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Enduring effects of psychological treatments for anxiety disorders: meta-analysis of follow-up studies

  • Borwin Bandelow (a1), Anne Sagebiel (a1), Michael Belz (a1), Yvonne Görlich (a1), Sophie Michaelis (a1) and Dirk Wedekind (a1)...

It is a widespread opinion that after treatment with psychotherapy, patients with anxiety disorders maintain their gains beyond the active treatment period, whereas patients treated with medication soon experience a relapse after treatment termination.


We aimed to provide evidence on whether enduring effects of psychotherapy differ from control groups.


We searched 93 randomised controlled studies with 152 study arms of psychological treatment (cognitive–behavioural therapy or other psychotherapies) for panic disorder, generalised anxiety disorder and social anxiety disorder that included follow-up assessments. In a meta-analysis, pre-post effect sizes for end-point and all follow-up periods were calculated and compared with control groups (medication: n = 16 study arms; pill and psychological placebo groups: n = 17 study arms).


Gains with psychotherapy were maintained for up to 24 months. For cognitive–behavioural therapy, we observed a significant improvement over time. However, patients in the medication group remained stable during the treatment-free period, with no significant difference when compared with psychotherapy. Patients in the placebo group did not deteriorate during follow-up, but showed significantly worse outcomes than patients in cognitive–behavioural therapy.


Not only psychotherapy, but also medications and, to a lesser extent, placebo conditions have enduring effects. Long-lasting treatment effects observed in the follow-up period may be superimposed by effects of spontaneous remission or regression to the mean.

Declaration of interest

In the past 12 months and in the near future, Dr Bandelow has been/will be on the speakers/advisory board for Hexal, Mundipharma, Lilly, Lundbeck, Pfizer and Servier. Dr Wedekind was on the speakers' board of AstraZeneca, Essex Pharma, Lundbeck and Servier. All other authors have nothing to declare.

Corresponding author
Correspondence: Dr Borwin Bandelow, Department of Psychiatry and Psychotherapy, University of Göttingen, von-Siebold-Straβe 5, D-37075 Göttingen, Germany. Email:
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Enduring effects of psychological treatments for anxiety disorders: meta-analysis of follow-up studies

  • Borwin Bandelow (a1), Anne Sagebiel (a1), Michael Belz (a1), Yvonne Görlich (a1), Sophie Michaelis (a1) and Dirk Wedekind (a1)...
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Does pharmacotherapy really have as enduring effects as psychotherapy in anxiety disorders ? Some doubts.

Falk Leichsenring, Professor, Univerity of Giessen
Jürgen Hoyer, Professor, University of Dresden
12 June 2018

Bandelow et al. recently presented a meta-analysis testing the assumption that the effects of psychotherapy in anxiety disorders are more endurable than those of pharmacotherapy.1 From non-significant differences between psychotherapy and pharmacotherapy in pre-follow-up effect sizes the authors concluded that 1, p. 3 "... patients who stopped taking a drug showed the same durable improvement as patients who stopped psychotherapy."

Besides the severe (and properly discussed) limitation that an unclear percentage of patients may have started new psychological treatment or taken medications in the follow-up period, this meta-analysis raises further serious concerns.

(1) The authors did not clearly specify their inclusion criteria. Apparently they did not require head-to head comparisons of psychotherapy and pharmacotherapy as an inclusion criterion.

(2) As a consequence, Bandelow et al. compared pre-post and pre-follow-up effect sizes of psychotherapy, medication and placebo obtained from different randomized controlled trials. Thus, the studies being compared may differ with regard to important treatment moderators such as characteristics of patient populations and setting conditions. For these and other reasons analyses of pre-post and pre-follow-up effect sizes should be avoided in meta-analyses.2

(3) Bandelow et al. did not adhere to the logic of equivalence testing which includes the definition of a margin compatible with equivalence and performing two is questionable.3 The traditional two-sided test and TOST often yield inconsistent results.4

(4) Furthermore, Bandelow et al. seem to have not controlled for researcher allegiance.5 Thus, a bias in favour of pharmacotherapy cannot be excluded given that the first and last authors disclose multi-fold collaboration with pharmaceutical companies.

(5) Interestingly, the authors avoid discussing potential long-term negative effects that any type of psychotropic drug treatment, particularly after long-term use, may have, e.g. by increasing the risk of experiencing additional psychopathological problems that do not necessarily subside with discontinuation of the drug or of modifying responsiveness to subsequent treatments.6

The data presented by Bandelow et al. suggest that pharmacotherapy may have endurable effects in anxiety disorders as well. However, the authors´ conclusion that in the long-term term psychotherapy and pharmacotherapy are equally efficacious in anxiety disorders is questionable for the reasons given above.

Conflicts of Interest Falk Leichsenring and Jürgen Hoyer are trained psychotherapists.


1. Bandelow B, Sagebiel A, Belz M, Gorlich Y, Michaelis S, Wedekind D. Enduring effects of psychological treatments for anxiety disorders: meta-analysis of follow-up studies. Br J Psychiatry 2018:1-6.

2. Cuijpers P, Weitz E, Cristea IA, Twisk J. Pre-post effect sizes should be avoided in meta-analyses. Epidemiology and psychiatric sciences 2017;26:364-8.

3. Walker E, Nowacki AS. Understanding equivalence and noninferiority testing. J Gen Intern Med 2011;26:192-6.

4. Barker LE, Luman ET, McCauley MM, Chu SY. Assessing equivalence: an alternative to the use of difference tests for measuring disparities in vaccination coverage. Am J Epidemiol 2002;156:1056-61.

5. Mellers B, Hertwig R, Kahneman D. Do frequency representations eliminate conjunction effects? An exercise in adversarial collaboration. Psychol Sci 2001;12:269-75.

6. Fava GA, Benas iG, Cosci F. The potential role of iatrogenic comorbidity in the interaction between pharmacotherapy and psychotherapy in anxiety disorders Verhaltenstherapie 2017; 27 275-80.

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Conflict of interest: Falk Leichsenring and Jürgen Hoyer are trained psychotherapists.

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