Does cognitive behavioural therapy (CBT) work better than minimal management or other psychological therapies for older adults with anxiety disorders?
Key messages
• Evidence suggests that cognitive behavioural therapy (CBT) may reduce anxiety severity right after treatment compared to minimal management. However, the lessening in anxiety severity may not be sustained and, at six months, there may be no difference between treatments.
• Due to a lack of evidence, we do not know if CBT is more or less effective than other psychological treatments.
• Larger, well-designed studies are needed to determine whether older people with anxiety issues who receive CBT recover fully or show an improvement in symptoms.
What is cognitive behavioural therapy for older adults with an anxiety disorder, and why may it be important?
Anxiety disorders are a common mental health problem for older adults. Anxiety disorders are characterised by excessive fear, worry and nervousness in normal situations or during normal activities. People suffering from anxiety disorders experience physical symptoms such as pounding of the heart, sweating, shaking, nausea, and difficulty breathing. As a result, people with anxiety disorders usually try to avoid situations or activities in which they experience this excessive and overwhelming fear. Anxiety disorders interfere with daily life and normal functioning.
Generalised anxiety disorder (GAD) is described as excessive and chronic worry about day-to-day issues such as work, finances, family, health, and other daily activities, where there is no particular reason for concern.
Cognitive behavioural therapy (CBT) is an effective treatment for anxiety disorders in adults and may also be effective in older adults. CBT helps people with anxiety by exposing them gradually to situations that cause feelings of anxiety, and then changing negative thought patterns. CBT can be given in groups, or one-to-one.
What did we want to find out?
We wanted to find out whether CBT works better than interventions that do not explicitly provide treatment (minimal management) for older adults (over 55 years) with an anxiety disorder. We also wanted to find out whether CBT works better than other psychological treatments in the same population and improves quality of life.
What did we do?
We searched for studies that compared:
• CBT against minimal management;
• CBT against other psychological treatments.
We summarised the results, and rated our confidence in the evidence, based on factors such as study methods and number of participants.
Summary of results
What did we find?
We found 21 studies that involved 1234 older people (aged over 55 years) with anxiety disorders. The biggest study included 180 people and the smallest study included nine people. Studies were conducted in seven countries. Ten studies focused on GAD. Most studies compared CBT to minimal management (defined as standard care without psychological treatment); only two studies compared CBT to another psychological treatment.
Main results
We found that, compared to minimal management, CBT may result in a small-to-moderate reduction in the symptoms of anxiety and symptoms of both worry and depression post-treatment. However, these effects may not be sustained and, at six months, there may be little or no difference between CBT and minimal management. There is not enough evidence to determine whether CBT results in people making a full recovery or a reduction in symptoms. Nor is there enough evidence to determine whether CBT works better than other psychological treatments for older adults with anxiety disorders.
Main limitations of the evidence
We have limited confidence in the evidence because the studies were very heterogeneous with a large variety of risk of bias assessments, and mainly concerned older adults with generalised anxiety disorder. People were also aware of which treatment they were getting. This knowledge could have influenced the results. Only two studies investigated CBT in comparison with another psychological treatment. These studies did not yield enough evidence to draw any conclusions.
The evidence is up-to-date to 12 February 2024.
CBT may be more effective than minimal management in reducing anxiety and symptoms of worry and depression post-treatment in older adults with anxiety disorders. The evidence is less certain longer-term and for other outcomes including clinical recovery/improvement. There is not enough evidence to determine whether CBT is more effective than alternative psychological therapies for anxiety in older adults.
Cognitive behavioural therapy (CBT) is the most researched psychological therapy for anxiety disorders in adults, and known to be effective in this population. However, it remains unclear whether these results apply to older adults, as most studies include participants between 18 and 55 years of age. This systematic review aims to provide a comprehensive and up-to-date synthesis of the available evidence on CBT and third wave approaches for older adults with anxiety and related disorders.
To assess the effects of Cognitive Behavioural Therapy (CT, BT, CBT and third-wave CBT interventions) on severity of anxiety symptoms compared with minimal management (not providing therapy) for anxiety and related disorders in older adults, aged 55 years or over.
To assess the effects of CBT and related therapies on severity of anxiety symptoms compared with other psychological therapies for anxiety and related disorders in older adults, aged 55 years or over.
We searched the Cochrane Common Mental Disorders Controlled studies Register (CCMDCTR), CENTRAL, Ovid MEDLINE, Ovid Embase and Ovid PsycINFO to 21 July 2022. These searches were updated on 2 February 2024. We also searched the international studies registries, including Clinicalstudies.gov and the WHO International Clinical Trials Registry Platform (ICTRP), to identify additional ongoing and unpublished studies. These sources were manually searched for studies up to 12 February 2024.
We included randomised controlled trials (RCTs) in older adults (≥ 55 years) with an anxiety disorder, or a related disorder, including obsessive compulsive disorder (OCD), acute stress disorder and post-traumatic stress disorder (PTSD), that compared CBT to either minimal management or an active (non-CBT) psychological therapy. Eligible studies had to have an anxiety-related outcome.
Several authors independently screened all titles identified by the searches. All full texts were screened for eligibility according to our prespecified selection criteria. Data were extracted and the risk of bias was assessed using the Cochrane tool for RCTs. The certainty of evidence was evaluated using GRADE. Meta-analyses were performed for outcomes with quantitative data from more than one study.
We included 21 RCTs on 1234 older people allocated to either CBT or control conditions. Ten studies focused on generalised anxiety disorder; others mostly included a mix of clinical diagnoses. Nineteen studies focused on the comparison between CBT and minimal management.
Key issues relating to risk of bias were lack of blinding of participants and personnel, and participants dropping out of studies, potentially due to treatment preference and allocation.
CBT may result in a small-to-moderate reduction of anxiety post-treatment (SMD -0.51, 95% CI -0.66 to -0.36, low-certainty evidence). However, compared to this benefit with CBT immediately after treatment, at three to six months post-treatment, there was little to no difference between CBT and minimal management (SMD -0.29, 95% CI -0.59 to 0.01, low-certainty evidence). CBT may have little or no effect on clinical recovery/ improvement post-treatment compared to minimal management, but the evidence is very uncertain (RR 1.56, 95% CI 1.20 to 2.03, very low-certainty evidence). Results indicate that five people would need to receive treatment for one additional person to benefit (NNTB = 5).
Compared to minimal management, CBT may result in a reduction of comorbid depression symptoms post-treatment (SMD -0.57, 95% CI -0.74 to -0.40, low-certainty evidence). There was no difference in dropout rates post-treatment, although the certainty of the evidence was low (RR 1.19, 95% CI 0.80 to 1.78). Two studies reported adverse events, both of which related to medication in the control groups (very low-certainty evidence, no quantitative estimate).
Only two studies compared CBT to other psychological therapies, both of which only included participants with post-traumatic stress disorder. Low-certainty evidence showed no difference in anxiety severity post-treatment and at four to six months post-treatment, symptoms of depression post-treatment, and dropout rates post-treatment.
Other outcomes and time points are reported in the results section of the manuscript.