What works? - Treatment

Anxiety: A Very Short Introduction - Daniel Freeman, Jason Freeman 2012

What works?

Around one-third of the adult population reports difficulties with anxiety, with close to one in five having problems severe enough to meet criteria for a clinical disorder. And anxiety can feel horrible, as Holly Golightly pointed out back in Chapter 1. Anxiety, then, can be a big problem. How are we faring for solutions?

In fact, simply establishing which treatments are effective is an immensely complex, labour-intensive business. The undoubted ’gold standard’ for clinical research is what’s known as randomized controlled trials. These involve participants being randomly assigned to one of at least two groups. Group one will receive a specific treatment, and group two either a ’control’ non-treatment (a placebo, for example) or an alternative treatment. (Sometimes trials will assess two or more treatments against a control.) Allocating participants randomly means that the composition of each group should be similar, and by following their outcomes, you can see whether the treatment has helped, over and above natural recovery.

But even randomized controlled trials are not as straightforward as they can appear. This is why medical researchers are encouraged to follow the CONSORT (Consolidated Standards of Reporting Trials) guidelines. The latest CONSORT statement was issued in 2010, after seven years of consultations, and it has the backing of the leading medical journals (which is where most scientists hope to publish their results).

Among the numerous factors CONSORT urges researchers to consider when designing and reporting a trial are: the nature of the patients selected (for example, how severe their problem; how long-lasting it is; whether they have other problems); the techniques used to randomly allocate participants to treatment groups (there are several alternatives); the nature of the control treatment; the composition and quality of the treatment being tested; what types of outcome are measured; whether the research assessors and patients were blind to treatment allocation; what to do about people who drop out of the trial; length of follow-up after the treatment has concluded; appropriate statistical analysis — and so on. And on.

Unfortunately, not all clinical trials adhere to the CONSORT guidelines — and they didn’t exist at all until 1996. And even the best trials can only tell us about particular durations or dosages of treatment for a particular group over a particular time period. This means that there are uncertainties and gaps in knowledge. Hence clinicians often debate the question: what works for whom?

What works?

Establishing the efficacy of specific treatments, then, is an inordinately tricky business. And yet in the case of anxiety disorders, we do have a consensus.

The number one treatment of choice is psychological therapy — principally cognitive behaviour therapy (CBT) and its variants. (We’ve highlighted the theoretical foundations of CBT in the chapters on specific disorders.) Anxiety occurs when we believe a situation is threatening. CBT’s core objective is to test the accuracy of those beliefs. This is achieved by carefully exposing individuals to the situations and feelings that they fear in a way that allows them to learn from the experience. When the tests are carried out in a controlled, graduated, and individually tailored fashion, the person discovers that they are actually much safer than they had thought and their anxiety decreases.

But anxiety is also tackled with medication. For long-term treatment, SSRI antidepressants (such as paroxetine) are preferred. But in the short term, specific anxiolytic (anti-anxiety) drugs may be prescribed to help a patient cope with a crisis. The most commonly used anxiolytics are the benzodiazepines: these tend to work very rapidly and effectively, but can lead to tolerance (your body becomes used to the effects of the drug and therefore increasing doses are required) and to addiction — hence the recommendation that they only be used in the short term.

The gains brought about by CBT are sometimes greater, and typically last longer, than those produced by medication. Moreover, medication can sometimes produce side effects — and giving them up can be tricky. This is why the UK’s National Institute for Clinical Excellence recommends CBT as the first line of treatment for each of the anxiety disorders, with SSRIs as a second choice. (We’ll look at the various treatment alternatives in greater detail below.)

Interestingly, combining psychological therapy and medication doesn’t seem to bring any additional benefits. In fact, in some cases (panic disorder, for instance), medication may actually interfere with the therapy. This is because, in order to learn that you can cope with your anxiety in a controlled exposure, it’s necessary to really feel your fear — which is something anti-anxiety medication is intended, of course, to prevent.

One interesting development, however, is the use of drugs to boost the effects of psychological therapy. It is early days, but promising results have been obtained with ’cognitive enhancers’ such as D-cycloserine (drugs that quicken learning). D-cycloserine appears to speed up the progress made when individuals test out the accuracy of their fearful thoughts.