The effectiveness of behavioral therapy interventions for anxiety disorders has been proven in many well-done studies. Thus, cognitive behavioral therapy is mentioned in all guidelines for anxiety treatment as the intervention of first choice [Bandelow B et al. S3-Leitlinie Angststörungen. Stand 2021]. Nevertheless, psychotherapy researchers are always confronted with the critical question of whether what they have investigated in perfectly controlled studies at university research institutions, i.e., in the ivory tower, so to speak, can also be transferred to everyday clinical practice.

Internationally and also in Germany, cognitive behavioral therapy (CBT) is best anchored in the training of prospective therapists and is also frequently used, especially for anxiety disorders. However, experienced clinicians can confirm that the documented effectiveness (efciency) from randomized controlled trials (RCT) can also be transferred to the effectiveness in real life (efectiveness), mainly through personal experience. The number of studies on routine care has so far been unclear, especially since available reviews were not up to date.

The meta-analysis by Öst et al. from this year now clearly answers the question: the effect sizes of cognitive behavioral anxiety therapy in routine clinical care are as impressively large as in RCTs. Therapeutic change within treated groups produced anxiety reduction, the primary measure of progress, as well as depressive symptom reduction, a secondary measure that was not a direct target of the intervention.

Efect sizes, benchmarking, and quality of meta-analysis.

Efect sizes (ES) were very large for changes in anxiety from the beginning to the end of terapy (ES=1.09), with individuals with panic disorder or generalized anxiety disorder performing even better than those with social anxiety disorder. Thus, the results were almost exactly similar to those obtained for the gold standard, RCT. The remission rate in the clinical setting was also not significantly different from that in RCT (52.3% vs. 49.1%). Likewise, anxiety reduction at the time of catamnesis was again significantly greater (ES=1.39), as were remission rates (58.7%). Ovenbar still consolidates defects after treatment completion, and affected individuals extend their range of motion. This is probably also due to operant mechanisms, as patients experience numerous reinforcers for discontinuing anxiety-typical avoidance behaviors as a result of improved participation [Alpers GW. New York: Springer Science+Business Media; 2010. pp.209-30].

The quality of the meta-analysis presented can be rated as extraordinarily high. Beyond previous analyses, all studies of the last ten years were included. Because of the high practical relevance, studies with additional psychoactive medication therapy were also included. Most importantly, the focus was on comparison with suitable efcacy studies (“benchmarking”): A total of 66 efectiveness studies were compared with 131 efcacy studies. In addition to concluding that routine treatments are just as effective as controlled research therapies in the university setting, the new analysis, taking into account recent observations, also shows no decline in efficacy over the years – which seems to be the case for many other interventions.

Comment

Efficacy in routine clinical care is ultimately what counts – anxiety disorders in particular require appropriate care as they are highly prevalent and often associated with comorbidity; worldwide, anxiety disorders are among the conditions with the greatest limitations for sufferers [Baxter AJ et al. Psychol Med. 2014; 44(11):2363-74]. Doubts about the transferability of research findings to clinical practice are reasonable, as treatments may differ in different settings. While clinical trials must select subjects, routine care patients do not adhere to specifications of standardization. They may be more severely distressed, have multiple and unclear comorbid diagnoses, and (in the worst case) be suicidal.

The therapists can also differ: In university study centers, they are often younger, but all the better trained in the procedure. Compliance with the treatment manuals is also strictly monitored there. Powerful meta-analyses are ideally suited for an overview of the complicated study situation, since the data of thousands of subjects from several studies can be analyzed together. In the meta-analysis presented, it is noteworthy that the average number of therapeutic sessions in routine care was only 11.5 sessions or 17 treatment hours. If it is additionally taken into account that the duration of treatment correlated with efficacy, it is interesting to note that for outpatient treatments in Germany, with twice twelve sessions for short-term therapy, a larger time frame is already available, which can be extended as long-term therapy if needed.

A limitation of the analysis is that in the studies reviewed, effects were quantified as changes within a treated group from the beginning of the intervention to the end (or catamnesis). This is the weakest way to test the mechanisms of action of a change. In RCTs, comparisons with waiting lists or effective control groups are common – such as a relaxation procedure. In such comparisons, the effect sizes turn out to be much smaller [Leichsenring F et al. World Psychiatry. 2022;21(1):133-45].

However, the authors defend their approach with the argument that the individual patient is naturally interested in the expected change compared to before therapy. However, even in the meta-analysis presented, all results represent mean values across treated groups. Thus, the meta-analysis is not able to provide information about who will benefit from the interventions in practice. However, answering such questions is increasingly becoming the focus of current research [Taubitz FS et al. Behav Res Ther. 2022; doi:10.1016/j.brat.2022.104116]. Although training and care in Germany are good, it should be noted that gaps in care exist.

Our conclusion

While in some areas of medicine we have succeeded in radically minimizing the prevalence of the disorder being treated by establishing effective therapies, in psychotherapy we still seem to be far from achieving this [Ormel J et al. Psychother Psychosom. 2023;92(2):73-80]. Thus, for better dissemination of highly efective cognitive-behavioral therapy, there is still work to be done. And so Öst et al. conclude their article with the decisive appeal to integrate effective therapies as fully as possible into routine care.