Cognitive-behavioral therapy (CBT) is often recommended for generalized anxiety disorder (GAD) due to its proven efficacy in reducing worry, physical symptoms, and avoidance behaviors.
CBT helps individuals identify and challenge anxiety-provoking thoughts, develop coping skills, and gradually confront feared situations.
By targeting these maintaining factors, CBT aims to alleviate distress, improve functioning, and prevent relapse in GAD.
Basile, V. T., Newton‐John, T., McDonald, S., & Wootton, B. M. (2024). Brief remote cognitive behaviour therapy for generalized anxiety disorder: An open trial. British Journal of Clinical Psychology. https://doi.org/10.1111/bjc.12516
Key Points
- Brief videoconference-delivered cognitive behavioral therapy (VCBT) resulted in significant improvements in generalized anxiety disorder (GAD) symptoms from pre-treatment to post-treatment and 3-month follow-up with large effect sizes.
- Brief VCBT was found to be an acceptable and satisfactory treatment for patients with GAD.
- Benchmarking analyses showed brief VCBT had comparable outcomes to standard length VCBT and in-person CBT for GAD.
- Brief VCBT has potential to overcome barriers to accessing treatment for GAD such as cost, access to trained clinicians, and logistical issues.
- Further research with larger, more diverse samples and controlled trials is needed to confirm the efficacy of brief VCBT for GAD.
Rationale
Generalized anxiety disorder (GAD) is a chronic mental health condition that results in significant individual and economic burden.
However, uptake of evidence-based treatment like cognitive behavioral therapy (CBT) is low due to barriers like cost and access (Konnopka & König, 2020; Trenoska Basile, Newton-John, & Wootton, 2024).
While remote therapies like videoconference-delivered CBT (VCBT) can help improve access, there is limited research on whether brief VCBT is efficacious for treating GAD specifically.
Brief treatments have shown promise for other anxiety disorders (Otto et al., 2012; Singh & Samantaray, 2022) and in reducing sessions required for clinical improvement (Levy et al., 2020; Robinson et al., 2020).
Therefore, this open trial aimed to provide preliminary evidence for the efficacy and acceptability of a 5-session VCBT intervention for GAD.
Method
The study used an open trial design comparing pre-treatment to post-treatment and 3-month follow-up outcomes in 36 participants with GAD who received 5 weekly 50-minute sessions of manualized VCBT.
Treatment was based on the Intolerance of Uncertainty model and covered psychoeducation, cognitive restructuring, problem-solving, behavioral experiments, imaginal exposure, and relapse prevention.
Sessions were delivered by provisionally registered or fully registered psychologists via Zoom under supervision of an experienced clinical psychologist.
Sample
Participants were predominately female (77.8%), had a mean age of 36.81 years (SD=12.25), 25% were on stable medication, and 66.7% had comorbid depressive disorders.
Inclusion criteria were being an Australian resident aged 18+, meeting DSM-5 criteria for GAD as the primary disorder of at least moderate severity, and having regular internet access.
Exclusion criteria were high risk of harm to self/others and current engagement in weekly psychotherapy.
Measures
Primary outcome measure was the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7).
Secondary measures included the Generalized Anxiety Disorder Dimensional Scale (GAD-D), Penn State Worry Questionnaire-3 item (PSWQ-3), Patient Health Questionnaire-9 item (PHQ-9), Sheehan Disability Scale (SDS), and NIMH Clinical Global Impression Improvement Scale self-report version.
Diagnostic status was assessed using the Diagnostic Interview for Anxiety, Mood and OCD and Related Neuropsychiatric Disorders (DIAMOND).
Treatment satisfaction and acceptability were measured using the Client Satisfaction Questionnaire (CSQ) and Acceptability Questionnaire (AQ).
Statistical Methods
Mixed-linear models using intention-to-treat principles with multiple imputation for missing data were used to examine changes in symptom measures over time.
Within-group Cohen’s d effect sizes were calculated. Clinical improvement was assessed by changes in diagnostic status.
Benchmarking compared the magnitude of symptom change to a standard-length VCBT trial and meta-analysis of in-person CBT.
Results
The brief VCBT intervention resulted in significant improvements on the GAD-7 from pre-treatment to mid-treatment (d=0.76), post-treatment (d=1.13), and 3-month follow-up (d=1.58).
Similar results were found on secondary GAD measures. At post-treatment, 79.2% no longer met GAD diagnostic criteria, increasing to 87% at follow-up.
Participants were highly satisfied, with 92% reporting treatment was worth their time.
Benchmarking showed comparable effect sizes to standard length VCBT and in-person CBT.
Insight
This study provides promising initial evidence that brief VCBT, consisting of just 5 sessions, can lead to substantial and durable improvements in GAD symptoms.
The magnitude of symptom reduction was on par with lengthier VCBT and in-person CBT treatments, suggesting abbreviated remote therapy may be a viable option for expanding access to care.
Participants found the intervention highly acceptable, which bodes well for uptake and engagement.
However, it’s important to note that nearly half still met diagnostic criteria after treatment, so while gains were clinically meaningful, a subset likely required further care.
Future research should explore for whom brief VCBT is sufficient versus better positioned as part of a stepped-care approach.
Trials directly comparing brief and standard protocols would help elucidate the incremental benefits of additional sessions.
The sample was predominately female and well-educated, so generalizability to more diverse populations warrants investigation.
Examining predictors of response, mechanisms of change, and system-level implementation are other key directions for advancing brief VCBT as an accessible, evidence-based option for the millions affected by impairing GAD.
Implications
Brief VCBT shows promise as an accessible, effective treatment approach for GAD that could overcome common barriers to care.
Its efficacy on par with lengthier in-person CBT suggests meaningful benefits may be achievable through more efficient, affordable, convenient delivery.
If replicated, brief VCBT warrants incorporation into clinical training, treatment guidelines, and care systems to expand its reach.
However, non-remission in nearly half the sample highlights potential need for a stepped-care approach where initial non-responders receive further treatment.
Engagement issues and attrition also bear monitoring in remote therapy. Overall, this study illuminates brief VCBT’s potential to make evidence-based GAD treatment more accessible and patient-centered, but additional research is needed to optimize its impact.
Strengths
The study had many methodological strengths including:
- Using a structured diagnostic interview (DIAMOND) to establish GAD diagnosis and assess comorbidities
- Employing manualized VCBT based on an empirically supported model (Intolerance of Uncertainty)
- Having sessions delivered by trained clinicians under expert supervision to ensure fidelity
- Assessing multiple symptom domains with well-validated measures
- Examining post-treatment and follow-up outcomes to evaluate durability of gains
- Comparing effect sizes to established benchmarks for lengthier VCBT and in-person CBT
- Collecting acceptability data to inform patient perceptions and satisfaction
- Applying intent-to-treat analyses with multiple imputation for missing data to minimize bias
Limitations
This study also had several methodological limitations, including:
- Lack of control group prevents ruling out alternative explanations for symptom improvement, but GAD’s chronicity makes spontaneous remission unlikely
- Small, homogenous sample of mostly well-educated females limits generalizability to diverse populations
- High dropout rate (36%) may reflect engagement challenges or reduced motivation due to treatment brevity
- Missing post-treatment and follow-up data for sizable subsets reduced power and representativeness of retained sample
- Effectiveness in routine care contexts untested as clinicians had small caseloads and regular supervision atypical of community practice
References
Primary reference
Basile, V. T., Newton‐John, T., McDonald, S., & Wootton, B. M. (2024). Brief remote cognitive behaviour therapy for generalized anxiety disorder: An open trial. British Journal of Clinical Psychology. https://doi.org/10.1111/bjc.12516
Other references
Konnopka, A., & König, H. (2020). Economic burden of anxiety disorders: a systematic review and meta-analysis. Pharmacoeconomics, 38(5), 437-453.
https://doi.org/10.1007/s40273-019-00849-7
Levy, H. C., Worden, B. L., Davies, C. D., Stevens, K., Katz, B. W., Mammo, L., … & Tolin, D. F. (2020). The dose-response curve in cognitive-behavioral therapy for anxiety disorders. Cognitive behaviour therapy, 49(6), 439-454. https://doi.org/10.1080/16506073.2020.1771413
Otto, M. W., Pollack, M. H., Dowd, S. M., Hofmann, S. G., Pearlson, G., Szuhany, K. L., … & Tolin, D. F. (2016). Randomized trial of d‐cycloserine enhancement of cognitive‐behavioral therapy for panic disorder. Depression and Anxiety, 33(8), 737-745. https://doi.org/10.1002/da.22531
Robinson, L., Delgadillo, J., & Kellett, S. (2020). The dose-response effect in routinely delivered psychological therapies: A systematic review. Psychotherapy Research, 30(1), 79-96. https://doi.org/10.1080/10503307.2019.1566676
Singh, P., & Samantaray, N. N. (2022). Brief Cognitive behavioral group therapy and verbal-exposure-augmented cognitive behavioral therapy for social anxiety disorder in university students: a randomized controlled feasibility trial. Indian Journal of Psychological Medicine, 44(6), 552-557.
https://doi.org/10.1177/02537176211026250
Basile, V. T., Newton‐John, T., & Wootton, B. M. (2024). Treatment histories, barriers, and preferences for individuals with symptoms of generalized anxiety disorder. Journal of Clinical Psychology, 80(6), 1286-1305. https://doi.org/10.1002/jclp.23665
Keep Learning
Here are some Socratic questions to stimulate further discussion and critical thinking about this paper in a college class:
- How might the efficacy of brief VCBT compare to other GAD treatment approaches not examined in this study, such as meditation, medication, or in-person therapy formats besides CBT? What are the pros and cons of each option from patient and provider perspectives?
- Nearly half the sample still met GAD diagnostic criteria after treatment. Does this call into question the potency of brief VCBT or simply reflect the recalcitrance of this disorder? How might “success” be defined differently by various stakeholders (e.g., patients, clinicians, payers)?
- The sample lacked diversity in gender, education level, and presumably culture given the Australian context. What adaptations might make brief VCBT more inclusive and applicable across a wider population? Are there groups for whom this approach may be contraindicated?
- Many effect sizes and remission rates actually improved between post-treatment and 3-month follow-up. To what might we attribute these continued gains? Are there ways to capitalize on this momentum and further optimize long-term outcomes?
- Remote videoconferencing makes therapy more convenient, but may also reduce accountability and connection compared to in-person meetings. How can clinicians build and sustain a strong therapeutic alliance in brief, virtual interventions for GAD? What strategies could enhance engagement and reduce attrition?
- Beyond symptom reduction, what other metrics and methods might enrich our understanding of patient improvement and quality of life? For example, could incorporating qualitative interviews or real-time ecological momentary assessments provide a more holistic picture of functioning?
