Anxiety disorders represent a key public health concern. They are highly prevalent in the general population across the world (Kessler et al., 2009) and have previously been reported as the sixth most common cause of disability globally (Baxter et al., 2014). Worryingly, more recent evidence shows that rates of anxiety disorders are continuing to rise (for example, read Alice and Derek’s Mental Elf blog), especially since the outbreak of COVID-19 (Brunier & Drysdale, 2020; Rogers et al., 2020).
In light of this evidence, it is essential that we have evidence-based, cost-effective and well-accepted treatment options.
Guided self-help (GSH) is a brief and low-intensity psychoeducational intervention that perfectly fits the stepped-care model implemented in the UK and is routinely delivered in NHS Talking Therapies (formerly known as IAPT) for mild-to-moderate anxiety (Coull & Morris, 2011).
GSH interventions involve six to eight sessions that last approximately 30 minutes and are facilitated by trained and regularly supervised practitioners. GSH is typically based on cognitive-behavioural therapy (CBT). Although the scientific literature highlights that the short- and long-term effects of this treatment are comparable to face-to-face psychotherapy (Cuijpers et al., 2010), studies have showed that a significant number of patients consider CBT-GSH unacceptable, leading to early dropouts, incomplete treatment plans, and poor treatment outcomes (Delgadillo et al., 2014).
Accommodating personal preferences regarding the treatment type and modality is a key, but often neglected aspect to improving treatment compliance and reducing dropouts (Wasmann et al., 2019). Kellett and colleagues (2023) conducted a clinical trial to address this issue and further investigate the impact of supporting patients’ preferences on the acceptability and efficacy of two versions of GSH for anxiety.
Anxiety disorders are highly prevalent worldwide so we need to identify evidence-based, cost-effective and well-accepted interventions that can be offered to people, without ignoring their personal preferences.
Methods
Kellett and colleagues (2023) conducted a partially randomised patient preference trial (PRPPT) of two versions of GSH: CBT-GSH vs cognitive–analytic therapy GSH (CAT-GSH) for patients meeting diagnostic criteria for an anxiety disorder on the Mini International Neuropsychiatric Interview (MINI) and on the Beck Anxiety Inventory (BAI ≥10).
- CBT-GSH was described as “working purely in the here-and-now, having a focus on thought–feeling–behaviour linkages, using homework exercises and making less use of the therapeutic relationship”.
- CAT-GSH was described as “working with the past and present, working with the therapeutic relationship and those dynamics, making use of homework exercises, and taking an explicitly relational approach”
The study took place in an NHS Talking Therapies for Anxiety and Depression service in northern England and, in line with PRPPT designs, participants with strong treatment preferences received their treatment of choice, while those without strong preferences were randomised to either CAT-GSH or CBT-GSH by an independent researcher. Hence, the study resulted in four arms:
- Preference allocation to CAT-GSH (arm 1)
- Preference allocation to CBT-GSH (arm 2)
- Random allocation to CAT-GSH (arm 3)
- Random allocation to CBT-GSH (arm 4).
Interventions were delivered by 16 qualified and regularly supervised psychological wellbeing practitioners (PWPs) and involved 6–8 weekly telephone sessions of one-to-one GSH lasting 30-35 minutes. Interventions followed structured workbooks, involving psychoeducation and in-session and at-home activities to complete, and differed based on the underlying theories of CBT and CAT.
Anxiety severity on the BAI at 8- and 24-weeks follow-up was the main outcome.
Results
Preference effect
Of the 469 patients assessed for eligibility, 271 were included in the study; of these, 19 (7%) agreed to be randomised (Mage = 38.47, SDage = 16.22; 74% females; 95% white) and 252 (93%) chose their treatment (Mage = 36.62, SDage = 13.74; 75% females; 90% white).
In the preference group, 181 (72%) opted for CAT-GSH and 71 (28%) chose CBT-GSH.
The authors compared attendance, drop-out and lost-to-follow-up rates in the randomised and preference cohorts and found an:
overall pattern of better attendance and engagement in the preference cohort, although most differences were not statistically significant, except for significantly greater rates of attendance for the preference cohort in the total and CAT-GSH samples.
Treatment effect
No significant differences between the preference and randomised cohorts in anxiety severity were found at the 8-week and 24-week assessments.
Similarly, no significant differences in anxiety severity between CAT-GSH and CBT-GSH at 8 weeks (F(1, 263) = 0.22, p = 0.639) or at 24 weeks (F(1, 263) = 0.22, p = 0.639) emerged, even after accounting for allocation method and baseline covariates.
Considering the change in anxiety severity from baseline following the intervention, for CAT-GSH there was a mean BAI score reduction of 9.28 (SE = 1.03) at 8 weeks and 12.90 (SE = 0.96) at 24 weeks; for CBT-GSH there was a mean BAI score reduction of 9.78 (SE = 1.18) at 8 weeks and 12.43 (SE = 1.10) at 24 weeks.
The authors found that patients who received CAT-GSH were significantly more likely to start and complete treatments, and overall attended significantly more sessions; however, no significant differences between the two GSH interventions were found in terms of drop-out or subsequent stepping-up rates (i.e., percentages of patients stepped up to traditional psychotherapies because of lack of response to GSH).
Only 7% of the participants accepted being randomised, while 93% chose their treatment, showing a preference for CAT-guided self-help; however, CAT-guided self-help and CBT-guided self-help were found to result in similar anxiety outcomes at the follow-up assessments.
Conclusions
This trial clearly shows that:
patients accessing routine primary care talking treatments prefer to choose the intervention they receive.
The two interventions, CAT-GSH and CBT-GSH, resulted in a largely similar reduction of anxiety severity at 8- and 24-week follow-up.
These findings suggest that CAT-GSH may represent an effective and well-accepted alternative treatment for patients presenting low-to-moderate anxiety, expanding the low-intensity treatment offer in primary care and accommodating those seeking a brief but analytically informed GSH solution. However, further research involving true randomisation is needed to fully determine this.
Patients prefer to choose the intervention they receive, which in the current study was CAT-guided self-help. This may represent a useful alternative to CBT-guided self-help within primary care settings.
Strengths and limitations
The authors conducted a PRPPT that was carefully designed and concerned a topic of great clinical importance, namely the acceptability and efficacy of two versions of GSH for anxiety disorders. The study complied with the standards of all relevant ethical boards, the full study protocol was published and adhered to, and CONSORT reporting guidelines were followed. Outcomes were assessed via appropriate standardised tools at two time-points (8- and 24-week follow-up), controlling for baseline symptom severity, as well as baseline differences in gender, previous treatment history and allocation choice.
However, the results should be considered in light of a number of limitations:
- The specific study design adopted led to unequal sample sizes in the four arms. Importantly, a preference pattern emerged, with more patients consistently opting for CAT-GSH, which resulted in the CBT-GSH arm being underpowered. This also meant that the level of randomisation present within the trial was almost non-existent. Hence, findings should be taken with caution, and a fully randomised trial is needed in order to draw more substantive conclusions.
- The study sample lacks diversity, possibly because the therapy material was not translated and interpreters were not involved, thus limiting the generalisability of the findings to the general population. Consequently, replication studies are warranted to test this.
- Although data are collected longitudinally, a longer follow-up assessment would be important to test whether the intervention effects are stable over time.
This is an interesting trial, but the general preference for CAT-guided self-help resulted in the CBT-guided self-help arm being underpowered, meaning that these findings should be taken with caution.
Implications for practice
This study has important implications for clinical practice, especially considering that GSH interventions for anxiety disorders are routinely delivered in services.
The patient preference design enabled the first examination of patients’ preferences for two different versions of GSH. The fact that most participants clearly preferred to choose their treatment and may have otherwise refused participation unless offered this option is a particularly key finding and should be carefully taken into account in routine practice.
Indeed, listening to and accommodating patient preferences when making health care decisions is increasingly considered an essential element of evidence‐based practice, with research indicating that patients are more willing to initiate and engage in treatments that match their preferences, leading to better clinical outcomes (Swift et al., 2021).
Patients showed a stronger preference for CAT-GSH, compared to CBT-GSH, and CAT-GSH participants were found to be more likely to complete full treatment. However, findings seem to indicate that preference accommodation did not have an impact on clinical outcomes, and the two GSH versions evaluated were found to be equally effective treatment options for the treatment of anxiety. Hence, CAT-GSH may represent an effective and well-tolerated option that could be offered to anxious patients in primary care settings.
However, more research is needed: these findings should be replicated, translating the therapy material to different languages to include a more representative sample, increasing the sample size to make sure that all study arms are adequately powered, and using full randomisation.
Patients should be given the option to choose their treatment. CAT-guided self-help could represent an effective and well-tolerated alternative to CBT-guided self-help, but further research is warranted to confirm and generalise these findings.
Statement of interests
Nothing to declare.
Links
Primary paper
Kellett, S., Bee, C., Smithies, J., Aadahl, V., Simmonds-Buckley, M., Power, N., … & Delgadillo, J. (2023). Cognitive–behavioural versus cognitive–analytic guided self-help for mild-to-moderate anxiety: a pragmatic, randomised patient preference trial. The British Journal of Psychiatry, 1-8.
Other references
Baxter, A. J., Vos, T., Scott, K. M., Ferrari, A. J., & Whiteford, H. A. (2014). The global burden of anxiety disorders in 2010. Psychological Medicine, 44(11), 2363-2374. doi:10.1017/s0033291713003243.
Brunier, A., & Drysdale, C. (2020). COVID-19 disrupting mental health services in most countries, WHO survey. World Health Organization, 2021-2006.
Coull, G., & Morris, P. G. (2011). The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: a systematic review. Psychological Medicine, 41(11), 2239-2252.
Cuijpers, P., Donker, T., van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine, 40(12), 1943-1957.
Delgadillo, J., McMillan, D., Lucock, M., Leach, C., Ali, S., & Gilbody, S. (2014). Early changes, attrition, and dose–response in low intensity psychological interventions. British Journal of Clinical Psychology, 53(1), 114-130.
Grishkov, A., & Tracy, D. (2021). Living in anxious times? The rise of anxiety disorders in the UK. The Mental Elf.
Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., . . . Wang, P. S. (2009). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiology and Psychiatric Sciences, 18(1), 23-33.
Rogers, J. P., Chesney, E., Oliver, D., Pollak, T. A., McGuire, P., Fusar-Poli, P., . . . David, A. S. (2020). Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. The Lancet Psychiatry, 7(7), 611-627.
Swift, J. K., Mullins, R. H., Penix, E. A., Roth, K. L., & Trusty, W. T. (2021). The importance of listening to patient preferences when making mental health care decisions. World Psychiatry, 20(3), 316.
Wasmann, K. A., Wijsman, P., van Dieren, S., Bemelman, W., & Buskens, C. (2019). Partially randomised patient preference trials as an alternative design to randomised controlled trials: systematic review and meta-analyses. BMJ Open, 9(10), e031151.
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