ReviewRemission in CBT for adult anxiety disorders: A meta-analysis
Introduction
The efficacy of cognitive behavioral therapy (CBT) for anxiety disorders is well established with multiple controlled trials demonstrating that CBT outperforms not only waitlist and placebo controls but also other psychological treatments (Butler, Chapman, Forman, & Beck, 2006; Tolin, 2010). Meta-analytic reviews of CBT for anxiety disorders have commonly found medium to large effect sizes from pre- to post-treatment, depending on the anxiety disorder (Butler et al., 2006; Olatunji, Cisler, & Deacon, 2010). A recent meta-analysis of response rates in CBT for anxiety suggest a less optimistic view of CBT efficacy; there was a 49.5% response rate at post-treatment and a 53.6% response rate at follow-up (Loerinc et al., 2015).
One complication with interpreting the Loerinc et al. (2015) meta-analysis is that the constructs of response and remission were combined. Therefore, we examined how different definitions of remission lead to different remission rates among the anxiety disorders. Response refers to overall change over the course of treatment (e.g., a patient exhibited a 25% or greater reduction in symptoms). However, a patient could exhibit clinical response but still be quite impaired. For example, a patient with obsessive-compulsive disorder (OCD) might show a decrease in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989) scores from 32 to 20; although that is more than a 25% decrease (and thus the patient may be considered a responder), the post-treatment score is still in the moderate range, suggesting clinically elevated symptoms. Remission, on the other hand, refers to end status after treatment; in other words, a patient in remission is considered “well.” This is a critical distinction: in order to determine how well CBT impacts the substantial public health burden of anxiety disorders (Kessler, Alonso, Chatterji, & He, 2014), it is important to know not only how many patients show a change in symptoms, but also how many can be considered “well” after treatment.
Remission has been defined in several different ways. One common definition is that the patient no longer meets diagnostic criteria for the disorder being treated. An important limitation of this definition is that a patient may no longer meet criteria for a diagnosis simply because he/she is one symptom short of the criteria, yet continue to have severe and impairing symptoms. Another definition of remission is scoring below a clinical cutoff on a continuous measure. However, some researchers have used cutoff scores that could still reflect the presence of mild to moderate symptoms (e.g., a Y-BOCS score of 15 or less). A third and related definition is clinically significant change (CSC; Jacobson & Truax, 1991), which can reflect post-treatment scores that are outside the pathological range, within the normative range, or past the midpoint between the pathological and normative ranges (McGlinchey, Atkins, & Jacobson, 2002). It is noted that some authors have confused CSC with reliable change (i.e., a degree of change that is unlikely to be due to measurement error); however, these constructs should be considered separately, as reliable change refers to movement over time (analogous to the construct of response) whereas CSC refers to end status (analogous to the construct of remission; Jacobson, Roberts, Berns, & McGlinchey, 1999). A fourth definition of remission is good (or high) end state functioning, a less well-defined construct that refers to overall psychological health across multiple domains of functioning, such as anxiety, depression, and general stress. Practically speaking, good end state functioning is often defined in treatment studies as scoring below cutoffs on measures not only of the disorder being treated, but also on measures of commonly co-occurring problems such as depression.
As can be seen from the wide range of remission definitions, as well as the fact that some authors have defined remission as a combination of two or more of these factors, it is clear that there is no universally accepted definition of remission in anxiety disorders, which may lead to significantly different estimates of treatment efficacy. It is important, therefore, to determine not only the overall remission rate in CBT for anxiety, but also to understand whether different definitions of remission lead to significantly different estimates. Of course, universally accepted and applied definitions are needed in order to clarify true remission rates in CBT.
To this end, the present meta-analysis examined rates of remission (defined as end state after treatment) in CBT for DSM-IV (American Psychiatric Association, 1994) anxiety disorders. Our primary aim was to compare remission rates across various definitions, including no longer meeting criteria for the primary diagnosis, CSC, scoring below a clinical cutoff, good end state functioning, and commonly used combinations of these definitions. A secondary aim was to compare remission rates across anxiety disorders. We also examined whether certain demographic variables (e.g., age, gender) and psychological factors (e.g., medication status, comorbidity) impacted remission rates.
In addition to establishing standardized definitions for remission, it is important to consider the methodological quality of the research. One might expect that key indices of methodological rigor (e.g., Foa & Meadows, 1997; Jadad et al., 1996), would affect remission estimates, with more rigorous trials yielding more conservative estimates. Accordingly, randomized controlled trials (RCTs) would be expected to yield lower remission rates than would open trials. Intent-to-treat (ITT) analyses would be expected to yield lower rates than would completer analyses. Studies that used independent evaluators, blind to treatment condition, would be expected to yield lower rates than would studies that used unblinded evaluators or self-report measures. Studies that used manualized treatments and assessed treatment fidelity would be expected to yield lower remission rates than would those that did not. Finally, studies that employed reliable and valid measures for the disorder being treated would be expected to yield lower remission rates than would those that used non-validated measures (e.g., daily diaries). In the present meta-analysis, we investigated whether these methodological quality factors impacted reported remission rates.
Section snippets
Data sources
Journal articles were identified using searches of the PsycINFO and Medline electronic databases from January 2000 through February 2018 in order to keep the literature current. Other meta-analyses have used similar time frames (e.g., Loerinc et al., 2015).
The following search terms were used: (Cognitive Behavior Therapy or CBT or Cognitive Therapy or Behavior Therapy or Exposure Therapy) and (Remission or Recovery or Clinically Significant Change or Good End State or High End State) and
Results
Across all analyses, the mean remission rate was 51.0% (95% CI = 47.8%–54.2%) at post-treatment and 55.1% (95% CI = 51.0%–59.1%) at follow-up. ITT and completer samples were not associated with significantly different overall mean remission rate at post-treatment (47.9% vs. 53.0%, Q = 2.51, p = 0.11) or at follow-up (53.6% vs. 56.1%, Q = 0.39, p = 0.53) (see Table 1). The Trim and Fill procedure suggested that no ITT studies were missing at post-treatment; however, at follow-up, seven missing
Discussion
One complication with interpretations of previous research is that the constructs of response and remission were combined (Loerinc et al., 2015). We argue that it is important to consider each of these variables separately with response being change over the course of therapy, and remission being a healthy end-state. In our study, there were no significant differences in remission rates in anxiety disorders between the ITT and completer samples, with an overall remission rate of 51.0%. The
Role of funding sources
There has been no significant financial support for this work that could have influenced its outcome.
Contributors
We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. Authors Kristen Springer and Hannah Levy coded all abstracts and articles, generated the data set, and collaboratively wrote the first draft of the manuscript. Author David Tolin ran all of the analyses and provided
Conflict of interest
We wish to confirm that there are no known conflicts of interest associated with this publication.
Acknowledgements
The authors wish to thank Bailey D'Antonio and Pamela Scalise for their assistance with collecting and organizing articles.
Kristen S. Springer received her Ph.D. in Clinical and Health Psychology from the University of Florida in Gainesville, FL in 2015 with a specialty in cognitive behavioral treatments for chronic pain and anxiety disorders. She then completed her pre-doctoral internship at Eastern Virginia Medical School in Norfolk, VA. Dr. Springer subsequently completed a clinical post-doctoral fellowship at the Anxiety Disorders Center/Center for Cognitive Behavioral Therapy at the Institute of Living in
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Kristen S. Springer received her Ph.D. in Clinical and Health Psychology from the University of Florida in Gainesville, FL in 2015 with a specialty in cognitive behavioral treatments for chronic pain and anxiety disorders. She then completed her pre-doctoral internship at Eastern Virginia Medical School in Norfolk, VA. Dr. Springer subsequently completed a clinical post-doctoral fellowship at the Anxiety Disorders Center/Center for Cognitive Behavioral Therapy at the Institute of Living in Hartford, CT and remains on staff as a licensed psychologist. Dr. Springer has authored several scientific journal articles in the fields of both anxiety and chronic pain.