Effect of Cognitive Behavioral Therapy for Anxiety Disorders on Quality of Life: A Meta-Analysis

Anxiety disorders are the most prevalent psychiatric disorders, with a lifetime prevalence rate of 28.8% (Kessler et al., 2005). These disorders are associated with high personal and economic costs (DuPont et al., 1996) and low quality of life (Cramer, Torgersen & Kringlen, 2005; Mendlowicz, & Stein, 2000; Olatunji, Cisler, & Tolin, 2007; Rapaport, Clary, Fayyad, & Endicott, 2005). For example, it has been reported that obsessive-compulsive disorder (Koran, Thienemann, & Davenport 1996), panic disorder (Candilis et al.,1999; Rubin et al., 2000) and social anxiety disorder (Safren, Heimberg, Brown, & Holle, 1996–1997; Wittchen & Beloch, 1996) have substantially poorer quality of life than community samples. In some cases, anxiety disorders have an even greater impact on quality of life than chronic medical disorders (Spitzer et al., 1995; Sherbourne, Wells, & Judd, 1996). Quality of life (QOL) is difficult to define. It includes subjective well-being, life satisfaction, perceptions of social relationships, physical health, economic status, and functioning in daily activities and work (Angermeyer & Kilian, 1997; Mendlowitz & Stein, 2000). Accordingly, the assessment of QOL typically includes subjective views of one’s life circumstances, perceptions of mental and physical health, social and family relationships, and functioning at work and home (DuPont et al., 1996). Cognitive behavioral therapy (CBT) is an effective treatment for reducing symptoms of anxiety disorders (Hofmann & Smits, 2008). Although symptom reduction is an important goal of treatment, some authors have urged investigators to include QOL as another important indicator of treatment efficacy (Frisch, 1998; Gladis, Gosh, Sishuk, & Crits-Christoph, 1999). The objective of this study was to conduct a quantitative review of the effect of CBT on QOL in patients with anxiety disorders. Although there are different emphases of the various cognitive and behavioral techniques for the range of anxiety disorders, one important commonality of all of these treatment protocols is the premise that cognitions causally influence fear and anxiety, and that the dysfunctional beliefs and cognitive distortions contribute to the maintenance of anxiety disorder (Hofmann, Asmundson, & Beck, 2013). This premise and one of the defining features of a variety of different treatment protocols and include more traditional CBT protocols as well as more modern mindfulness-based cognitive therapy, At the same time, this core assumption is the primary distinguishing feature to other treatments, such as Acceptance and Commitment Therapy and mindfulness-based stress reduction. Our review focuses only on CBT protocols that share the core premise of the centrality of maladaptive cognitions. We examined controlled and within-group random effect sizes of changes in QOL during the course of CBT for specific phobias, panic disorder with and without agoraphobia, social anxiety disorder, generalized anxiety disorder, obsessive compulsive disorder and posttraumatic stress disorder. To examine whether study quality moderated the effect of CBT on QOL, we quantified study quality by using Effective Public Health Practice Project criteria (EPHPP; Thomas, Ciliska, Dobbins & Micucci, 2004). The effects of study quality and publication year are two important reporting items identified by the PRISMA group (Moher et al., 2009). In a large-scale analysis of 2,400 patients, treatment length has been demonstrated to positively correlate with efficacy of cognitive-behavioral treatment (Howard, Kopta, Krause, & Orlinsky, 1986). Furthermore, internet-based delivery of cognitive behavioral therapy for anxiety disorders has proven to be promising but not uniformly efficacious across extant trials (Andersson, 2009). Therefore, we also examined whether treatment administration modality (individual face-to-face, group face-to-face, and internet-delivered) moderated the effect of the treatment on quality of life.