Critical Evaluation of Naturopathic Care for Anxiety: RCT Analysis

This report critically appraises the journal article "Naturopathic Care for Anxiety" by Cooley et al. (2009), a randomized controlled trial (RCT) investigating the effectiveness of naturopathic care for anxiety. The report evaluates the introduction, which includes a literature review and the study's aim, followed by an in-depth analysis of the methodology, including subject selection, instrumentation, control groups, and treatment parameters. The results section is assessed, focusing on tables, graphs, statistical methods, and interpretation of findings. The conclusion examines internal and external validity, and the overall quality of the study. The analysis highlights the strengths, such as attempts to account for biases, and weaknesses, such as the small sample size. The report provides a comprehensive overview of the research, discussing its implications for anxiety disorder treatment and the broader field of healthcare research.

Running head: CRITICAL WRITING 1
Critical Writing
Naturopathic Care for Anxiety: A Randomized Controlled
Trial
Student’s Name
Institutional Affiliation
Professor’s Name
Date

CRITICAL WRITING 2
Critical Writing
1. Introduction
In this assignment, the journal article “Naturopathic Care for Anxiety” by Cooley et al.
(2009) which was based on randomised control trial technique will be critically appraised
through an in-depth analysis and evaluation of the literature, the methodology, results and the
findings. In the article, the authors acknowledged that anxiety had a severe burden on the overall
quality of life as one of the chronic health condition among the people. Additionally, the scholars
alluded that the disorder imposed significant costs to the healthcare system and the productivity
because of the medical covers offered to the employees as well as the time they spend off duty
because of anxiety disorder as supported by Evans-Lacko et al. (2018). The team sought to
investigate the effectiveness of administering naturopathic care to anxiety disorder victims
through the RCT approach. The reason of selecting this article for appraisal is due to the global
increment in the anxiety disorder that stands out to be a socio-economic concern that calls for
effective measures to be taken to curb its implications (Watad et al., 2017). Therefore, the
analysis and evaluation of the article could be paramount to future studies that seek to address
the anxiety disorder in society.
2. Evaluation of the introduction section
2.1. Literature review
In the article, the authors managed to conduct a detailed literature review that is
supported with solid pieces of evidence through the references that cite the authors of the
examples given. Moreover, the introduction section entails a background to the anxiety
disorders, which is backed up with quality and the adequate number of references that are
pertinent to the topic of study as recommended by Polgar and Thomas (2011).

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2.2. The aim of the study
The authors clearly stated the aim of their study that was inclined to the topic of research
and the design that was going to be deployed in the study as well as the intended intervention
thus managed to align the objective of the study to the background and literature review.
Additionally, the clear statement of the aim prepares the reader on what to expect in the
subsequent sections of the article.
3. Evaluation of the method section
3.1. Subjects
The authors used an advertisement for selecting the participants in the study.
Advertisement ensured that only those interested in taking part are selected through voluntary
means as required by the ethical codes in researches (Timmermans, 2016). Before participation,
the authors ensured the participants have read and understood the purpose of the study and
signed written consent for participation after seeking approval to carry out the research (Hancock
et al. 2018). The subjects represented the population under study since they underwent tests to
ensure only those with an anxiety disorder are selected for participation through appropriate
inclusion criteria. For an individual to qualify as a subject for the study, the authors used
adequate tools such as the Beck Depression Inventory (BDI) for screening depression to levels to
eliminate those who could not comply with the protocols (Bringmann et al., 2015). Exclusion
ensured that the subjects are representative of the target population under study for accurate
results. Concisely, the scholars deployed appropriate sampling, in essence, the stratified
randomization that enabled the allocation of the participants into the naturopathic care (active
group) and psychotherapy (control) groups as well as blinding of the participants to treatment

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allocation to eliminate the expectation biases as per the requirement of the RCT technique (Raine
et al., 2016).
3.2. Apparatus/ instrumentation
Cooley and his colleagues used useful depression tools and techniques such as the BDI
and BAI that were vital in determining the suitability of the subjects for participation. Moreover,
the instruments used were the basis of inclusion and exclusion criteria of the participants. The
authors established the validity of the apparatus through suitable protocols that are inclined to the
study such as DSM-IV criteria that ensured the reliability of the tools used (Morrison et al.,
2016).
3.3. Control groups
For a randomised control trial, the authors sampled the subjects into an experimental and
a control group, which were consistent across the entire study. The placebo control groups were
adequately defined with their respective treatment and the section criteria of the subject to each
group. Through these explanations, the authors made it easier for the readers to understand the
reasons for allocating the participants to these groups. Ethical considerations were put into the
account in the placebo groups where consented blinding of participants was deployed in during
the randomised allocation of the subjects (Timmermans, 2016).
3.4. Subject assignment
Assignment of the participants into the study groups was randomised using the age and
gender of the subjects and stratified into the treatment groups and elaborated in detail in the
method section. The differences explained at the entry point of assigning the subjects to the
groups are essential in defining the confound outcomes since a chronological alternating of the
practitioners was done at the time of enrolment.

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3.5. Treatment parameters
Like any effective experimental study, Cooley et al. (2009) defined the treatment
parameters for their experiment in the treatment section. The scholars logically explain the
timelines and the actual treatment delivered to the groups within the time of the visit. The article
revealed the subjects in the naturopathic care and the psychotherapy care groups were subjected
to an equal time of study with distinguished treatments parameters for each group (Colantuoni et
al., 2018). Through the treatment groups section, the readers can quickly establish the different
treatment parameters delegated to the groups. Concisely, qualified licensed doctors with more
than four and five years were deployed in the administration of the treatment ensuring that there
were no or limited medical mistakes during the treatment processes.
3.6. Rosenthal and Hawthorn effects
The Hawthorn effect is the tendency of the subjects to change their behaviour in the
course of research because they are being studied whereas the Rosenthal or the Pygmalion effect
is the changes in the respondent’s behaviour caused by the researcher’s expectation referred to an
as self-fulfilling prophecy (Heydari et al., 2019). The article indicates that the authors addressed
these effects, in essence, the expectation biases through blinding of the subjects and the
investigators throughout the study.
4. Evaluation of the results section
4.1. Tables and graphs
The use of tables was paramount in the evaluation and results section in the presentation
of the findings. It is observed that the authors were consistent in the use of tables, which were
adequately indexed for easier identification. Professionalism is depicted where the headings for
each table is given with labelling of all the rows and columns as well as a legend section for

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defining the abbreviations used in the tables and the graph. Additionally, a correlation between
the effectiveness of the treatment between the groups is shown using the charts whereby the
trend lines of different colours are used for distinguishing between the groups. Generally, these
features employed by the authors were crucial in understanding the interpretation of the data that
is presented in the tables and the graphs.
4.2. Selection of statistics
In the determination of the reduction in the anxiety scores, an assumption of 20 per cent
normal standard deviation population was made in the calculation of the sample sizes that
enabled the replacement of the missing data for week 12 using that of week 8. This allowed the
scholars to ensure the entire period of the study is filled with the BAI entries for accuracy in the
findings. During the selection of the sample size, the authors had sampled extra participants so
that they could cater for the limitations of opting out by some subjects in the course of the study
thus addressing the effects of sample size in the descriptive statistics. Additionally, the
calculation of the numbers needed to treat for both the NC care and the control group, which was
36 and 39 respectively. The confidence interval of 95% was quoted in the analysis section that
was consistent throughout the study implying that the data could be having some true value of
the unknown population parameters thus the interval level is significant in establishing the
estimation (Kai, Qattan, & Brar, 2018).
4.3. Interpretation of the findings
The article reports that there were significant improvements in both the outcomes of the
groups as shown in the BAI with NC showing greater gains compared to the PT group. The
findings of the authors are supported by the results, which are indicated in the tables discussed
earlier as evidence of the outcomes. Concisely, the authors could have made an inappropriate

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generalisation for the adverse events during the study whereby all the reactions that were
reported to be overstimulation by the subjects were considered mild for the NC group (Cooley et
al., 2009). For instance, the gastrointestinal complaints raised by the subjects could lead to severe
implications such as prolonged stomach pain that could likely affect the general health condition
of the subjects. On the other side, a clinical significance ± 20 per cent is discussed with a p-value
being less than 0.05 for most of the treatment except for the role physical as shown in the
outcomes section (Cooley et al., 2009). However, as much as the treatment led to statistically
significant improvements in the symptoms does not necessarily imply that the indicated
improvement could be clinically significant as that was for the doctors and the subjects to
determine.
5. Conclusion
5.1. Internal validity
The authors achieved the internal validity through the attempts to account for the non-
specified impacts of the treatment in both the NC and the PT groups through the absence of
assessment biases and prevention of contamination of the medications (Cooley et al., 2009).
Additionally, participants in both groups were given patient-centred counselling, motivation, a
mind-body exercise, education, and a therapeutic doctor-patient relationship. The blind
allocation of the participants was also an essential aspect of the internal validity that limited the
potential biases during the study despite the limitations to internal validity due to the lack of “no
treatment” control group that made it difficult for the researchers to account for anxiety levels
due to the spontaneous changes within the study design.

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5.2. External validity
The authors attempted to maximise the external validity through few exclusion criteria
and the inclusion of some variability or the flexibility in the intervention basing on the individual
needs of the subjects. Through this, the authors aimed at achieving generalisation in the study,
which could be a critical component for accurate results viable for replication of the results.
However, a herbal component used that was the specific treatment of all the participants in the
NC group was deployed which contradicts the potential psychoactive for supportive evidence in
the control group. Unfortunately, the authors narrate that external validity could not be
sufficiently achieved due to the limitation of the small sample size (Cooley et al., 2009). Rouf,
Grech and Allman-Farinelli (2018) alluded that small sample sizes are inaccurate for duplication
of the findings to a larger population as the sample could be inefficient in representing the
general characteristics of the target population.
5.3. Overall quality
Despite the successful establishment of a statistical significance in reducing the
symptoms of anxiety disorder, the authors acknowledge the challenges in the methodology due
to the study design and the population as the primary weaknesses. The small sample size used
prevented the heterogeneity of the study participants leading to large variability in BAI scores
between the groups. However, the successful attempts to curb the limitations of validity were the
significant strengths in the research, which resulted in significant reductions in BAI scores from
the baseline in both groups.

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