Anxiety Prevention Interventions: How Effective Are They?
Cost-effectiveness studies indicate that treatment alone is insufficient to eliminate the disease burden of anxiety.
Anxiety disorders affect an estimated 18.1% of US adults and 25.1% of adolescents age 13 to 18 each year.1,2 Between 2005 and 2015, there was a 14.8% increase in the burden of disease among these individuals, as measured by years lived with disability.3
“Anxiety disorders are persistent and incapacitating, and despite the availability of effective treatments, not all individuals with anxiety receive adequate treatment,” Patricia Moreno-Peral, PhD, of the Institute of Biomedical Research in Málaga, Spain, told Psychiatry Advisor. “Cost-effectiveness studies indicate that treatment alone is insufficient to eliminate the associated disease burden,” she added.
Only 36.9% of individuals with anxiety disorders receive any treatment, and 34.3% of those patients are only receiving minimally adequate treatment. This represents only 12.7% of the total number of people with anxiety disorders.1 Additionally, earlier findings suggest that even if every patient received optimal treatment, the burden of disease would be averted by no more than half.4
Another worthwhile goal in anxiety treatment would be a reduction in the incidence of new cases, which may be accomplished through prevention efforts. From a public health perspective, even “small effects on prevention could have a high impact, thereby improving quality of life and reducing costs,” wrote Dr Moreno-Peral and colleagues in a recent paper.3 Whereas studies on this topic support the effectiveness of anxiety prevention interventions, such research has focused primarily on children. “For this reason, we conducted the first meta-analysis on the effectiveness of preventive psychological and educational interventions for anxiety in varied populations,” she said.
A total of 29 randomized controlled trials met inclusion criteria, comprising a combined 10,430 patients from 11 countries across 4 continents. Results of the analysis show that preventive interventions for anxiety had a small and statistically significant effect, with a pooled standard mean difference of -0.31 (95% CI, -0.40 to -0.21; P <.001). The equivalent pooled odds ratio (OR) was 0.57 (95% CI, 0.48-0.68; P <.001), indicating a 43% reduction in the incidence of anxiety. Substantial heterogeneity was observed between studies (I2 = 61.1%; 95% CI, 44%-73%), which was found to be the result of waiting list conditions and small sample sizes in some of the studies.
Results of selected studies are summarized below:
- A 2007 study investigated the efficacy of brief cognitive-behavioral psychoeducation as a preventive intervention for depression and anxiety.5 Participants (n=152) were randomly assigned to prevention or control groups. At 8-week follow-up, symptoms were lower among the intervention group vs the control group.
- In a 2009 study of 1748 children and adolescents, an education-based prevention program for social anxiety was shown to reduce social anxiety in the total sample.6 In addition, social anxiety developed in significantly fewer participants who received the intervention during a 1-year period compared with those in the control group.
- Other research published in 2009 examined the effects of a stepped-care program for anxiety (n=86) and depression prevention vs usual care (n=84).7 The program sequentially consisted of “a watchful waiting approach, cognitive behavior therapy-based bibliotherapy, cognitive behavior therapy-based problem-solving treatment, and referral to primary care for medication, if required.” The incidence of DSM-IV anxiety and depressive disorders after 1 year was 50% lower in the intervention group (0.12) compared with 0.24 in the usual care group (relative risk, 0.49; 95% CI, 0.24-0.98).
- Findings reported in the American Journal of Psychiatry in 2015 demonstrated the impact of a family-based psychosocial intervention for the children (age 6-13 years; n=136) of individuals with a DSM-IV anxiety disorder.8 A lower incidence of anxiety disorders (as indicated by scores on the Anxiety Disorders Interview Schedule for Children) was observed in the intervention group (n=70) vs the control group (n=66) at the 1-year follow-up (5% vs 31%; OR, 8.54; 95% CI, 2.27-32.06).
- A study published in Behaviour Research and Therapy in 2017 investigated the effects of a 6-week cognitive behavioral preventive intervention that targeted repetitive negative thinking (worry and rumination) in 251 adolescents and young adults.9 Both group-based and Web-based interventions led to a lower 12-month prevalence of depression (group: 15.3%, Web-based: 14.7%) and generalized anxiety disorder (group: 18.0%, Web-based: 16.0%), vs the waitlist control group (32.4% and 42.2%, respectively). These effects were found to be mediated by the reductions in repetitive negative thinking.
Dr Moreno-Peral noted that the main takeaway for mental health clinicians is that anxiety can be prevented through various approaches, including time-limited educational interventions. She also noted that “psychological and educational interventions are effective regardless of the individual's age.
“These results suggest that these preventive interventions for anxiety should be further developed and implemented,” Dr Moreno-Peral said.
Further research needs include assessment of the effectiveness and cost utility of anxiety prevention programs, particularly with larger sample sizes. “Although we can say that these interventions are effective, we still do not have answers about which ones are most effective. Thus, new trials are needed to compare the different interventions with each other,” she added. Randomized controlled trials with follow-up of at least 2 years are also needed to examine the longer-term effectiveness of such approaches.
- National Institute of Mental Health. Any Anxiety Disorder Among Adults. https://www.nimh.nih.gov/health/statistics/prevalence/any-anxiety-disorder-among-adults.shtml. Accessed September 30, 2017.
- National Institute of Mental Health. Any Anxiety Disorder Among Children. https://www.nimh.nih.gov/health/statistics/prevalence/any-anxiety-disorder-among-children.shtml. Accessed September 30, 2017.
- Moreno-Peral P, Conejo-Cerón S, Rubio-Valera M, et al. Effectiveness of psychological and/or educational interventions in the prevention of anxiety: a systematic review, meta-analysis, and meta-regression [published online October 1, 2017]. JAMA Psychiatry. oi:10.1001/jamapsychiatry.2017.2509
- Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H. Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Br J Psychiatry. 2004;184:526-533.
- Cukrowicz KC, Joiner TE Jr. Computer-based intervention for anxious and depressive symptoms in a non-clinical population. Cognit Ther Res. 2007;31:677-693.
- Aune T, Stiles TC. Universal-based prevention of syndromal and subsyndromal social anxiety: a randomized controlled study. J Consult Clin Psychol. 2009;77:867-879.
- van't Veer-Tazelaar PJ, van Marwijk HW, van Oppen P, et al. Stepped-care prevention of anxiety and depression in late life: a randomized controlled trial. Arch Gen Psychiatry. 2009;66:297-304.
- Ginsburg GS, Drake KL, Tein JY, Teetsel R, Riddle MA. Preventing onset of anxiety disorders in offspring of anxious parents: a randomized controlled trial of a family-based intervention. Am J Psychiatry. 2015;172:1207-1214.
- Topper M, Emmelkamp PM, Watkins E, Ehring T. Prevention of anxiety disorders and depression by targeting excessive worry and rumination in adolescents and young adults: a randomized controlled trial. Behav Res Ther. 2017;90:123-136.