressive symptoms in these diseases. This study concludes that tDCS can serve as a non-invasive brain stimulation technology for treating these disorders, and the therapeutic effects can be maintained for a period of time.

Neurocognitive performance in the context of acute symptom reduction in OCD: Treatment effects and the impact of BDNF.

BACKGROUND: Obsessive-compulsive disorder (OCD) has been associated with neurocognitive impairments. The present study examined the effect of treatment on neurocognitive performance in OCD and the relationship between neurocognitive change and symptom change. The present study also examined polymorphisms influencing brain derived neurotrophic factor (BDNF) as predictors of neurocognitive change. METHOD: Treatment-seeking participants with OCD (N = 125) were assigned to cognitive behavioural therapy (CBT) alone, CBT combined with regular physical exercise, exercise alone, or a waitlist control group. Measures of OCD symptom severity and a neuropsychological battery were completed pre- and post-treatment. Blood or saliva samples were used to genotype the BDNF Val66Met polymorphism. RESULTS: OCD symptom severity was not cross-sectionally associated with neurocognitive performance. Several neurocognitive measures improved over treatment. The BDNF Val66Met polymorphism was significantly associated with worse performance on the Stroop test but did not significantly predict change in neurocognitive performance over time. LIMITATIONS: Limitations include lack of a healthy control group. CONCLUSION: Improvement in neurocognitive performance corresponded to symptomatic improvement and was independent of the BDNF Val66Met genotype.

The Relationship of Rumination, Worry and OCD Symptoms During Technology Supported Mindfulness Therapy for OCD.

BACKGROUND: In this study, we re-examined data from a previous randomized controlled trial investigating 'technology supported mindfulness' (TSM)-an 8-week treatment intervention for individuals experiencing OCD. The current analysis involves an examination of the longitudinal relationships between rumination, worry and OCD symptom changes during mindfulness treatment, in comparison to a waitlist control. METHODS: Participants experiencing OCD (n = 71) were randomly assigned to 8 weeks of (1) TSM or (2) waitlist control. We tested the extent to which rumination (using the Ruminative Response Scale) and worry (using the Penn State Worry Questionnaire) are associated with OCD symptom changes during the acute phase of treatment, concurrently (i.e., within the same longitudinal model). RESULTS: Generalized linear model (GLM) results indicated a significant time (week 1 vs. week 8) by condition interaction involving decreased rumination in the TSM condition: F(1, 61) = 13.37, p = 0.001, partial η2 = 0.18 and observed power = 0.94. A second GLM demonstrated decreased worry in the TSM condition: F(1, 69) = 37.34, p = 0.001, partial η2 = 0.35 and observed power = 0.83. Longitudinal 'latent difference' structural equation analyses demonstrated a cross-lagged association between worry (but not rumination) and OCD symptom changes. CONCLUSIONS: Individuals in the TSM condition experienced greater reductions in rumination and worry during 8 weeks of TSM treatment compared to the waitlist control, and reduced worry predicted subsequent OCD symptom reduction.

Disruption of neural periodicity predicts clinical response after deep brain stimulation for obsessive-compulsive disorder.

Recent advances in surgical neuromodulation have enabled chronic and continuous intracranial monitoring during everyday life. We used this opportunity to identify neural predictors of clinical state in 12 individuals with treatment-resistant obsessive-compulsive disorder (OCD) receiving deep brain stimulation (DBS) therapy ( NCT05915741 ). We developed our neurobehavioral models based on continuous neural recordings in the region of the ventral striatum in an initial cohort of five patients and tested and validated them in a held-out cohort of seven additional patients. Before DBS activation, in the most symptomatic state, theta/alpha (9 Hz) power evidenced a prominent circadian pattern and a high degree of predictability. In patients with persistent symptoms (non-responders), predictability of the neural data remained consistently high. On the other hand, in patients who improved symptomatically (responders), predictability of the neural data was significantly diminished. This neural feature accurately classified clinical status even in patients with limited duration recordings, indicating generalizability that could facilitate therapeutic decision-making.

Investigating brain structure and tDCS response in obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is characterized by intrusive thoughts and repetitive behaviors, with associated brain abnormalities in various regions. This study explores the correlation between neural biomarkers and the response to transcranial Direct Current Stimulation (tDCS) in OCD patients. Using structural MRI data from two tDCS trials involving 55 OCD patients and 28 controls, cortical thickness, and gray matter morphometry was analyzed. Findings revealed thicker precentral and paracentral areas in OCD patients, compared to control (p < 0.001). Correlations between cortical thickness and treatment response indicated a significant association between a thinner precentral area and reduced Yale-Brown Obsessive Compulsive Scale (YBOCS) scores (p = 0.02). While results highlight the complexity of treatment response predictors, this study sheds light on potential neural markers for tDCS response in OCD patients. Further investigations with larger datasets are warranted to better understand the underpinnings of these biomarkers and their implications for personalized treatment approaches.

Cognitive behavioural therapy and third-wave approaches for anxiety and related disorders in older people.

BACKGROUND: Cognitive behavioural therapy (CBT) is the most researched psychological therapy for anxiety disorders in adults, and known to be effective in this population. However, it remains unclear whether these results apply to older adults, as most studies include participants between 18 and 55 years of age. This systematic review aims to provide a comprehensive and up-to-date synthesis of the available evidence on CBT and third wave approaches for older adults with anxiety and related disorders. OBJECTIVES: To assess the effects of Cognitive Behavioural Therapy (CT, BT, CBT and third-wave CBT interventions) on severity of anxiety symptoms compared with minimal management (not providing therapy) for anxiety and related disorders in older adults, aged 55 years or over. To assess the effects of CBT and related therapies on severity of anxiety symptoms compared with other psychological therapies for anxiety and related disorders in older adults, aged 55 years or over. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled studies Register (CCMDCTR), CENTRAL, Ovid MEDLINE, Ovid Embase and Ovid PsycINFO to 21 July 2022. These searches were updated on 2 February 2024. We also searched the international studies registries, including Clinicalstudies.gov and the WHO International Clinical Trials Registry Platform (ICTRP), to identify additional ongoing and unpublished studies. These sources were manually searched for studies up to 12 February 2024. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in older adults (≥ 55 years) with an anxiety disorder, or a related disorder, including obsessive compulsive disorder (OCD), acute stress disorder and post-traumatic stress disorder (PTSD), that compared CBT to either minimal management or an active (non-CBT) psychological therapy. Eligible studies had to have an anxiety-related outcome. DATA COLLECTION AND ANALYSIS: Several authors independently screened all titles identified by the searches. All full texts were screened for eligibility according to our prespecified selection criteria. Data were extracted and the risk of bias was assessed using the Cochrane tool for RCTs. The certainty of evidence was evaluated using GRADE. Meta-analyses were performed for outcomes with quantitative data from more than one study. MAIN RESULTS: We included 21 RCTs on 1234 older people allocated to either CBT or control conditions. Ten studies focused on generalised anxiety disorder; others mostly included a mix of clinical diagnoses. Nineteen studies focused on the comparison between CBT and minimal management. Key issues relating to risk of bias were lack of blinding of participants and personnel, and participants dropping out of studies, potentially due to treatment preference and allocation. CBT may result in a small-to-moderate reduction of anxiety post-treatment (SMD -0.51, 95% CI -0.66 to -0.36, low-certainty evidence). However, compared to this benefit with CBT immediately after treatment, at three to six months post-treatment, there was little to no difference between CBT and minimal management (SMD -0.29, 95% CI -0.59 to 0.01, low-certainty evidence). CBT may have little or no effect on clinical recovery/ improvement post-treatment compared to minimal management, but the evidence is very uncertain (RR 1.56, 95% CI 1.20 to 2.03, very low-certainty evidence). Results indicate that five people would need to receive treatment for one additional person to benefit (NNTB = 5). Compared to minimal management, CBT may result in a reduction of comorbid depression symptoms post-treatment (SMD -0.57, 95% CI -0.74 to -0.40, low-certainty evidence). There was no difference in dropout rates post-treatment, although the certainty of the evidence was low (RR 1.19, 95% CI 0.80 to 1.78). Two studies reported adverse events, both of which related to medication in the control groups (very low-certainty evidence, no quantitative estimate). Only two studies compared CBT to other psychological therapies, both of which only included participants with post-traumatic stress disorder. Low-certainty evidence showed no difference in anxiety severity post-treatment and at four to six months post-treatment, symptoms of depression post-treatment, and dropout rates post-treatment. Other outcomes and time points are reported in the results section of the manuscript. AUTHORS' CONCLUSIONS: CBT may be more effective than minimal management in reducing anxiety and symptoms of worry and depression post-treatment in older adults with anxiety disorders. The evidence is less certain longer-term and for other outcomes including clinical recovery/improvement. There is not enough evidence to determine whether CBT is more effective than alternative psychological therapies for anxiety in older adults.