Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis

doi:10.1016/S0005-7894(97)80048-2

Behavior Therapy

Volume 28, Issue 2, 1997, Pages 285-305

https://doi.org/10.1016/S0005-7894(97)80048-2 Get rights and content

This study provides a meta-analytic review of controlled trials examining cognitive behavior therapy (CBT) and pharmacotherapy for generalized anxiety disorder (GAD). Thirty-five studies, published or presented between 1974 and January 1996, were identified, and provided 61 separate treatment interventions. Both modalities of treatment offered clear efficacy to patients, and the overall effect size (ES) for CBT (ES = .70) was not statistically different from pharmacotherapy (ES = 0.60) for measures of anxiety severity. CBT was associated with significantly greater effects on depression severity, and was associated with clear maintenance of treatment gains, whereas the long-term efficacy of pharmacologic treatment was attenuated following medication discontinuation. Data concerning the efficacy of specific cognitive behavioral and pharmacologic interventions are provided, as are analyses of the influence of methodological factors (e.g., gender distribution, length of treatment) on the efficacy of treatments.

References (67)

BeckA.T. et al.
Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation
Clinical Psychology Review
(1988)
BarlowD.H. et al.
Behavioral treatment of generalized anxiety disorder
Behavior Therapy
(1992)
BlowersC. et al.
Generalised anxiety: A controlled treatment study
Behaviour Research and Therapy
(1987)
FeskeU. et al.
Cognitive behavioral versus exposure only treatment for social phobia: A meta-analysis
Behavior Therapy
(1995)
FontaineR. et al.
Comparison of withdrawal of buspirone and diazepam: A placebo controlled study
Neuro-Psychopharmacology and Biological Psychiatry
(1987)
GouldR.A. et al.
A meta-analysis of treatment outcome for panic disorder
Clinical Psychology Review
(1995)
MarksI.M. et al.
Brief standard self-rating for phobic patients
Behaviour Research and Therapy
(1979)
MeyerT.J. et al.
Development and validation of the Penn State Worry Questionnaire
Behaviour Research and Therapy
(1990)
OttoM.W. et al.
Maintenance of remission following cognitive-behavior therapy for panic disorder: Possible deleterious effects of concurrent medication treatment
Behavior Therapy
(1996)
PowerK.G. et al.
A controlled comparison of cognitive-behaviour therapy, diazepam, and placebo, alone and in combination, for the treatment of generalised anxiety disorder
Journal of Anxiety Disorders
(1990)

WolpeJ. et al.

A fear survey schedule for use in behaviour therapy

Behaviour Research and Therapy

(1964)

WoodwardR. et al.

Cognitive restructuring treatment: A controlled trial with anxious patients

Behaviour Research and Therapy

(1980)

ZungW.W.K.

A rating instrument for anxiety disorders

Psychosomatics

(1971)

Diagnostic and statistical manual of mental disorders

(1980)

Diagnostic and statistical manual of mental disorders

(1987)

Diagnostic and statistical manual of mental disorders

(1994)

PsychLIT Database (CD-ROM)

(1994)

AnsseauM. et al.

Initial study of methylclonazepam in generalized anxiety disorder: Evidence for greater power in the cross-over design

Psychopharmacology

(1985)

BallS.G. et al.

Predicting prospective episodes of depression in patients with panic disorder: A longitudinal study

Journal of Consulting and Clinical Psychology

(1994)

BjerrumH. et al.

Treatment of generalized anxiety disorder: Comparison of a new beta-blocking drug (CGP 361A), low-dose neuroleptic (flupenthixol), and placebo

Pharmacopsychiatry

(1992)

BorisonR.L. et al.

Efficacy and safety of putative anxiolytic agent: Ipsapirone

Psychopharmacology Bulletin

(1990)

BorkovecT.D. et al.

Psychosocial treatments for generalized anxiety disorder

BorkovecT.D. et al.

Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder

Journal of Consulting and Clinical Psychology

(1993)

BorkovecT.D. et al.

The effects of relaxation training with cognitive or nondirective therapy and the role of relaxation-induced anxiety in the treatment of generalized anxiety

Journal of Consulting and Clinical Psychology

(1987)

ButlerG. et al.

Anxiety management for persistent generalised anxiety

British Journal of Psychiatry

(1987)

ButlerG. et al.

Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder

Journal of Consulting and Clinical Psychology

(1991)

CastilloA. et al.

Alprazolam compared to clobazam and placebo in anxious outpatients

Neuropsychobiology

(1987)

CeulemansD.L.S. et al.

The influence of ritanserin, a serotonin antagonist, in anxiety disorders: A double-blind placebo-controlled study versus lorazepam

Pharmacopsychiatry

(1985)

ChamblessD.L. et al.

Cognitive therapy of anxiety disorders

Journal of Consulting and Clinical Psychology

(1993)

ClarkD.M. et al.

A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder

British Journal of Psychiatry

(1994)

ClumG.A. et al.

A meta-analysis for panic disorder

Journal of Consulting and Clinical Psychology

(1993)

CohnJ.B. et al.

A pooled, double-blind comparison of the effects of buspirone, diazepam and placebo in women with chronic anxiety

Current Medical Research and Opinion

(1989)

CoviL. et al.

Primary depression or primary anxiety? A possible psychometric approach to diagnose the dilemma

Clinical Neuropharmacology

(1984)

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Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis

Clinical Psychology Review

Behavior Therapy

Behaviour Research and Therapy

Behavior Therapy

Neuro-Psychopharmacology and Biological Psychiatry

Clinical Psychology Review

Behaviour Research and Therapy

Behaviour Research and Therapy

Behavior Therapy

Journal of Anxiety Disorders

Behaviour Research and Therapy

Behaviour Research and Therapy

Psychosomatics

Diagnostic and statistical manual of mental disorders

Diagnostic and statistical manual of mental disorders

Diagnostic and statistical manual of mental disorders

PsychLIT Database (CD-ROM)

Initial study of methylclonazepam in generalized anxiety disorder: Evidence for greater power in the cross-over design

Psychopharmacology

Predicting prospective episodes of depression in patients with panic disorder: A longitudinal study

Journal of Consulting and Clinical Psychology

Treatment of generalized anxiety disorder: Comparison of a new beta-blocking drug (CGP 361A), low-dose neuroleptic (flupenthixol), and placebo

Pharmacopsychiatry

Efficacy and safety of putative anxiolytic agent: Ipsapirone

Psychopharmacology Bulletin

Psychosocial treatments for generalized anxiety disorder

Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder

Journal of Consulting and Clinical Psychology

The effects of relaxation training with cognitive or nondirective therapy and the role of relaxation-induced anxiety in the treatment of generalized anxiety

Journal of Consulting and Clinical Psychology

Anxiety management for persistent generalised anxiety

British Journal of Psychiatry

Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder

Journal of Consulting and Clinical Psychology

Alprazolam compared to clobazam and placebo in anxious outpatients

Neuropsychobiology

The influence of ritanserin, a serotonin antagonist, in anxiety disorders: A double-blind placebo-controlled study versus lorazepam

Pharmacopsychiatry

Cognitive therapy of anxiety disorders

Journal of Consulting and Clinical Psychology

A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder

British Journal of Psychiatry

A meta-analysis for panic disorder

Journal of Consulting and Clinical Psychology

A pooled, double-blind comparison of the effects of buspirone, diazepam and placebo in women with chronic anxiety

Current Medical Research and Opinion

Primary depression or primary anxiety? A possible psychometric approach to diagnose the dilemma

Clinical Neuropharmacology