The Impact Of Cognitive Behavioural Therapy (CBT) In The Management Of Anxiety On Patients With A Diagnosis Of Mental Illness

Background

This essay aims to carry out a comprehensive literature review in relation to the use of CBT in the management of patients experiencing anxiety symptoms as part of mental health disorder. The strategy utilized to search and obtain relevant literature will be presented. The literature gathered will be analyzed, synthesize and presented in this literature review as well as making references to the corresponding authors.

Department of Health indicated that National Health Service Outcome Framework (NHS OF) is a government standard which addresses adults and children healthcare needs and management of long-term health conditions in the United Kingdom. The five domains of NHS outcome framework 2017 / 2018 are Premature Death Prevention, Enhancement of quality of life among individual with long-term condition, facilitation of recovery from episode of illness or injury, Promotion of positive and high-quality experience of healthcare and provision of treatment and care in a safe environment as well as protecting individual from avoidable harm (NHS Outcomes Framework (NHS OF), n.d.). Enhancement of quality of life among individual with a long-term condition is the chosen area in this assignment (NHS OF, n.d.).

Background knowledge about anxiety

According to Greenberg et al. (2015) anxiety disorder such as specific phobia, agoraphobia, separation anxiety disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder are a common mental health problem.  Baxter et al. (2013) indicated that one in nine people had had a recent experience of anxiety disorder globally.  It is well documented that anxiety is often a symptom of other mental health disorders such as bipolar disorder, paranoid schizophrenia (Gustad et al., 2013). According to Craske and Stein (2016), Anxiety can be the common experience of everyday life. However, individuals are diagnosed with an anxiety disorder if the level of fear, anxious and stress expressed by that individual is highly out of proportion in relation to the threat in question and continues to be out of proportion for at least six months. Therefore, it is essential to explore current treatment option available in the management of anxiety disorder and promote evidence-based practice in the management of this debilitating condition.

According to Ehde et al. (2014), CBT is a psychological therapy which involves talking with the aim of influencing individuals’ behavior. It manipulates that individual physical sensation, feeling, and thoughts with the goal of having a positive influence on the individual undertaking the treatment. Hofmann et al. (2014) suggested that CBT breaks down overwhelming problems into smaller components and provides the individual a step by step approach to address the problem successfully. CBT emphasizes the imminent problem as well as considerations to the past issues.  CBT focuses on a practical task that can be adopted on a regular basis to promote positive behavior.

Anxiety disorders have been found to be the most prevalent mental disorders globally (Greenberg et al., 2015).  Baxter et al. (2013) reviewed the worldwide prevalence of anxiety disorders and found out that the sixth leading cause of morbidity with respect to years of life lived with the disability was anxiety disorders regardless of the economic status of the countries. The most affected gender were women (65%) with the disease being common in both males and females aged between 15 and 34 years. Anxiety disorders have a significant effect on the quality of life (Hofmann et al. (2014) and is linked to decreasing in work productivity, diminished functioning in social activities, and economic instability (Olatunji et al., 2013). Due to the magnitude of the effects of anxiety, several treatment options have been proposed. The treatment options for anxiety are majorly psychotherapy and pharmacotherapy. The study by Blanco et al. (2013) suggested the use of pharmacotherapy such as antidepressants in the first-line treatment of anxiety disorders. But there is a negative response to the treatment using antidepressants in most of the patients (40%). Individual cognitive therapy for the treatment of anxiety disorders has been demonstrated to be effective for different forms of anxiety disorders (Pollack et al., 2014). Despite the existence of several studies that recommend the use of cognitive behavioral therapy in the treatment of anxiety disorders, there is limited literature research on its effectiveness or impact. This study aims at exploring the impact of Cognitive Behavioural Therapy (CBT) in the management of anxiety on the patient with a diagnosis of mental illness by critiquing five recent randomized control trials (RCTs).

Background knowledge about anxiety

The research question used in this literature review was formulated using Population Intervention, comparison and outcome (PICO) analysis with the omission of Comparison. The research question is Does CBT reduce anxiety among patients with a mental health problem?

Population: Patient with the mental health problem.

Intervention: CBT. There is no comparison and Outcome is reduced incidences of anxiety among patients with mental health problems.

This essay seeks to examine the impact of CBT in the management of anxiety on patients with a diagnosis of mental illness. Incidences of anxiety disorders have been reported to be on the rise both in developed and in developing countries (Baxter et al., 2013). Furthermore, several studies have pointed out that CBT is more effective in the treatment of anxiety disorders when compared to other conventional methods (Goldin et al., 2013; Høifødt et al., 2013). This study will provide more and recent information on whether CBT is the most suitable approach based on its impacts on reducing anxiety among patients with the mental health problem.

The research question needs to be answered because of a proper understanding of the impact of CBT on the management of anxiety among patients with mental diseases. Furthermore, the right response to the question will provide reliable information to physicians when choosing the most appropriate intervention to undertake in patients with anxiety.

The outcomes of the review are likely to have a range of implications both to the physician and the patient. With this information, medical providers will be able to make treatment decisions for anxiety disorders thus increasing contributing towards reducing the global prevalence of anxiety in people with mental illness. Additionally, this review will act as a basis for further studies.

The researcher searched databases such as PubMed, Google Scholar, and PMC for relevant articles. The search terms used in the search include cognitive behavior, behavioral therapy, anxiety, mental illness, management of anxiety, anxiety disorders. Moreover, manual searches for most suitable articles were carried out through reference lists of published studies. The inclusion criteria for the studies were as follows: the research had to be randomized control trials and must have been five years old from the date of publication. The articles must be about cognitive behavioral therapy and its efficacy in treating anxiety. The articles were excluded if: it was not freely accessible and the full paper not available in English language, it was a literature review, qualitative study or meta-analysis, the article was more than five years old after publication. If two studies from a similar trial were retrieved, the one with the most completed data was preferred. However, in case duplicate articles were retrieved, only one of them was picked for review. The item lists in the CASP for RCTs were used to evaluate and determine whether the studies indeed were RCTs or not.

A total of 20 studies were identified different databases and 3 of them excluded due to duplication, three more were excluded because they were not randomized control trials and did not examine CBT. The remaining fourteen studies were retrieved for inclusion and with a further check led to the exclusion of five studies which were published before 2013. After further screening and quality check, five studies were included in the review. Authors were not contacted for original data.

Background knowledge about CBT

The inclusion and exclusion criteria adopted in this paper was critical because it ensured that only relevant information was reviewed and was also up to date. This increases the reliability and validity of the findings (Noble and Smith, 2015).

The five articles were critically appraised using the CASP (Critical Appraisal Skills Programme) checklist (CASP, 2018). The specific elements of the checklist that were used in appraisal include if the study population and intervention were identified, concealment of allocation, randomization of participants to experimental groups, primary and secondary outcomes.

Data extraction was conducted using the Cochrane Data Extraction tool with five checklists of data elements namely source, eligibility, methods, participants and results.  A data extraction table was used as indicated below (Savovi? et al., 2014). Moons et al. (2014) observes that a data extraction form is appropriate because it connects the report by investigators in papers, reports, and reviews. Furthermore, the forms provided information for inclusion in the analysis.

Sanatinia et al. (2016) conducted a study on the personality effect on the effectiveness of CBT for health anxiety using patients attending six hospitals in Middlesex, London, and Nottinghamshire. The subjects were allocated to their groups in a random manner. This ensured that there was a limited allocation bias. Moreover, randomization was carried out using a technological system with the generated random sequence. The sequence of allocation was masked to all members until the databases were completed and locked. The outcomes were also specified to both primary and secondary outcomes.

Yoshinaga et al. (2016) carried out a prospective randomized study using two parallel groups of patients who were recruited from medical institutions in Chiba. The objective of the study was to evaluate the effectiveness of CBT in comparison with antidepressants in social anxiety disorder patients. The subjects were assigned randomly to the intervention and non-intervention groups at an equal ratio. The study also blinded the assessors by ensuring that they had no contacts with patients — randomization and concealment during allocation provided that selection bias was minimized (Higgins et al., 2011). The findings were defined into primary outcomes (symptoms determined by the independent assessor) and secondary results (self-reported symptoms). According to Zeng et al. (2015), the presentation of study findings into primary and secondary helps to correctly achieve the goal of the study and answer the research question.

The study obtained ethical approval from the relevant institutions Review Board in addition to receiving a written informed consent. According to Nishimura et al. (2013), ethical approval of RCTs is crucial because it shows that the study adhered to the ethical procedures needed in a survey and thus the findings can be relied upon. The limitation of the study is that the subjects were recruited from without while the CBT was carried out in the hospital. Additionally, there was a quality variation of CBT therapists as observed in their daily clinical practice. This compromises the credibility of the outcomes.

Wuthrich and Rapee (2013) undertook a study an RCT to assess the effectiveness of CBT for comorbid anxiety and depression in senior adults. The study was conducted using 62 community residents aged 60-84 years: both primary (variations in the severity of anxiety symptoms) and secondary outcomes (long-term changes in anxiety symptoms. The patients were taken through standardized clinical cognitive and behavioral evaluation. The identification of the study population, intervention and considering the outcomes ensures that the study addressed a focused issue (CASP, 2018).

Formulation of the research question

The participants were randomly allocated to their groups using random numbers generated by the computer and the post-treatment assessments done by clinicians not aware of the condition allocation. Randomization in assigning the subjects minimizes selection and allocation bias thus increasing the validity and reliability of the study (Noble and Smith, 2015).

The research was ethically approved by the Ethics Committee of the University. Moreover, written informed consent was obtained from the participants before participating in the study. According to Nishimura et al. (2013), ethical approval of studies involving humans is critical as it shows that the research adhered to moral principles while obtaining information from wilful participants. Thus, the findings are likely to be accurate and reliable. However, the study had limitations, for instance, the comparison of the treatment a waitlist control instead of active intervention.

Goldin et al. (2013) undertook an RCT on the impact of CBT for social anxiety disorder using 65 patients diagnosed with generalized social anxiety disorders at the Stanford University psychology department. The intervention included 16 sessions of personalized CBT for social anxiety disorders. However, the outcomes were not categorized into primary or secondary but under specific themes. The disclosure of the population, intervention, and outcomes in an RCT is evidence enough that the study has addressed the focussed issue (CASP, 2018).

The subjects were randomly assigned to their intervention and waitlist-control groups using the Efron biased coin randomization process (Ma et al., 2013). This technique of allocation was used because it fosters equal sample sizes throughout the clinical trial thus minimizing any possibility of allocation bias. The study by Goldin et al. (2013) obtained ethical approval from the institution’s ethics committee in addition to written consent from the participants. The limitation of the study is associated with its limitation to inferences regarding reappraisal of the subjects.

Fitzpatrick et al. (2017) carried out an RCT to ascertain the impact of CBT on youths with anxiety symptoms when a fully computerized conversational agent is used. Seventy participants aged 18-28 years were included in the study. The authors found out that CBT was much more effective when delivered using conversational agents. The participants were randomized into the study, and each received 20 lessons for fourteen days. All the participants were not blinded in the research due to its nature (online). Hróbjartsson et al. (2013) indicate that randomization during group allocation ensures that allocation bias is minimal thus increasing its credibility.

The study was approved by the Institutional Review Board and informed consent obtained from the participants after they were informed of the goal of the research and before commencing the study. Informed consent increases the validity and reliability of the findings because the respondents are likely to provide credible information because of their individual decision to participate (Nishimura et al., 2013).

Five articles were selected for this essay with each article addressing the impact of CBT on different forms of disorders, carried out in a different setting and with various limitations.

The study by Yoshinaga et al. (2016) found out that CBT was the most preferred first-line treatment option for anxiety disorders because it has a more extensive and more prolonged effect. The study found out that CBT took 16 weeks to reduce symptoms related to anxiety. Similar findings were arrived at by Singewald et al. (2015) who found out that respondents demonstrated positive cognitive changes before and after treatment. The authors recommended the use of CBT as the first option for the treatment of social phobia which is also caused by high levels of anxiety. Mayo-Wilson et al. (2014) also found out that individual CBT was more efficacious when tested using the Clark and Wells model. The author further demonstrated that CBT produces long-lasting effects when compared with pharmacotherapies such as cognitive boosting drugs like escitalopram, fluoxetine, and fluvoxamine. Furthermore, CBT remained effective in alleviating the symptoms of anxiety for three months after intervention.

Methodology

The study by Sanatinia et al. (2016 examined the impact of CBT for health anxiety concerning the influence of personality status, the findings showed that the effects of CBT were maintained two years after the intervention. Moreover, CBT was effective despite personality disorders which have been thought to impair its efficacy. Furthermore, the cost of CBT treatment was found to be economical except for cases of severe personality disorders.  

According to Goldin et al. (2013) individualized CBT (I-CBT) led to reduced levels of negative emotions in response to reappraising NSBs. I-CBT also led to a significant reduction in self-reported negative feelings when compared with other interventions. Patients under CBT treatment, when withdrawn from the intervention, are less likely to relapse compared to those removed from pharmacotherapy. Thus CBT has an enduring effect even after patients are withdrawn from acute treatment (Cuijpers et al., 2013).  CBT can also be used to treat a larger population of patients within a short time. Technology such as the use of mobile apps has also been found to be one of the effective ways of delivering CBT to reach a broader group  Fitzpatrick et al. (2017).

All the critiqued articles indicated that CBT reduced symptoms of CBT irrespective of the period of the intervention and the mode of implementation. CBT was efficacious in older adults with severe levels of anxiety and depression when compared to the waitlist control group Wuthrich and Rapee (2013). Additionally, the extent of improvement in primary anxiety and primary mood issues was relatively the same implying that the CBT successfully treated both depression and anxiety symptoms. Similar findings on the efficacy of CBT in treating both anxiety and depression. Wilansky et al. (2016) found out that CBT reduced anxiety in depressed students and enhanced homework compliance through mobile technology. CBT also reduces stress, depression, and anxiety in patients diagnosed with multiple sclerosis. A substantial mean score was reported by Pahlavanzade et al. (2017) for stress and depression (p=0.03) and anxiety (p= 0.02).

This study wholly relied on published data, and this implies that any inherent weakness on the published data could affect the reliability and validity of the findings. Future research should also focus on obtaining actual data. This review only focused on the impacts of CBT on the management of anxiety in patients with mental illnesses. Since, studies have confirmed that anxiety symptoms vary significantly depending on age and gender (Hofmann et al., 2014), future studies should focus on specific age bracket so as to make the study applicable to a specific group. The studies included in this review were designed differently thus restricting their comparability.

Additionally, there exist distinct methodological variations in the papers included in the review such as study designs, measures of the findings, and the period for intervention, thus limiting comparability and hence generalization. Therefore, there is a need for further reviews to focus on studies with relative similarity in the differences that exist in the current review.  This review undertook an exploratory approach to ascertain the impact of CBT on the management of anxiety in people diagnosed with mental illness.  

Conclusion

The impacts of CBT on anxiety in people diagnosed with mental illness is significant in terms of alleviating anxiety symptoms and producing a larger and long-lasting effect. CBT was the most preferred first-line treatment option for anxiety disorders because the positive effects after intervention lasted for three months and above. CBT is also useful in the treatment of different complications that come with anxiety such as social phobia. CBT was more effective than Pharmacotherapy in the treatment of CBT and its related complications.

Furthermore, the intervention was not impaired by factors such as personality disorders which significantly affected other treatment options for anxiety. Additionally, the cost of CBT in the treatment of anxiety is much cheaper when compared to other options such as pharmacotherapy.  The CBT approach is so efficient that it has an enduring effect even after patients are withdrawn from acute treatment. The intervention can also be easily integrated into technology such as mobile apps thus increasing its impacts by reaching a wide population range. Overall, CBT significantly reduces anxiety symptoms and associated complications such as stress and depression. This review, therefore, recommends the use of CBT intervention in treating anxiety complications. Healthcare providers should be offered additional training on CBT to help reduce the increasing incidences of anxiety and the economic burden that comes as a result.

References

Baxter, A.J., Scott, K.M., Vos, T. and Whiteford, H.A., 2013. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological medicine, 43(5), pp.897-910.

Blanco, C., Bragdon, L.B., Schneier, F.R. and Liebowitz, M.R., 2013. The evidence-based pharmacotherapy of social anxiety disorder. International Journal of Neuropsychopharmacology, 16(1), pp.235-249.

Craske, M.G. and Stein, M.B., 2016. Anxiety. Lancet Published online June 24, 2016.

Critical Appraisal Skills Programme, 2018. CASP (Randomised Controlled Trial) Checklist. [online] Available at: file:///C:/Users/Admin/Downloads/Documents/CASP-Randomised-Controlled-Trial-Checklist-2018_4.pdf  [Accessed: 13 Dec. 18].

Cuijpers, P., Hollon, S.D., van Straten, A., Bockting, C., Berking, M. and Andersson, G., 2013. Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ open, 3(4), p.e002542.

Ehde, D.M., Dillworth, T.M. and Turner, J.A., 2014. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. American Psychologist, 69(2), p.153.

Fitzpatrick, K.K., Darcy, A. and Vierhile, M., 2017. Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (Woebot): a randomized controlled trial. JMIR mental health, 4(2).

Goldin, P.R., Ziv, M., Jazaieri, H., Hahn, K., Heimberg, R. and Gross, J.J., 2013. Impact of cognitive behavioral therapy for social anxiety disorder on the neural dynamics of cognitive reappraisal of negative self-beliefs: randomized clinical trial. JAMA psychiatry, 70(10), pp.1048-1056.

Greenberg, P.E., Fournier, A.A., Sisitsky, T., Pike, C.T. and Kessler, R.C., 2015. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). The Journal of clinical psychiatry, 76(2), pp.155-162.

Gustad, L.T., Laugsand, L.E., Janszky, I., Dalen, H. and Bjerkeset, O., 2013. Symptoms of anxiety and depression and risk of acute myocardial infarction: the HUNT 2 study. European heart journal, 35(21), pp.1394-1403.

Higgins, J.P., Altman, D.G., Gøtzsche, P.C., Jüni, P., Moher, D., Oxman, A.D., Savovi?, J., Schulz, K.F., Weeks, L. and Sterne, J.A., 2011. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj, 343, p.d5928.

Hofmann, S.G., Wu, J.Q. and Boettcher, H., 2014. Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: a meta-analysis. Journal of Consulting and Clinical Psychology, 82(3), p.375.

Høifødt, R.S., Lillevoll, K.R., Griffiths, K.M., Wilsgaard, T., Eisemann, M., Waterloo, K. and Kolstrup, N., 2013. The clinical effectiveness of web-based cognitive behavioral therapy with face-to-face therapist support for depressed primary care patients: randomized controlled trial. Journal of medical Internet research, 15(8).

Hróbjartsson, A., Thomsen, A.S.S., Emanuelsson, F., Tendal, B., Hilden, J., Boutron, I., Ravaud, P. and Brorson, S., 2013. Observer bias in randomized clinical trials with measurement scale outcomes: a systematic review of trials with both blinded and nonblinded assessors. Canadian Medical Association Journal, pp.cmaj-120744.

Ma, J., Yank, V., Xiao, L., Lavori, P.W., Wilson, S.R., Rosas, L.G. and Stafford, R.S., 2013. Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA internal medicine, 173(2), pp.113-121.

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D.M., Ades, A.E. and Pilling, S., 2014. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), pp.368-376.

Moons, K.G., de Groot, J.A., Bouwmeester, W., Vergouwe, Y., Mallett, S., Altman, D.G., Reitsma, J.B. and Collins, G.S., 2014. Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist. PLoS medicine, 11(10), p.e1001744.

NHS Outcomes Framework (NHS OF). Framework Domains, n.d. [online] available from  https://digital.nhs.uk/data-and-information/publications/ci-hub/nhs-outcomes-framework [Accessed 13 Dec 2018].

Nishimura, A., Carey, J., Erwin, P.J., Tilburt, J.C., Murad, M.H. and McCormick, J.B., 2013. Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials. BMC medical ethics, 14(1), p.28.

Noble, H. and Smith, J., 2015. Issues of validity and reliability in qualitative research. Evidence-Based Nursing, pp.ebnurs-2015.

Olatunji, B.O., Davis, M.L., Powers, M.B. and Smits, J.A., 2013. Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of psychiatric research, 47(1), pp.33-41.

Pahlavanzadeh, S., Abbasi, S. and Alimohammadi, N., 2017. The effect of group cognitive behavioral therapy on stress, anxiety, and depression of women with multiple sclerosis. Iranian journal of nursing and midwifery research, 22(4), p.271.

Pollack, M.H., Van Ameringen, M., Simon, N.M., Worthington, J.W., Hoge, E.A., Keshaviah, A. and Stein, M.B., 2014. A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder. American Journal of Psychiatry, 171(1), pp.44-53.

Sanatinia, R., Wang, D., Tyrer, P., Tyrer, H., Crawford, M., Cooper, S., Loebenberg, G. and Barrett, B., 2016. Impact of personality status on the outcomes and cost of cognitive–behavioural therapy for health anxiety. The British Journal of Psychiatry, 209(3), pp.244-250.

Savovi?, J., Weeks, L., Sterne, J.A., Turner, L., Altman, D.G., Moher, D. and Higgins, J.P., 2014. Evaluation of the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials: focus groups, online survey, proposed recommendations and their implementation. Systematic reviews, 3(1), p.37.

Singewald, N., Schmuckermair, C., Whittle, N., Holmes, A. and Ressler, K.J., 2015. Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders. Pharmacology & therapeutics, 149, pp.150-190.

Viswanathan, M., Patnode, C.D., Berkman, N.D., Bass, E.B., Chang, S., Hartling, L., Murad, M.H., Treadwell, J.R. and Kane, R.L., 2017. Assessing the Risk of Bias in Systematic Reviews of Health Care Interventions. In Methods guide for effectiveness and comparative effectiveness reviews [Internet]. Agency for Healthcare Research and Quality (US).

Wilansky, P., Eklund, J.M., Milner, T., Kreindler, D., Cheung, A., Kovacs, T., Shooshtari, S., Astell, A., Ohinmaa, A., Henderson, J. and Strauss, J., 2016. Cognitive Behavior Therapy for Anxious and Depressed Youth: Improving Homework Adherence Through Mobile Technology. JMIR research protocols, 5(4).

Wuthrich, V.M. and Rapee, R.M., 2013. Randomised controlled trial of group cognitive behavioural therapy for comorbid anxiety and depression in older adults. Behaviour Research and Therapy, 51(12), pp.779-786.

Yoshinaga, N., Matsuki, S., Niitsu, T., Sato, Y., Tanaka, M., Ibuki, H., Takanashi, R., Ohshiro, K., Ohshima, F., Asano, K. and Kobori, O., 2016. Cognitive behavioral therapy for patients with social anxiety disorder who remain symptomatic following antidepressant treatment: a randomized, assessor-blinded, controlled trial. Psychotherapy and psychosomatics, 85(4), pp.208-217.

Zeng, X., Zhang, Y., Kwong, J.S., Zhang, C., Li, S., Sun, F., Niu, Y. and Du, L., 2015. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta?analysis, and clinical practice guideline: a systematic review. Journal of evidence-based medicine, 8(1), pp.2-10.

Order an Essay Now & Get These Features For Free:

Turnitin Report

Formatting

Title Page

Citation

Outline

Place an Order