Enduring effects of psychological treatments for anxiety disorders: meta-analysis of follow-up studies.

BACKGROUND: It is a widespread opinion that after treatment with psychotherapy, patients with anxiety disorders maintain their gains beyond the active treatment period, whereas patients treated with medication soon experience a relapse after treatment termination.AimsWe aimed to provide evidence on whether enduring effects of psychotherapy differ from control groups. METHOD: We searched 93 randomised controlled studies with 152 study arms of psychological treatment (cognitive-behavioural therapy or other psychotherapies) for panic disorder, generalised anxiety disorder and social anxiety disorder that included follow-up assessments. In a meta-analysis, pre-post effect sizes for end-point and all follow-up periods were calculated and compared with control groups (medication: n = 16 study arms; pill and psychological placebo groups: n = 17 study arms). RESULTS: Gains with psychotherapy were maintained for up to 24 months. For cognitive-behavioural therapy, we observed a significant improvement over time. However, patients in the medication group remained stable during the treatment-free period, with no significant difference when compared with psychotherapy. Patients in the placebo group did not deteriorate during follow-up, but showed significantly worse outcomes than patients in cognitive-behavioural therapy. CONCLUSIONS: Not only psychotherapy, but also medications and, to a lesser extent, placebo conditions have enduring effects. Long-lasting treatment effects observed in the follow-up period may be superimposed by effects of spontaneous remission or regression to the mean.Declaration of interestIn the past 12 months and in the near future, Dr Bandelow has been/will be on the speakers/advisory board for Hexal, Mundipharma, Lilly, Lundbeck, Pfizer and Servier. Dr Wedekind was on the speakers' board of AstraZeneca, Essex Pharma, Lundbeck and Servier. All other authors have nothing to declare.

Treatment of anxiety disorders.

Anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, social anxiety disorder, and others) are the most prevalent psychiatric disorders, and are associated with a high burden of illness. Anxiety disorders are often underrecognized and undertreated in primary care. Treatment is indicated when a patient shows marked distress or suffers from complications resulting from the disorder. The treatment recommendations given in this article are based on guidelines, meta-analyses, and systematic reviews of randomized controlled studies. Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence. First-line drugs are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Benzodiazepines are not recommended for routine use. Other treatment options include pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others. After remission, medications should be continued for 6 to 12 months. When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered.

Los trastornos de ansiedad (trastorno de ansiedad generalizada, trastorno de pánicolagorafobia, trastorno de ansiedad social y otros) son los trastornos psiquiátricos más prevalentes y están asociados con una alta carga de enfermedad. En la atención primaria los trastornos de ansiedad tienen a menudo un bajo reconocimiento y son subtratados. La terapia se indica cuando un paciente muestra un marcado distrés causado por el trastorno o sufre por complicaciones debidas a él. Las recomendaciones terapéuticas que se entregan en este artículo están basadas en guías clínicas, estudios de meta-análisis, revisiones sistemáticas y estudios controlados randomizados. Los trastornos de ansiedad deben ser tratados con terapia psicológica, farmacoterapia ylo una combinacíon de ambas. La terapia cognitivo conductual puede ser considerada la psicoterapia con el mayor nivel de evidencia. Los fármacos de primera línea son los inhibidores selectivos de la recaptura de serotonina y los inhibidores de la recaptura de serotonina/noradrenalina. No se recomiendan las benzodiacepinas para un empleo rutinario. Otras opciones terapéuticas incluyen pregabalina, antidepresivos tricíclicos, buspirona, moclobemide y otros. Después de la remisión, los medicamentos deben continuarse por unos 6 a 12 meses. Cuando se desarrolla un plan terapéutico se debe considerar la eficacia, los efectos adversos, las interacciones, los costos y la preferencia del paciente.

Les troubles anxieux (anxiété généralisée, trouble panique/agoraphobie, anxiété sociale et autres) sont les troubles psychiatriques les plus prévalents et ils s'associent à une morbidité importante. Les troubles anxieux sont souvent peu reconnus et peu traités en soins primaires. Le traitement est indiqué quand ces troubles causent une détresse manifeste chez le patient ou lorsqu'il souffre de complications. Les conseils de traitement donnés dans cet article sont basés sur des recommandations, des métaanalyses et des revues systématiques d'études contrôlées randomisées. Les troubles anxieux doivent être soignés par un traitement psychologique, une pharmacothérapie, ou une association des deux. Le traitement cognitivo-comportemental est considéré comme la psychothérapie ayant niveau de preuve le plus élevé. Les inhibiteurs sélectifs de la recapture de la sérotonine et les inhibiteurs de la recapture de la sérotonine et de la noradrénaline sont les médicaments de première ligne. Les benzodiazépines ne sont pas recommandées en routine. La prégabaline, les antidépresseurs tricycliques, la buspirone, le moclobémide et d'autres sont d'autres traitements possibles. Les médicaments doivent être poursuivis 6 à 12 mois après la rémission. Lors de l'élaboration d'un plan de traitement, il faut tenir compte de l'efficacité, des effets indésirables, du coût et de la préférence du patient.

Epidemiology of anxiety disorders in the 21st century.

Anxiety disorders, including panic disorder with or without agoraphobia, generalized anxiety disorder, social anxiety disorder, specific phobias, and separation anxiety disorder, are the most prevalent mental disorders and are associated with immense health care costs and a high burden of disease. According to large population-based surveys, up to 33.7% of the population are affected by an anxiety disorder during their lifetime. Substantial underrecognition and undertreatment of these disorders have been demonstrated. There is no evidence that the prevalence rates of anxiety disorders have changed in the past years. In cross-cultural comparisons, prevalence rates are highly variable. It is more likely that this heterogeneity is due to differences in methodology than to cultural influences. Anxiety disorders follow a chronic course; however, there is a natural decrease in prevalence rates with older age. Anxiety disorders are highly comorbid with other anxiety disorders and other mental disorders.

Los trastornos de ansiedad, que incluyen el trastorno de pánico con o sin agorafobia, el trastorno de ansiedad generalizada, el trastorno de ansiedad social, las fobias específicas y el trastorno de ansiedad por separación son los trastornos mentales más prevalentes y están asociados con inmensos costos de atención de salud y una alta carga de enfermedad. De acuerdo con investigaciones basadas en grandes poblaciones, hasta un 33,7% de la población presenta un trastorno de ansiedad durante su vida. Se ha demostrado que el subdiagnóstico y el subtratamiento de estos trastornos es significativo. No existe evidencia acerca del cambío en las frecuencias de prevalencia de los trastornos de ansiedad en los últimos años. En comparaciones interculturales las frecuencias de prevalencía son altamente variables. Es más probable que esta heterogeneidad se deba a diferencias en la metodología más que a influencias culturales. Los trastornos de ansiedad siguen un curso crónico; sin embargo, hay una disminución natural en las frecuencias de prevalencia a mayor edad. Los trastornos de ansiedad son altamente comórbidos con otros trastornos ansiosos y otros trastornos mentales.

Les troubles anxieux, dont le trouble panique avec ou sans agoraphobie, le trouble anxieux généralisé, l'anxiété sociale, les phobies spécifiques et l'anxiété de séparation, sont les troubles mentaux les plus prévalents avec des coûts immenses en termes de santé et une charge élevée. D'après de grandes études basées sur la population, jusqu'à 33,7 % de la population souffre d'un trouble anxieux au cours de la vie. Ces pathologies sont manifestement sous-diagnostiquées et sous-traitées. Leur prévalence n'a pas montré de modification ces dernières années et est très variable dans les comparaisons interculturelles. Cette hétérogénéité est probablement plus due à des biais méthodologiques qu'à des influences culturelles. L'évolution des troubles anxieux est chronique mais leur prévalence diminue cependant naturellement avec l'âge. Leur comorbidité avec les autres troubles anxieux et les autres maladies mentales est très élevée.

Efficacy of treatments for anxiety disorders: a meta-analysis.

To our knowledge, no previous meta-analysis has attempted to compare the efficacy of pharmacological, psychological and combined treatments for the three main anxiety disorders (panic disorder, generalized anxiety disorder and social phobia). Pre-post and treated versus control effect sizes (ES) were calculated for all evaluable randomized-controlled studies (n = 234), involving 37,333 patients. Medications were associated with a significantly higher average pre-post ES [Cohen's d = 2.02 (1.90-2.15); 28,051 patients] than psychotherapies [1.22 (1.14-1.30); 6992 patients; P < 0.0001]. ES were 2.25 for serotonin-noradrenaline reuptake inhibitors (n = 23 study arms), 2.15 for benzodiazepines (n = 42), 2.09 for selective serotonin reuptake inhibitors (n = 62) and 1.83 for tricyclic antidepressants (n = 15). ES for psychotherapies were mindfulness therapies, 1.56 (n = 4); relaxation, 1.36 (n = 17); individual cognitive behavioural/exposure therapy (CBT), 1.30 (n = 93); group CBT, 1.22 (n = 18); psychodynamic therapy 1.17 (n = 5); therapies without face-to-face contact (e.g. Internet therapies), 1.11 (n = 34); eye movement desensitization reprocessing, 1.03 (n = 3); and interpersonal therapy 0.78 (n = 4). The ES was 2.12 (n = 16) for CBT/drug combinations. Exercise had an ES of 1.23 (n = 3). For control groups, ES were 1.29 for placebo pills (n = 111), 0.83 for psychological placebos (n = 16) and 0.20 for waitlists (n = 50). In direct comparisons with control groups, all investigated drugs, except for citalopram, opipramol and moclobemide, were significantly more effective than placebo. Individual CBT was more effective than waiting list, psychological placebo and pill placebo. When looking at the average pre-post ES, medications were more effective than psychotherapies. Pre-post ES for psychotherapies did not differ from pill placebos; this finding cannot be explained by heterogeneity, publication bias or allegiance effects. However, the decision on whether to choose psychotherapy, medications or a combination of the two should be left to the patient as drugs may have side effects, interactions and contraindications.