Evidence-Based Treatments for Anxiety-Related Presentations
The Underutilisation of ET
The Contribution of Implementation Science
The Current Review
Objectives of the Review
Methods
Search Strategy
Eligibility Criteria
Selection Process
Data Extraction and Quality Appraisal
Individual Results and Synthesis
Results
Included Studies
Study Characteristics and Quality Appraisal
Study | Design | Method | Presentation | Developmental Subgroup |
---|---|---|---|---|
(Whiteside et al., 2023) | Quantitative randomised controlled trial | – | Anxiety disorders (e.g., generalised anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder). | Youth (9 to 17 years). |
(Klan et al., 2017) | Quantitative non-randomised | Cohort | Anxiety disorders (agoraphobia). | Adults (unspecified). |
(Becker et al., 2018) | Quantitative descriptive | Survey | Anxiety disorders (panic disorder and/or agoraphobia). | Lifespan (unspecified). |
(Kannis-Dymand et al., 2022) | Quantitative descriptive | Survey | Anxiety disorders. | Lifespan (16 years or older). |
(Keleher et al., 2020) | Quantitative descriptive | Survey | OCD. | Youth (unspecified). |
(Hertz et al., 2023) | Quantitative non-randomised | Cross-sectional | OCD. | Adults (unspecified). |
(Moritz et al., 2019) | Quantitative descriptive | Survey | OCD. | Lifespan (unspecified). |
Mixed methods | Sequential | PTSD. | Adults (unspecified). | |
Quantitative descriptive | Survey | PTSD. | Adults (unspecified). | |
(Cook et al., 2014) | Mixed methods | Convergence | PTSD. | Adults (unspecified). |
(Cook et al., 2013) | Mixed methods | Sequential | PTSD. | Adults (unspecified). |
Mixed methods | Sequential | PTSD. | Adults (unspecified). | |
Quantitative descriptive | Survey | PTSD. | Adults (unspecified). | |
Quantitative descriptive | Survey | PTSD. | Adults (unspecified). | |
(Finley et al., 2015) | Quantitative descriptive | Survey | PTSD. | Adults (unspecified). |
(Foa et al., 2020) | Quantitative randomised controlled trial | - | PTSD. | Adults (unspecified). |
(Garcia et al., 2020) | Quantitative descriptive | Survey | PTSD. | Adults (unspecified). |
(Kline et al., 2021) | Quantitative descriptive | Survey | PTSD. | Adults (unspecified). |
(Maguen et al., 2019) | Quantitative non-randomised | Cross-sectional | PTSD. | Adults (unspecified). |
(Rosen et al., 2019) | Quantitative non-randomised | Cohort | PTSD. | Adults (unspecified). |
(Rosen et al., 2017) | Quantitative descriptive | Survey | PTSD. | Adults (unspecified). |
(Ruzek et al., 2017) | Quantitative non-randomised | Repeated measures | PTSD. | Adults (unspecified). |
(Becker et al., 2004) | Quantitative descriptive | Survey | PTSD. | Lifespan (unspecified). |
(Harned et al., 2021) | Quantitative non-randomised | Repeated measures | PTSD. | Lifespan (unspecified). |
(Sherrill et al., 2021) | Quantitative non-randomised | Repeated measures | PTSD. | Lifespan (unspecified). |
(van Minnen et al., 2010) | Quantitative randomised controlled trial | - | PTSD. | Lifespan (unspecified). |
(Wade et al., 2020) | Quantitative non-randomised | Repeated measures | PTSD. | Lifespan (unspecified). |
(Becker-Haimes et al., 2017) | Quantitative descriptive | Survey | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD). | Youth (unspecified). |
(de Jong et al., 2020) | Quantitative descriptive | Survey | Anxiety-related presentations (unspecified). | Youth (unspecified). |
(Reid et al., 2017) | Quantitative descriptive | Survey | Anxiety disorders, OCD, and PTSD. | Youth (7 to 17 years). |
(Reid et al., 2018) | Quantitative descriptive | Survey | Anxiety disorders, OCD, and PTSD. | Youth (7 to 17 years). |
(Vande Voort et al., 2010) a | Quantitative non-randomised | Cross-sectional | Anxiety-related presentations (combined anxiety disorders and OCD). | Youth (6 to 18 years). |
Quantitative non-randomised | Repeated measures | Anxiety-related presentations (combined anxiety disorders and OCD). | Youth (7 to 17 years). | |
Quantitative randomised controlled trial | - | Anxiety-related presentations (combined anxiety disorders and OCD). | Youth (8 to 18 years). | |
Quantitative descriptive | Survey | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD). | Youth (unspecified). | |
Quantitative non-randomised | Cross-sectional | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD). | Youth (7 to 17 years). | |
(Chen et al., 2022) | Quantitative descriptive | Survey | Anxiety-related presentations (unspecified). | Adults (unspecified). |
(Rowe & Kangas, 2020) | Quantitative descriptive | Survey | Anxiety-related presentations (combined anxiety disorders and OCD). | Adults (unspecified). |
(Becker‐Haimes et al., 2020) | Quantitative descriptive | Survey | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
(Deacon et al., 2013) b | Q
uantitative non-randomised | Repeated measures | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
(Harned et al., 2013) | Quantitative randomised controlled trial | - | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
(Harned et al., 2014) | Quantitative randomised controlled trial | - | Anxiety-related presentations (combined anxiety disorders and PTSD). | Lifespan (unspecified). |
(Harned et al., 2011) | Quantitative randomised controlled trial | - | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
(Hipol & Deacon, 2013) | Quantitative descriptive | Survey | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD). | Lifespan (unspecified). |
(Meyer et al., 2020) | Quantitative descriptive | Survey | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
(Moses et al., 2022) | Mixed methods | Sequential | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD), anxiety disorders, OCD, and PTSD. | Lifespan (unspecified). |
(Moses et al., 2021) | Quantitative descriptive | Survey | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD), anxiety disorders, OCD, and PTSD. | Lifespan (unspecified). |
(Parker & Waller, 2019) | Quantitative descriptive | Survey | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
(Pittig et al., 2019) | Quantitative descriptive | Survey | Anxiety-related presentations (combined anxiety disorders, OCD, and PTSD). | Lifespan (unspecified). |
(Sars & van Minnen, 2015) | Quantitative descriptive | Survey | Anxiety disorders and OCD. | Lifespan (unspecified). |
(Schumacher et al., 2018) | Quantitative descriptive | Survey | Anxiety disorders and PTSD. | Lifespan (unspecified). |
(Živčić-Bećirević et al., 2019) | Quantitative descriptive | Survey | Anxiety-related presentations (unspecified). | Lifespan (unspecified). |
Results Synthesised by Theoretical Domains Framework Domains
TDF Domain | Definition and Constructs (Cane et al., 2012) | Current Operationalisation | Constructs Coded a |
---|---|---|---|
Knowledge | An awareness of the existence of something. Includes knowledge (i.e., knowledge of condition/scientific rationale), procedural knowledge, and knowledge of task environment. | An awareness of the existence of therapeutic techniques including ET (i.e., knowledge of theory, rationale for use, application). | Knowledge of ET; unspecified ET training; unspecified CBT training; post-qualification accreditation. |
Skills | An ability or proficiency acquired through practice. Includes skills, skill development, competence, ability, interpersonal skills, practice, and skill assessment. | An ability or proficiency in therapeutic techniques including ET acquired through practice. | Practical training in ET; experience using ET; experience treating anxiety-related presentations; general clinical experience. |
Social/Professional Role and Identity | A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting. Includes professional identity, professional role, social identity, identity, professional boundaries, professional confidence, group identity, leadership, and organisational commitment. | A coherent set of individual or group behaviours and displayed personal qualities in a social or work setting. | Clinician factors: Qualification in psychology (e.g., clinical psychology, other); registration status as a psychologist (e.g., provisional, general, with endorsement); education; profession; therapeutic theoretical orientation; self-identified specialisation in anxiety; demographics (i.e., age, gender). Client factors: Demographics (i.e., age, gender, race, relationship status, ethnicity, education); military experience (i.e., service branch, service component, rank, multiple deployments, deployment in combat zone). |
Beliefs about Capabilities | Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use. Includes self-confidence, perceived competence, self-efficacy, perceived behavioural control, beliefs, self-esteem, empowerment, and professional confidence. | Acceptance of the truth, reality, or validity of about an ability, talent, or facility relating therapeutic techniques including ET that a person can put to constructive use. | Self-efficacy using ET; self-efficacy using other therapeutic techniques; self-esteem; perceived control over treatment plan and schedule; self-efficacy receiving ET referrals; perceived resilience of children with anxiety. |
Optimism | The confidence that things will happen for the best or that desired goals will be attained. Includes optimism, pessimism, unrealistic optimism, and identity. | The confidence that therapeutic techniques including ET will have the best outcome or that desired goals will be attained. | None. |
Beliefs about Consequences | Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation. Includes beliefs, outcomes expectancies, characteristics of outcome expectancies, anticipated regret, and consequents. | Acceptance of the truth, reality, or validity about outcomes relating to therapeutic techniques including ET in a given situation. | Clinician factors: Negative beliefs about ET and CBT; perceived utility and risks of ET; perceived treatment credibility of ET; perceived superiority of ET to existing practices; perceived observability of ET results to others; perceived utility of ET treatment components; perceived utility and risks of other therapeutic techniques. Clinician and client factors: Outcome expectancies. |
Reinforcement | Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus. Includes rewards (proximal/distal, valued/not valued, probable/improbable), incentives, punishment, consequents, reinforcement, contingencies, and sanctions. | Increasing the probability of using therapeutic techniques including ET by arranging a dependent relationship, or contingency, between the response and a given stimulus. | None. |
Intentions | A conscious decision to perform a behaviour or a resolve to act in a certain way. Includes stability of intentions, stages of change model, and transtheoretical model and stages of change. | Motivation to use therapeutic techniques including ET. | Openness to and willingness to use ET; completion of an intervention aimed at improving motivation to use ET. |
Goals | Mental representations of outcomes or end states that an individual wants to achieve. Includes goals (distal/proximal), goal priority, goal/target setting, goals (autonomous/controlled), action planning, and implementation intention. | Mental representations of outcomes or end states (including implementation intention) for therapeutic techniques including ET that an individual wants to achieve. Includes actual use of other techniques as a reflection of goal priority. | Use of other techniques; use of therapist safety behaviours; likelihood of excluding clients from ET due to their characteristics; intention to use ET; allocation to a treatment condition delivering parent-coached ET; personal preference for ET. |
Memory, Attention, and Decision Processes | The ability to retain information, focus selectively on aspects of the environment, and choose between two or more alternatives. Includes memory, attention, attention control, decision-making, and cognitive overload/tiredness. | Factors influencing the retention of information, selective focusing on aspects of the environment, and choice between using therapeutic techniques and ET. | None. |
Environmental Context and Resources | Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour. Includes environmental stressors, resources/material resources, organisational culture/climate, salient events/critical incidents, person-environment interaction, and barriers and facilitators. | Circumstance of a person’s situation, context, or environment that can influence the development of skills and abilities, independence, social competence, and adaptive behaviour relating to using therapeutic techniques including ET. | Clinician factors: Current frequency of exposure to anxiety-related presentations; perceived impact of client’s resistance to change on ability to use ET; workload; consistency of prolonged exposure with the priorities of the adopter/service; practice setting; average anxiety treatment length; more frequently engaging in group, relative to individual therapy. Client factors: Comorbidities; residence relative to urban centres; military sexual trauma; smoking status; current medications; visit to
Veterans Health Administration following implementation of evidence-based practices; number of non-evidence-based therapy sessions received before ET; PTSD diagnosis related to military service; diagnoses; recent hospitalisation; level of impairment due to anxiety. System factors: Organisational structure and support; workforce size; organisational turnover; demands on residential treatment programmes; availability of resources for prolonged exposure; practical barriers to ET use; availability of interested clients; working within a PTSD specialty clinic; working within an integrated behavioural health setting. |
Social Influences | Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours. Includes social pressure, social norms, group conformity, social comparisons, group norms, social support, power, intergroup conflict, alienation, group identity, and modelling. | Interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours on using therapeutic techniques including ET. | Clinician factors: Social network; attachment style. Clinician and client factors: Therapeutic alliance. System factors: Organisational culture of implementation; leadership articulating goals to implement prolonged exposure; organisation prioritising cognitive processing and other therapies; organisational politics; fair treatment of clinicians by superiors; telephone consultations with prolonged exposure experts; group supervision on ET; amount of supervision given or received monthly; supervisors’ recommendation to use ET. |
Emotion | A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event. Includes fear, anxiety, affect, stress, depression, positive/negative affect, and burnout. | A complex reaction pattern, involving experiential, behavioural, and physiological elements by which the individual attempts to deal with a personally significant matter or event. | Clinician factors: Intuitive appeal of evidence-based practice; anxious and depressive symptoms; anxiety and disgust sensitivity; distress and avoidance relating to exposure. Client factors: Anxiety and depressive symptoms; distress. |
Behavioural Regulation | Anything aimed at managing or changing objectively observed or measured actions. Includes self-monitoring, breaking habit, and action planning. | Anything aimed at managing or changing objectively observed or measured actions, including using therapeutic techniques including ET. | Perceived divergence between evidence-based and current practices; willingness to use evidence-based practice if required to. |