Preventing Anxiety: It Can Be Done

Batya Swift Yasgur, MA, LSW

September 12, 2017

Psychological and educational interventions can prevent anxiety in a variety of populations and in persons of different ages, new research shows.

Investigators based in Malaga, Spain, reviewed data from 29 studies, representing 10,430 patients from 11 countries on four continents, and found a modest but statistically significant benefit for anxiety prevention in all populations that were evaluated.

The studies encompassed children, adolescents, adults, and the elderly. Settings in which the interventions were delivered included primary care, schools, and universities. Preventive interventions included cognitive- behavioral therapy (CBT), psychoeducation, and acceptance and commitment therapy (ACT).

"An immediately applicable take-home message is that clinicians need to know that anxiety can be prevented and that different types of interventions, including fewer sessions of educational interventions, can prevent anxiety," said Patricia Moreno-Peral, PhD, of the Institute of Biomedical Research in Malaga, who is the lead author of the study.

"Our results showed that psychological or educational interventions are effective regardless of the individual's age, so any age can be a 'window of opportunity,' " she told Medscape Medical News.

The study was published online September 6 in JAMA Psychiatry.

Prevention Understudied

Anxiety disorders are highly prevalent and impose a substantial burden. Although there are effective treatments for these disorders, "not all persons with anxiety receive the appropriate treatment, and cost-effectiveness studies suggest that treatment alone is not sufficient to eliminate the disease burden attributable to anxiety disorders," the authors write.

One way to reduce the burden of anxiety disorders is to "lower the incidence of new cases, which can be achieved through prevention rather than treatment," they write.

Previous systematic reviews or meta-analyses of interventions to prevent anxiety have been conducted primarily in children and adolescents. Those studies that have been conducted in adults have focused on specific anxiety disorders, such as posttraumatic stress disorder (PTSD).

No previous systematic reviews or meta-analyses have focused on the effectiveness of psychological and/or educational interventions in preventing anxiety in a range of ages and populations.

"For many years, we have been interested in the prevention of anxiety," said Dr Moreno-Peral. "We started performing a systematic review about risk factors for anxiety disorder, and then we developed a risk algorithm to predict anxiety disorders."

The next step was to investigate whether there were "effective interventions to prevent anxiety, and we realized that there were no meta-analyses about this topic," she said.

The researchers reviewed 3273 abstracts; they selected 131 for full-text review and analyzed 29 studies that met the inclusion criteria (n = 10,430 patients drawn from 11 countries on four continents).

To meet inclusion criteria, studies had to have been randomized clinical trials (RCTs) that focused on educational and/or psychological rather than medication or physical interventions. Acceptable comparators were care-as-usual, no intervention, a waiting list for intervention, or attention control.

Outcomes included either the incidence of new cases of any DSM-IV anxiety disorder and/or reduction of anxiety symptoms. PTSD was excluded because with PTSD, it can be difficult to distinguish treatment from prevention.

An "educational intervention" was defined as the offering of information about anxiety through lectures or fact sheets. By contrast, a "psychological intervention" was defined as an "attempt to change how people think by using a variety of strategies (eg, cognitive behavioral or interpersonal therapy)."

An Ounce of Prevention...

Sample sizes ranged from 24 to 2998 (median, 165). RCTs included adults (aged 18 to 65 years), children or adolescents, older adults, mixed adults and elderly individuals, and both adults and children. In 12 RCTs, study settings included school or university.

The most common intervention was CBT (25 studies). Four RCTs were based on other types of interventions (two psychoeducational, 12 ACT, and one biopsychosocial). Interventions included both group and individual formats, and four RCTs included computerized formats of guided self-help.

The number of sessions ranged from one to 12 (median, eight). Follow-up periods ranged from 7 weeks to 60 months (median, 12 months).

The researchers note that for eight RCTs, there was a low risk for bias (≤4 points); for nine, there was a moderate risk (5-6 points); and for 12, there was a high risk (≥7 points).

The pooled standardized mean difference (SMD) was -0.31 (95% confidence interval [CI], -0.40 to -0.21; P < .001). The equivalent pooled odds ratio (OR) was 0.57 (95% CI, 0.48 - 0.68; P < .001), representing a 43% reduction in the incidence of anxiety, but with substantial heterogeneity (I2 = 61.1%; Q35 = 90.13; P < .001).

"This finding means that psychological and/or educational preventive interventions for anxiety had a small and statistically significant effect on anxiety prevention," the authors note.

Although there was some evidence of publication bias, the effect size barely varied after adjustment (SMD, -0.27; 95% CI, -0.37 to -0.17; P < .001), and sensitivity analyses "confirmed the robustness of effect size results," the authors state.

The meta-analysis calculations were based on 36 comparisons performed in 29 RCTs. The pooled SMD was -0.31 (95% CI, -0.40 to -0.21; P < .001), with substantial heterogeneity (I2 = 61.1%; 95% CI, 44% to 73%).

A meta-regression found that as many as 85.3% of total variance was attributable to within-study variability, with the remaining 14.7% caused by between-study variability. The five variables included in the meta-regression model accounted for 99.6% of between-study variance.

The researchers found a statistically significant association between higher SMD, waiting list (comparator) (β = -0.33 [95% CI, -0.55 to -0.11]; P = .005), and a lower sample size (lg) (β = 0.15 [95% CI, 0.06 - 0.23]; P = .001).

No association was found between SMD and risk for bias, use of standardized interviews as outcomes, and interventions delivered by a family physician.

Dr Moreno-Peral said she was not surprised by the findings, because "it has long been known that psychological interventions to prevent depression are effective, and we expected a similar outcome for anxiety."

However, she continued, "until now, no meta-analysis has been conducted regarding anxiety prevention which includes, on the one hand, educational interventions in addition to psychological interventions, and on the other hand, all population types."

She added that treatments for anxiety "are applied when the person is already suffering from the disorder, while preventive interventions are carried out on people who have not yet developed an anxiety disorder, although they may have a high risk of suffering form it in the near future."

People who are at risk but are not yet suffering from an anxiety disorder "may be able to activate their internal and external resources more efficiently than when they already have an anxiety disorder," she said.

"From this point of view, interventions to prevent anxiety may be less complex and intense than those used for the treatment of anxiety disorders."

Convincing Evidence

Commenting on the study for Medscape Medical News, Jennifer L. Hudson, PhD, of the Center for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia, said the study provided "convincing evidence that efforts to prevent anxiety are effective."

This is an important contribution to the field, said Dr Hudson, who is the author of an accompanying editorial. She was not involved with the study.

"This is the first paper to examine prevention of anxiety disorders across the life span. The data from this study suggest that prevention is effective regardless of the individual's age."

She noted that "it is far more cost-effective to prevent disorders early in life to reduce the burden of the disease throughout an individual's life rather than later. Prevention programs need to be made available across the life span, as anxiety disorders can emerge across the life span."

The study has important implications, she said. "From a policy point of view, we need to invest in the prevention of anxiety disorders across the life span, since anxiety disorders are the most prevalent mental health problems. However, they have been overlooked and as a result, they have not received the attention they deserve."

From a clinical standpoint, "these results suggest that clinicians can be confident in offering evidence-based prevention for individuals at risk."

Preventive interventions can be delivered not only in clinical but also in educational settings. "We also need to be thinking more globally about integrating these programs into school curricula to ensure children receive effective prevention early in life."

Dr Moreno-Peral agreed, but she cautioned that although preventive interventions delivered in schools and the workplace are effective, "we cannot currently answer the question whether the preventive programs implemented by school educators to their students are as effective as when they are carried out by health professionals."

She concurred that the study has important public health implications.

"When preventive programs are scalable to large populations ― for example, through preventive programs accessible free of charge on the Internet, or with programs implemented in primary care ― from the point of view of public health, it is possible to obtain a great impact on the health and the quality of the population and also on the reduction of the costs for the society in general and for the health systems in particular."

The study was supported by the Spanish Ministry of Health, the Institute of Health Carlos III, the European Regional Development Fund Una manera de hacer Europa, the Andalusian Council of Health, the Prevention and Health Promotion Research Network, PRISMA group, and SAMSERAP group. The study authors and Dr Hudson have disclosed no relevant financial relationships.

JAMA Psychiatry . Published online September 6, 2017. Full text, Editorial

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