Efficacy of Yoga vs Cognitive Behavioral Therapy vs Stress Education for the Treatment of Generalized Anxiety Disorder: A Randomized Clinical Trial
Open accessAbstract
Importance: Generalized anxiety disorder (GAD) is common, impairing, and undertreated. Although many patients with GAD seek complementary and alternative interventions, including yoga, data supporting yoga's efficacy or how it compares to first-line treatments are lacking. Objectives: To assess whether yoga (Kundalini yoga) and cognitive behavioral therapy (CBT) for GAD are each more effective than a control condition (stress education) and whether yoga is noninferior to CBT for the treatment of GAD. Design, Setting, and Participants: For this randomized, 3-arm, controlled, single-blind (masked independent raters) clinical trial, participants were recruited from 2 specialty academic centers starting December 1, 2013, with assessment ending October 25, 2019. Primary analyses, completed by February 12, 2020, included superiority testing of Kundalini yoga and CBT vs stress education and noninferiority testing of Kundalini yoga vs CBT. Interventions: Participants were randomized to Kundalini yoga (n = 93), CBT for GAD (n = 90), or stress education (n = 43), which were each delivered to groups of 4 to 6 participants by 2 instructors during twelve 120-minute sessions with 20 minutes of daily homework. Main Outcomes and Measures: The primary intention-to-treat outcome was acute GAD response (Clinical Global Impression-Improvement Scale score of much or very much improved) after 12 weeks as assessed by trained independent raters. Results: Of 538 participants who provided consent and were evaluated, 226 (mean [SD] age, 33.4 [13.5] years; 158 [69.9%] female) with a primary diagnosis of GAD were included in the trial. A total of 155 participants (68.6%) completed the posttreatment assessment. Completion rates did not differ (Kundalini yoga, 60 [64.5%]; CBT, 67 [74.4%]; and stress education, 28 [65.1%]: χ2 = 2.39, df = 2, P = .30). Response rates were higher in the Kundalini yoga group (54.2%) than in the stress education group (33.%) (odds ratio [OR], 2.46 [95% CI, 1.12-5.42]; P = .03; number needed to treat, 4.59 [95% CI, 2.52-46.19]) and in the CBT group (70.8%) compared with the stress education group (33.0%) (OR, 5.00 [95% CI, 2.12-11.82]; P < .001; number needed to treat, 2.62 [95% CI, 1.91-5.68]). However, the noninferiority test did not find Kundalini yoga to be as effective as CBT (difference, 16.6%; P = .42 for noninferiority). Conclusions and Relevance: In this trial, Kundalini yoga was efficacious for GAD, but the results support CBT remaining first-line treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01912287.
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In Simon et al., at 6-month follow-up, the CBT response rate (76.7%) was significantly higher than the SE group (48%), with an NNT of 3.51.
“At 6-month follow-up, the CBT response rate (76.7%) was significantly higher than the SE group (48%), with a NNT of 3.51.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
In Simon et al., the Kundalini yoga (KY) group had a significantly higher response rate (54.2%) than the stress education (SE) group (33%) at posttreatment, with a number needed to treat (NNT) of 4.59.
“The KY group had a significantly higher response rate (54.2%) than the SE group (33%) at posttreatment, with a number needed to treat (NNT) of 4.59.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
CBT and KY were both more effective than SE as assessed by short-term response rates.
“CBT and KY were both more effective than SE as assessed by short-term response rates.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
In Simon et al., at 6-month follow-up, the response rate in the KY group was not significantly higher than that of the SE group.
“At 6-month follow-up, the response rate in the KY group was not significantly higher than that of the SE group.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
CBT appeared to have better long-term response outcomes compared to SE, while KY did not display a benefit in follow-up analyses.
“CBT appeared to have better long-term response outcomes compared to SE, while KY did not display a benefit in follow-up analyses.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
In Simon et al., the CBT group had a significantly higher response rate (70.8%) than the SE group (33%) at posttreatment, with an NNT of 2.62.
“The CBT group had a significantly higher response rate (70.8%) than the SE group (33%) at posttreatment, with a NNT of 2.62.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
In Simon et al., KY was not found to be as effective as CBT on noninferiority testing.
“KY was not found to be as effective as CBT on noninferiority testing.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
These findings may not generalize to how CBT and yoga are approached in the community.
“These findings may not generalize to how CBT and yoga are approached in the community.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
Overall, KY appears to have a less robust efficacy compared to CBT in the treatment of GAD.
“Overall, KY appears to have a less robust efficacy compared to CBT in the treatment of GAD.”
From Generalized anxiety disorder: 8 studies of psychosocial interventions (2022) · cites this paper as [5]
CBT is the golden standard psychological treatment in GAD.
“Several investigations found that CBT is the golden standard psychological treatment in GAD (Ladouceur et al., 2000; Simon et al., 2021).”
From Standard CBT versus integrative and multimodal CBT assisted by virtual-reality for generalized anxiety disorder (2022) · cites this paper as Simon et al., 2021
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- Authors
- Simon, N. M., Hofmann, S. G., Rosenfield, D., Hoeppner, S. S., Hoge, E. A., Bui, E., & Khalsa, S. B. S.
- Affiliations
- New York University (US)
- Boston University (US)
- Southern Methodist University (US)
- Harvard University (US)
- Georgetown University Medical Center (US)
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
- Brigham and Women's Hospital (US)
- Corresponding author
- Simon, Naomi M.
- ORCID
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2021-01-01
- Volume
- 78
- Issue
- 1
- Pages
- 13
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC7788465
- OpenAlex
- W3048917165
- Cited by
- 95
- References
- 38
- Citations by year
- 2026: 8 · 2025: 19 · 2024: 14 · 2023: 16 · 2022: 24 · 2021: 11 · 2020: 3
- FWCI
- 13.06
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health
- National Center for Complementary and Integrative Health (R01AT007257, R01AT007258)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- generalized anxiety disorder, Kundalini yoga, cognitive behavioral therapy, stress education, non-inferiority, complementary and alternative medicine, treatment efficacy comparison, treatment completion rate, dropout rates, adverse events, patient-reported outcomes, treatment acceptability
- MeSH terms
- Adult, Anxiety Disorders, Female, Humans, Male, Middle Aged, Patient Education as Topic, Stress, Psychological, Yoga, Cognitive Behavioral Therapy, Single-Blind Method, Outcome Assessment, Health Care, Young Adult
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