Cognitive–behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies.
Open accessAbstract
The efficacy of cognitive-behavioral therapy (CBT) for anxiety in adults is well established. In the present study, the authors examined whether CBT tested under well-controlled conditions generalizes to less-controlled, real-world circumstances. Fifty-six effectiveness studies of CBT for adult anxiety disorders were located and synthesized. Meta-analytic effect sizes are presented for disorder-specific symptom measures as well as symptoms of generalized anxiety and depression for each disorder, and benchmarked to results from randomized controlled trials. All pretest-posttest effect sizes for disorder-specific symptom measures were large, suggesting that CBT for adult anxiety disorders is effective in clinically representative conditions. Six studies included a control group, and between-groups comparisons yielded large effect sizes for disorder-specific symptoms in favor of CBT. Benchmarking indicated that results from effectiveness studies were in the range of those obtained in selected efficacy trials. To test whether studies that are more representative of clinical settings have smaller effect sizes, the authors coded studies for 9 criteria for clinical representativeness. Results indicate an inverse relationship between clinical representativeness and outcome, but the magnitude of the relationship is quite small.
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Exposure-based CBT has robust support from efficacy and effectiveness clinical trials.
“Despite the robust support for exposure-based CBT in efficacy and effectiveness clinical trials (Stewart & Chambless, 2009)”
From Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings (2019) · cites this paper as Stewart & Chambless, 2009
The Discussion reports that CBT for adult anxiety disorders was robustly effective in clinically representative settings, with effect sizes generally within the range of selected efficacy studies. The Method (Studies) defines CBT broadly to include cognitive treatments, behavioral treatments such as exposure, or both. The paper therefore supports the claim about CBT generally, but does not establish the same conclusion specifically for exposure-based CBT. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPrior studies have shown that increases in the quality and quantity of clinical supervision can explain some treatment effects.
“Prior studies have shown that increases in the quality and quantity of clinical supervision can explain some treatment effects.39,40”
From Controlled trial of psychotherapy for Congolese survivors of sexual violence (2013) · cites this paper as [40]
The Results (page unavailable) associate lack of therapist training and treatment monitoring with smaller outcome effect sizes. The Discussion (page unavailable) cautions that these analyses are exploratory and correlational. The paper does not assess increases in the quality or quantity of clinical supervision specifically, or establish that supervision explains treatment effects. (LLM, conf=0.84)
Experimental — accuracy not yet measuredCBT for anxiety disorders is effective in routine care settings (Cohen's d = 0.9-2.6).
“there is evidence from meta-analyses supporting that CBT for anxiety disorders is effective in routine care settings (Cohen ' s d = 0.9 -2.6; Hans and Hiller, 2013; Stewart and Chambless, 2009; van Ingen et al ., 2009)”
From Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting (2024) · cites this paper as Stewart and Chambless, 2009
The Discussion concludes that CBT is effective for adult anxiety disorders in clinical settings. The Results report large, uncontrolled pretest–posttest effects for disorder-specific symptoms, but give a range of 0.83–2.59, not the cited 0.9–2.6; the cited lower bound is slightly too high. (LLM, conf=0.85)
Experimental — accuracy not yet measuredCBT has become the strongest empirically supported psychological treatment for anxiety.
“cognitive behavioral therapy (CBT) has become the strongest empirically supported psycho logical treatment for anxiety”
From Which emotion regulation strategies are mediating the outcome of acceptance and commitment therapy compared to cognitive-behaviour therapy in the treatment of anxiety symptoms? (2025) · cites this paper as Stewart & Chambless, 2009
The Abstract (page not available) says CBT appears prominently among empirically supported treatments for adult anxiety disorders, and the Discussion reports that it is effective in clinical practice. Neither section establishes that CBT is the strongest-supported psychological treatment relative to other therapies. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe present study satisfied multiple effectiveness-trial criteria involving representative patients, therapists, and services.
“This study met several criteria for an effectiveness trial, including clinically representative patients (various primary disorders, highly comorbid, severe, referred by health practitioners), therapists (broad caseload, various levels of experience), and services (naturalistic community mental health clinic, Stewart & Chambless, 2009).”
From Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: An effectiveness trial (2015) · cites this paper as Stewart & Chambless, 2009
Meta-analytic evidence on routine-care outcomes supports the idea that treatments shown to work in trials can also work well in non-research settings.
“Meta-analyses investigating the effectiveness of treatments under real world conditions have supported the proposition that efficacious protocols can be highly effective outside of research trials (Stewart & Chambless, 2009).”
From Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: An effectiveness trial (2015) · cites this paper as Stewart & Chambless, 2009
CBT seems to be effective in treating GAD in naturalistic settings.
“Altogether, CBT seems to be effective in treating GAD in naturalistic settings.”
From Psychological interventions for generalized anxiety disorder: Effects and predictors in a naturalistic outpatient setting (2023) · cites this paper as [34]
These results were similar to those reported in randomized trials for adult depression and effectiveness trials for adult anxiety disorders.
“These results were similar to those reported in various randomized trials for adult depression [47] and similar to those reported for effectiveness trials of adult anxiety disorders [48].”
From Blended care-cognitive behavioral therapy for depression and anxiety in real-world settings: Pragmatic retrospective study (2020) · cites this paper as [48]
Open recruitment (OR) trials often apply strict inclusion and exclusion criteria, such as excluding patients taking psychoactive medication, patients with comorbid disorders, or severely depressed patients.
“Often these studies apply strict inclusion and exclusion criteria; for example, they may exclude patients taking psychoactive medication, patients with comorbid disorders, or severely depressed patients [8,9].”
From Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis (2019) · cites this paper as [9]
A previous meta-analysis by Stewart and Chambless found a small but significant effect size (d=-0.08; P<.05) indicating smaller improvements in more clinically representative patient studies than in less clinically representative studies.
“The difference in results we found between OR and CSR trials for studies with WLC comparators is in line with a previous meta-analysis on effectiveness of face-to-face CBT for anxiety disorders by Stewart and Chambless [9]. The small but significant effect size (d=–0.08; P<.05) they found indicated smaller improvements in more clinically representative patient studies than in less clinically repre”
From Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis (2019) · cites this paper as [9]
Clinical representativeness of studies is often rated based on a multitude of criteria besides recruitment type, such as setting of treatment delivery, experience of therapists, and flexibility in treatment manuals.
“Second, clinical representativeness of studies is often rated based on a multitude of criteria, besides recruitment type, such as setting of treatment delivery, experience of therapists, and flexibility in treatment manuals [9,109].”
From Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis (2019) · cites this paper as [9]
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- Authors
- Stewart, R. E., & Chambless, D. L.
- Affiliations
- University of Pennsylvania (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2009
- Volume
- 77
- Issue
- 4
- Pages
- 595-606
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC8022196
- OpenAlex
- W2132989097
- Cited by
- 483
- References
- 98
- Citations by year
- 2026: 8 · 2025: 15 · 2024: 24 · 2023: 28 · 2022: 25 · 2021: 41 · 2020: 32 · 2019: 28 · 2018: 35 · 2017: 27 · 2016: 24 · 2015: 32 · 2014: 37 · 2013: 41 · 2012: 40
- FWCI
- 4.14
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (F31MH084486)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- cognitive behavioral therapy, efficacy versus effectiveness, generalized anxiety disorder, depression, symptom outcomes
- MeSH terms
- Adult, Aged, Anxiety Disorders, Female, Humans, Male, Middle Aged, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Treatment Outcome, Benchmarking
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