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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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“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
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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? (2026) · cites this paper as Stewart & Chambless, 2009
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“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
The cited source says what the claim attributes to it.
In the citing paper
“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
The cited source says what the claim attributes to it.
In the citing paper
“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]
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“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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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Metadata
- 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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