CBT for Anxiety in Mental Illness: A Comprehensive Review

This literature review comprehensively examines the impact of Cognitive Behavioral Therapy (CBT) on managing anxiety in patients diagnosed with mental illness. It begins by introducing the NHS Outcome Framework and its focus on enhancing the quality of life for individuals with long-term conditions, particularly anxiety disorders. The review delves into the background of anxiety and CBT, highlighting the prevalence and effects of anxiety disorders, and explaining how CBT breaks down problems into manageable steps. The research question, 'Does CBT reduce anxiety among patients with a mental health problem?' guides the study. The methodology involves searching databases like PubMed and Google Scholar, using specific search terms, and applying strict inclusion and exclusion criteria to select five relevant randomized controlled trials (RCTs). These articles are then critically appraised using CASP checklists and data extraction tools. The review discusses the findings of studies that examine the effectiveness of CBT, ethical considerations, and limitations, ultimately aiming to provide insights for physicians in choosing appropriate interventions for patients with anxiety and mental health issues. Desklib provides access to similar solved assignments and papers for students.

Cognitive Behavioural Therapy 1
The Impact of Cognitive Behavioural Therapy (CBT) in the management of anxiety on
patients with a diagnosis of mental illness.
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Cognitive Behavioural Therapy 2
1.0 Introduction
This essay aims to carry out a comprehensive literature review in relation to the use of CBT
in the management of patients experiencing anxiety symptoms as part of mental health
disorder. The strategy utilized to search and obtain relevant literature will be presented. The
literature gathered will be analyzed, synthesize and presented in this literature review as well
as making references to the corresponding authors.
Department of Health indicated that National Health Service Outcome Framework (NHS OF)
is a government standard which addresses adults and children healthcare needs and
management of long-term health conditions in the United Kingdom. The five domains of
NHS outcome framework 2017 / 2018 are Premature Death Prevention, Enhancement of
quality of life among individual with long-term condition, facilitation of recovery from
episode of illness or injury, Promotion of positive and high-quality experience of healthcare
and provision of treatment and care in a safe environment as well as protecting individual
from avoidable harm (NHS Outcomes Framework (NHS OF), n.d.). Enhancement of quality
of life among individual with a long-term condition is the chosen area in this assignment
(NHS OF, n.d.).
2.0 Background
2.1 Background knowledge about anxiety
According to Greenberg et al. (2015) anxiety disorder such as specific phobia, agoraphobia,
separation anxiety disorder, generalized anxiety disorder, social anxiety disorder, and panic
disorder are a common mental health problem. Baxter et al. (2013) indicated that one in nine
people had had a recent experience of anxiety disorder globally. It is well documented that
anxiety is often a symptom of other mental health disorders such as bipolar disorder, paranoid
schizophrenia (Gustad et al., 2013). According to Craske and Stein (2016), Anxiety can be

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the common experience of everyday life. However, individuals are diagnosed with an anxiety
disorder if the level of fear, anxious and stress expressed by that individual is highly out of
proportion in relation to the threat in question and continues to be out of proportion for at
least six months. Therefore, it is essential to explore current treatment option available in the
management of anxiety disorder and promote evidence-based practice in the management of
this debilitating condition.
2.2 Background knowledge about CBT
According to Ehde et al. (2014), CBT is a psychological therapy which involves talking with
the aim of influencing individuals’ behavior. It manipulates that individual physical
sensation, feeling, and thoughts with the goal of having a positive influence on the individual
undertaking the treatment. Hofmann et al. (2014) suggested that CBT breaks down
overwhelming problems into smaller components and provides the individual a step by step
approach to address the problem successfully. CBT emphasizes the imminent problem as
well as considerations to the past issues. CBT focuses on a practical task that can be adopted
on a regular basis to promote positive behavior.
Anxiety disorders have been found to be the most prevalent mental disorders globally
(Greenberg et al., 2015). Baxter et al. (2013) reviewed the worldwide prevalence of anxiety
disorders and found out that the sixth leading cause of morbidity with respect to years of life
lived with the disability was anxiety disorders regardless of the economic status of the
countries. The most affected gender were women (65%) with the disease being common in
both males and females aged between 15 and 34 years. Anxiety disorders have a significant
effect on the quality of life (Hofmann et al. (2014) and is linked to decreasing in work
productivity, diminished functioning in social activities, and economic instability (Olatunji et
al., 2013). Due to the magnitude of the effects of anxiety, several treatment options have been
proposed. The treatment options for anxiety are majorly psychotherapy and pharmacotherapy.

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The study by Blanco et al. (2013) suggested the use of pharmacotherapy such as
antidepressants in the first-line treatment of anxiety disorders. But there is a negative
response to the treatment using antidepressants in most of the patients (40%). Individual
cognitive therapy for the treatment of anxiety disorders has been demonstrated to be effective
for different forms of anxiety disorders (Pollack et al., 2014). Despite the existence of several
studies that recommend the use of cognitive behavioral therapy in the treatment of anxiety
disorders, there is limited literature research on its effectiveness or impact. This study aims at
exploring the impact of Cognitive Behavioural Therapy (CBT) in the management of anxiety
on the patient with a diagnosis of mental illness by critiquing five recent randomized control
trials (RCTs).
3.0 Formulation of the research question
The research question used in this literature review was formulated using Population
Intervention, comparison and outcome (PICO) analysis with the omission of Comparison.
The research question is Does CBT reduce anxiety among patients with a mental health
problem?
Population: Patient with the mental health problem.
Intervention: CBT. There is no comparison and Outcome is reduced incidences of anxiety
among patients with mental health problems.
This essay seeks to examine the impact of CBT in the management of anxiety on patients
with a diagnosis of mental illness. Incidences of anxiety disorders have been reported to be
on the rise both in developed and in developing countries (Baxter et al., 2013). Furthermore,
several studies have pointed out that CBT is more effective in the treatment of anxiety
disorders when compared to other conventional methods (Goldin et al., 2013; Høifødt et al.,
2013). This study will provide more and recent information on whether CBT is the most

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suitable approach based on its impacts on reducing anxiety among patients with the mental
health problem.
The research question needs to be answered because of a proper understanding of the impact
of CBT on the management of anxiety among patients with mental diseases. Furthermore, the
right response to the question will provide reliable information to physicians when choosing
the most appropriate intervention to undertake in patients with anxiety.
The outcomes of the review are likely to have a range of implications both to the physician
and the patient. With this information, medical providers will be able to make treatment
decisions for anxiety disorders thus increasing contributing towards reducing the global
prevalence of anxiety in people with mental illness. Additionally, this review will act as a
basis for further studies.
4.0 Methodology
The researcher searched databases such as PubMed, Google Scholar, and PMC for relevant
articles. The search terms used in the search include cognitive behavior, behavioral therapy,
anxiety, mental illness, management of anxiety, anxiety disorders. Moreover, manual
searches for most suitable articles were carried out through reference lists of published
studies. The inclusion criteria for the studies were as follows: the research had to be
randomized control trials and must have been five years old from the date of publication. The
articles must be about cognitive behavioral therapy and its efficacy in treating anxiety. The
articles were excluded if: it was not freely accessible and the full paper not available in
English language, it was a literature review, qualitative study or meta-analysis, the article was
more than five years old after publication. If two studies from a similar trial were retrieved,
the one with the most completed data was preferred. However, in case duplicate articles were

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retrieved, only one of them was picked for review. The item lists in the CASP for RCTs were
used to evaluate and determine whether the studies indeed were RCTs or not.
A total of 20 studies were identified different databases and 3 of them excluded due to
duplication, three more were excluded because they were not randomized control trials and
did not examine CBT. The remaining fourteen studies were retrieved for inclusion and with a
further check led to the exclusion of five studies which were published before 2013. After
further screening and quality check, five studies were included in the review. Authors were
not contacted for original data.
The inclusion and exclusion criteria adopted in this paper was critical because it ensured that
only relevant information was reviewed and was also up to date. This increases the reliability
and validity of the findings (Noble and Smith, 2015).
The five articles were critically appraised using the CASP (Critical Appraisal Skills
Programme) checklist (CASP, 2018). The specific elements of the checklist that were used in
appraisal include if the study population and intervention were identified, concealment of
allocation, randomization of participants to experimental groups, primary and secondary
outcomes.
Data extraction was conducted using the Cochrane Data Extraction tool with five checklists
of data elements namely source, eligibility, methods, participants and results. A data
extraction table was used as indicated below (Savović et al., 2014). Moons et al. (2014)
observes that a data extraction form is appropriate because it connects the report by
investigators in papers, reports, and reviews. Furthermore, the forms provided information for
inclusion in the analysis.

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Sanatinia et al. (2016) conducted a study on the personality effect on the effectiveness of
CBT for health anxiety using patients attending six hospitals in Middlesex, London, and
Nottinghamshire. The subjects were allocated to their groups in a random manner. This
ensured that there was a limited allocation bias. Moreover, randomization was carried out
using a technological system with the generated random sequence. The sequence of
allocation was masked to all members until the databases were completed and locked. The
outcomes were also specified to both primary and secondary outcomes.
Yoshinaga et al. (2016) carried out a prospective randomized study using two parallel groups
of patients who were recruited from medical institutions in Chiba. The objective of the study
was to evaluate the effectiveness of CBT in comparison with antidepressants in social anxiety
disorder patients. The subjects were assigned randomly to the intervention and non-
intervention groups at an equal ratio. The study also blinded the assessors by ensuring that
they had no contacts with patients — randomization and concealment during allocation
provided that selection bias was minimized (Higgins et al., 2011). The findings were defined
into primary outcomes (symptoms determined by the independent assessor) and secondary
results (self-reported symptoms). According to Zeng et al. (2015), the presentation of study
findings into primary and secondary helps to correctly achieve the goal of the study and
answer the research question.
The study obtained ethical approval from the relevant institutions Review Board in addition
to receiving a written informed consent. According to Nishimura et al. (2013), ethical
approval of RCTs is crucial because it shows that the study adhered to the ethical procedures
needed in a survey and thus the findings can be relied upon. The limitation of the study is that
the subjects were recruited from without while the CBT was carried out in the hospital.

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Additionally, there was a quality variation of CBT therapists as observed in their daily
clinical practice. This compromises the credibility of the outcomes.
Wuthrich and Rapee (2013) undertook a study an RCT to assess the effectiveness of CBT for
comorbid anxiety and depression in senior adults. The study was conducted using 62
community residents aged 60-84 years: both primary (variations in the severity of anxiety
symptoms) and secondary outcomes (long-term changes in anxiety symptoms. The patients
were taken through standardized clinical cognitive and behavioral evaluation. The
identification of the study population, intervention and considering the outcomes ensures that
the study addressed a focused issue (CASP, 2018).
The participants were randomly allocated to their groups using random numbers generated by
the computer and the post-treatment assessments done by clinicians not aware of the
condition allocation. Randomization in assigning the subjects minimizes selection and
allocation bias thus increasing the validity and reliability of the study (Noble and Smith,
2015).
The research was ethically approved by the Ethics Committee of the University. Moreover,
written informed consent was obtained from the participants before participating in the study.
According to Nishimura et al. (2013), ethical approval of studies involving humans is critical
as it shows that the research adhered to moral principles while obtaining information from
wilful participants. Thus, the findings are likely to be accurate and reliable. However, the
study had limitations, for instance, the comparison of the treatment a waitlist control instead
of active intervention.
Goldin et al. (2013) undertook an RCT on the impact of CBT for social anxiety disorder
using 65 patients diagnosed with generalized social anxiety disorders at the Stanford
University psychology department. The intervention included 16 sessions of personalized

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CBT for social anxiety disorders. However, the outcomes were not categorized into primary
or secondary but under specific themes. The disclosure of the population, intervention, and
outcomes in an RCT is evidence enough that the study has addressed the focussed issue
(CASP, 2018).
The subjects were randomly assigned to their intervention and waitlist-control groups using
the Efron biased coin randomization process (Ma et al., 2013). This technique of allocation
was used because it fosters equal sample sizes throughout the clinical trial thus minimizing
any possibility of allocation bias. The study by Goldin et al. (2013) obtained ethical approval
from the institution's ethics committee in addition to written consent from the participants.
The limitation of the study is associated with its limitation to inferences regarding reappraisal
of the subjects.
Fitzpatrick et al. (2017) carried out an RCT to ascertain the impact of CBT on youths with
anxiety symptoms when a fully computerized conversational agent is used. Seventy
participants aged 18-28 years were included in the study. The authors found out that CBT
was much more effective when delivered using conversational agents. The participants were
randomized into the study, and each received 20 lessons for fourteen days. All the
participants were not blinded in the research due to its nature (online). Hróbjartsson et al.
(2013) indicate that randomization during group allocation ensures that allocation bias is
minimal thus increasing its credibility.
The study was approved by the Institutional Review Board and informed consent obtained
from the participants after they were informed of the goal of the research and before
commencing the study. Informed consent increases the validity and reliability of the findings
because the respondents are likely to provide credible information because of their individual
decision to participate (Nishimura et al., 2013).

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4.1 Data Extraction Tables
Source
Study ID
Citation/author email Sanatinia et al. (2016)
Eligibility
Type of study Case control
Population description patients attending medical out-patient clinics
Focused diseases/conditions cognitive–behavioural therapy for health
anxiety
Methods
Aim of study To test the impact of personality status on the
clinical and cost outcomes of treatment with
CBT
Study design Pragmatic RCT
Sampling technique Random
Study start date NA
Blinding Yes
Age 16 and 75 years
Sex Male :34, female: 29
Results
Sample size 63
Missing participants NA
Source
Study ID
Citation/author email Yoshinaga et al. (2016)
Eligibility
Type of study Case control
Population description SAD patients who were still symptomatic after
prescription of antidepressants
Focused diseases/conditions social anxiety disorder
Methods
Aim of study Assess the effectiveness of cognitive behavioral
therapy (CBT) as an adjunct to usual care (UC)
compared with UC alone in SAD patients who
remain symptomatic following antidepressant
treatment
Study design prospective randomized open-blinded end-
point study
Sampling technique Random
Study start date June 2012 and March 2014.
Blinding Open blinded
Age age 18–65 years
Sex Male :42
Results
Sample size 42
Missing participants NA

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Source
Study ID
Citation/author email Goldin et al. (2013)
Eligibility
Type of study Case control
Population description generalized SAD
Focused diseases/conditions social anxiety disorder (SAD)
Methods
Aim of study To determine whether CBT for SAD modifies
cognitive reappraisal–related prefrontal cortex
neural signal magnitude
Study design Randomized clinical trial
Sampling technique Random
Study start date NA
Blinding N/A
Age NA
Sex NA
Results
Sample size 75
Missing participants NA
Source
Study ID
Citation/author email Wuthrich and Rapee (2013).
Eligibility
Type of study Case control
Population description community dwelling participants with
subclinical levels of anxiety, depression or
both
Focused diseases/conditions anxiety and a mood disorder
Methods
Aim of study To ascertain the impact of CBT for comorbid
anxiety and depression in older adults
Study design Randomized clinical trial
Sampling technique Random
Study start date NA
Blinding N/A
Age 60-84 years
Sex Male: 22, female: 40
Results
Sample size 62
Missing participants NA

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Source
Study ID
Citation/author email Fitzpatrick et al. (2017).
Eligibility
Type of study Case control
Population description College students in the US community
experiencing symptoms of depression and
anxiety
Focused diseases/conditions anxiety and depression symptoms
Methods
Aim of study To determine the feasibility, acceptability, of an
automated conversation agent on alleviating
anxiety symptoms among college students
Study design Randomized clinical trial
Sampling technique Random
Study start date NA
Blinding unblinded trial
Age 18-28 years
Sex Male: 23, female: 47
Results
Sample size 70
Missing participants NA
5.0 Discussion
Five articles were selected for this essay with each article addressing the impact of CBT on
different forms of disorders, carried out in a different setting and with various limitations.
5.1 CBT produces a more significant and longer lasting effect
The study by Yoshinaga et al. (2016) found out that CBT was the most preferred first-line
treatment option for anxiety disorders because it has a more extensive and more prolonged
effect. The study found out that CBT took 16 weeks to reduce symptoms related to anxiety.
Similar findings were arrived at by Singewald et al. (2015) who found out that respondents
demonstrated positive cognitive changes before and after treatment. The authors