Background
Anxiety disorders are some of the most prevalent mental disorders. Morita therapy, a systematic psychological therapy based on eastern philosophy, has been used to treat anxiety disorders for decades. It encourages people with anxiety disorders to accept anxiety as a natural feeling, while at the same time it engages them in constructive behaviours via four phases, which sequentially are bed rest in isolation, light work, heavy work and preparation for normal daily living. Acceptance is merely redirecting attention towards purposeful behaviour. People get better when they stop trying to eliminate anxiety and fulfil their desires with study and work in their actual personal and social lives.
The efficacy of Morita therapy for the treatment of anxiety disorders has been a much-contested issue, often dividing opinion. To date, a systematic review (a review addressing a clearly worded question that uses systematic and explicit methods to identify, select and critically appraise relevant research) investigating the strength of evidence for Morita therapy in the treatment of anxiety disorders has not been conducted.
Study characteristics
We searched scientific databases for randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that compared Morita therapy with treatments with medicines or other psychological therapies (e.g. talking therapies), no treatment or wait list control (where people are waiting to receive a treatment) of adults with anxiety disorders. The evidence was current to December 2014.
Key results and quality of evidence
We found seven small Chinese studies with 449 participants to include in the review. Six of the seven studies provided useable data for us to analyse; they assessed Morita therapy for generalised anxiety disorder (a long-term illness that causes people to feel anxious about a wide range of situations and issues; one study), social phobia (a persistent fear about social situations and being around people; two studies) and obsessive-compulsive disorder (where a person has obsessive thoughts and repetitive behaviours; three studies). However, these studies were small, imprecise and contained considerable risks of bias, so we were unable to draw conclusions on the effectiveness of Morita therapy in the treatment of anxiety disorders. The review highlighted the need for high-quality studies to assess the efficacy of Morita therapy on anxiety disorders.
The evidence base on Morita therapy for anxiety disorders was limited. All studies included in this review were conducted in China, and the results may not be applicable to Western countries. These included studies were small, provided insufficient information about drop-outs and adverse effects, and contained considerable risk of bias. Therefore, we graded the evidence as very low quality and were unable to draw conclusions on the effectiveness of Morita therapy in the treatment of anxiety disorders. Well-designed future studies that employ adequate allocation concealment, recruit large sample sizes, report drop-outs and adverse effects, and report outcomes clearly and consistently are needed to establish the effectiveness of Morita therapy for anxiety disorders.
Morita therapy, first proposed in 1919, is a systematic psychological therapy for anxiety disorders that is based on eastern philosophy. It is mainly used as an alternative therapy for anxiety disorders in Asian countries such as Japan and China. Varying foci of treatment outcomes have been reported. To date, there has been no systematic review to investigate the strength of evidence for Morita therapy in anxiety disorders.
To assess the effects of Morita therapy compared with pharmacological therapy, other psychological therapy, no intervention or wait list for anxiety disorders in adults.
We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR, which includes relevant randomised controlled trials from MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date)), Dissertation Abstracts International (DAI) and four main Chinese medical databases (Chongqing VIP Database, Wanfang Database, China Hospital Knowledge Database, China Biology Medicine disc) as described in the protocol of this review to December 2014. Furthermore, we extended our search in the Cochrane Central Register of Controlled Trials (CENTRAL) and the World Health Organization International Clinical Trials Registry Platform (ICTRP) and the Sagace, a web-based search engine for biomedical databases in Japan. We applied no date or language restrictions. We contacted experts in the field for supplemental data.
We included all relevant randomised controlled trials comparing Morita therapy with any other treatment in the treatment of anxiety disorders.
Two authors independently selected studies and extracted data. For homogenous dichotomous data, we calculated fixed-effect risk ratios (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat for an additional beneficial outcome (NNTB) on an intention-to-treat basis. For continuous data, we calculated fixed-effect standardised mean differences (SMD) and 95% CI.
We found seven small Chinese studies (449 participants), six of which provided useable data for meta-analysis. No study compared Morita therapy with an inactive control. Unclear randomisation methods, lack of blinding and low quality reporting of outcomes were common in the included studies. We graded the overall risk of bias as high and the quality of the evidence as very low.
Two social phobia studies (75 outpatients) directly compared Morita therapy with pharmacological therapy. In this comparison, the pooled RR of global state was 1.85 (95% CI 1.27 to 2.69) and the NNTB was 3 (95% CI 2 to 5), indicating a significant difference between groups favouring Morita therapy in the short term (up to 12 weeks' post-treatment). Data regarding drop-outs was insufficient and no description of adverse effects was provided. We graded the quality of the evidence for this comparison as very low, mainly due to high risk of bias in the studies and insufficient information in the results.
Four studies (288 inpatients) investigated the effect of Morita therapy plus pharmacological therapy versus pharmacological therapy alone, three studies for the treatment of obsessive-compulsive disorder (OCD) (228 participants) and one study for generalised anxiety disorder (60 participants). One of the OCD studies reported incomplete data of global state while the outcome of global state was missing in the other three studies. There was no significant difference between groups for drop-outs for any reason in two OCD studies in the short term (RR 1.76, 95% CI 0.47 to 6.67; I2 = 44%). Information pertaining to drop-outs for adverse effects was unclear. We rated the risk of bias of this comparison as high. We graded the quality of the evidence as very low.