On 2017 Sep 08, Falk Leichsenring commented:

Toward a more Balanced Perspective on Anxiety Treatment

Falk Leichsenring 1, Allan Abbass 2, Patrick Luyten13

1 Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Ludwigstr. 76, D-35392 Giessen, Germany 2 Department of Psychiatry, Dalhousie University; Centre for Emotions and Health, Halifax, 8203 5909 Veterans Memorial Lane, Halifax, NS, Canada, B3H 2E2 3 Faculty of Psychology and Educational Sciences, University of Leuven, Klinische Psychologie (OE), Tiensestraat 102 - bus 3722, 3000 Leuven, Belgium, and Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK

Stein and Craske recently published a viewpoint article entitled "Treating Anxiety in 2017".1 Yet, the treatment section excludes other evidence-based, widely-used non-medical treatment options while exclusively recommending pharmacotherapy and Cognitive Behavioral Therapy (CBT).

The authors state that most empirical support exists for CBT. However, a recent meta-analysis showed that only one sixth of studies are of high quality.2 In more than 80% of the studies CBT was compared to a waiting list, that is to a relatively weak comparator that may even represent a nocebo condition.2 In panic disorder, CBT was not superior to treatment-as-usual, only to waiting list.2 There was also significant evidence of publication bias.2 Based on these and other findings, this meta-analysis concluded that CBT was “at best probably effective” in anxiety disorders, which markedly contrasts with the overly optimistic depiction of the effects of CBT by Stein and Craske.

In exclusively recommending CBT, Craske and Stein completely bypass other forms of psychotherapy such as interpersonal therapy or psychodynamic therapy, even though both are efficacious in anxiety disorders. 3,4 Moreover, comorbidity is the norm in anxiety disorders but there is lack of evidence to support CBT in complex or comorbid anxiety populations, whereas brief psychodynamic therapy has been found to be more effective than other treatments in reducing anxiety in patients with depression. 5 The evidence for the proposed working mechanisms in anxiety disorders is also far less clear than Craske and Stein suggest, and their assertion that working mechanisms of CBT are different from other types of psychotherapy is similarly largely unsupported.

It is also quite perplexing that the authors recommend benzodiazepines for patients for whom SSRIs or CBT failed without consideration of the above mentioned other commonly used, non-medical treatments. Given evidence that long-term effects of pharmacotherapy in anxiety disorders are unknown due to the lack of follow-up studies6, such a suggestion biases patient care in favour of often endless medication treatments.

This unbalanced discussion of treatments for anxiety disorders is the more perplexing since the authors' attention was recently called to the fact that other types of psychotherapy have been found to be equally effective in anxiety disorders7, based on studies of good quality .4

Biased clinical guidance such as the one by Stein and Craske is highly undesirable from a scientific and clinical perspective, and can be easily avoided by including proponents of rival approaches (adversarial collaboration).

References

1. Stein MB, Craske MG. Treating Anxiety in 2017: Optimizing Care to Improve Outcomes. JAMA. Jul 18 2017;318:235-236.
2. Cuijpers P, Cristea IA, Karyotak E, Reijnders M, Huibers MHJ. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence World Psychiatry. 2016;15:245-258.
3. Markowitz JC, Petkova E, Neria Y, Van Meter PE, Zhao Y, Hembree E, Lovell K, Biyanova T, Marshall RD. Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD. Am J Psychiatry. May 2015;172:430-440.
4. Keefe JR, McCarthy KS, Dinger U, Zilcha-Mano S, Barber JP. A meta-analytic review of psychodynamic therapies for anxiety disorders. Clin Psychol Rev. Jun 2014;34:309-323.
5. Driessen E, Hegelmaier LM, Abbass AA, Barber JP, Dekker JJ, Van HL, Jansma EP, Cuijpers P. The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clin Psychol Rev. Aug 1 2015;42:1-15.
6. Leichsenring F, Leweke F. Social Anxiety Disorder. N Engl J Med. Jun 08 2017;376:2255-2264.
7. Steinert C, Leichsenring F. No psychotherapy monoculture for anxiety disorders. Lancet. May 13 2017;389:1882-1883.

On 2017 Sep 08, Falk Leichsenring commented:

Toward a more Balanced Perspective on Anxiety Treatment

Falk Leichsenring 1, Allan Abbass 2, Patrick Luyten13

1 Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Ludwigstr. 76, D-35392 Giessen, Germany 2 Department of Psychiatry, Dalhousie University; Centre for Emotions and Health, Halifax, 8203 5909 Veterans Memorial Lane, Halifax, NS, Canada, B3H 2E2 3 Faculty of Psychology and Educational Sciences, University of Leuven, Klinische Psychologie (OE), Tiensestraat 102 - bus 3722, 3000 Leuven, Belgium, and Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK

Stein and Craske recently published a viewpoint article entitled "Treating Anxiety in 2017".1 Yet, the treatment section excludes other evidence-based, widely-used non-medical treatment options while exclusively recommending pharmacotherapy and Cognitive Behavioral Therapy (CBT).

The authors state that most empirical support exists for CBT. However, a recent meta-analysis showed that only one sixth of studies are of high quality.2 In more than 80% of the studies CBT was compared to a waiting list, that is to a relatively weak comparator that may even represent a nocebo condition.2 In panic disorder, CBT was not superior to treatment-as-usual, only to waiting list.2 There was also significant evidence of publication bias.2 Based on these and other findings, this meta-analysis concluded that CBT was “at best probably effective” in anxiety disorders, which markedly contrasts with the overly optimistic depiction of the effects of CBT by Stein and Craske.

In exclusively recommending CBT, Craske and Stein completely bypass other forms of psychotherapy such as interpersonal therapy or psychodynamic therapy, even though both are efficacious in anxiety disorders. 3,4 Moreover, comorbidity is the norm in anxiety disorders but there is lack of evidence to support CBT in complex or comorbid anxiety populations, whereas brief psychodynamic therapy has been found to be more effective than other treatments in reducing anxiety in patients with depression. 5 The evidence for the proposed working mechanisms in anxiety disorders is also far less clear than Craske and Stein suggest, and their assertion that working mechanisms of CBT are different from other types of psychotherapy is similarly largely unsupported.

It is also quite perplexing that the authors recommend benzodiazepines for patients for whom SSRIs or CBT failed without consideration of the above mentioned other commonly used, non-medical treatments. Given evidence that long-term effects of pharmacotherapy in anxiety disorders are unknown due to the lack of follow-up studies6, such a suggestion biases patient care in favour of often endless medication treatments.

This unbalanced discussion of treatments for anxiety disorders is the more perplexing since the authors' attention was recently called to the fact that other types of psychotherapy have been found to be equally effective in anxiety disorders7, based on studies of good quality .4

Biased clinical guidance such as the one by Stein and Craske is highly undesirable from a scientific and clinical perspective, and can be easily avoided by including proponents of rival approaches (adversarial collaboration).

References

1. Stein MB, Craske MG. Treating Anxiety in 2017: Optimizing Care to Improve Outcomes. JAMA. Jul 18 2017;318:235-236.
2. Cuijpers P, Cristea IA, Karyotak E, Reijnders M, Huibers MHJ. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence World Psychiatry. 2016;15:245-258.
3. Markowitz JC, Petkova E, Neria Y, Van Meter PE, Zhao Y, Hembree E, Lovell K, Biyanova T, Marshall RD. Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD. Am J Psychiatry. May 2015;172:430-440.
4. Keefe JR, McCarthy KS, Dinger U, Zilcha-Mano S, Barber JP. A meta-analytic review of psychodynamic therapies for anxiety disorders. Clin Psychol Rev. Jun 2014;34:309-323.
5. Driessen E, Hegelmaier LM, Abbass AA, Barber JP, Dekker JJ, Van HL, Jansma EP, Cuijpers P. The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clin Psychol Rev. Aug 1 2015;42:1-15.
6. Leichsenring F, Leweke F. Social Anxiety Disorder. N Engl J Med. Jun 08 2017;376:2255-2264.
7. Steinert C, Leichsenring F. No psychotherapy monoculture for anxiety disorders. Lancet. May 13 2017;389:1882-1883.