Treatment for Anxiety

I wrote this reflection for my problem identification class at the University of Rochester. The professor asked us to reflect on a particular reading, the reading for this reflection was Bandelow's (2015) Efficacy of treatments for anxiety disorders: a meta-analysis. I have included my reflection below.

Treatment for Anxiety

This week, I chose to reflect on Bandelow's (2015) Efficacy of treatments for anxiety disorders: a meta-analysis. My initial reaction upon reading this piece was that I walked into a grudge match! Bandelow opens the paper with a very striking abstract, claiming his paper is unique, comparing all major forms of anxiety with treatment efficacy across drug-based treatment (pharmacological), therapy-based treatment (psychological), and controls, such as placebo pills or waitlists. Bandelow cites his usage of meta-analysis, displaying large number, with 234 studies analyzed covering 37,333 patients. Following this, Bandelow brings home his finding that medications were associated with significantly better patient outcomes, an effect size of 2.02, compared to therapy, with an effect size of 1.22. Bandelow does caveat that in some cases, CBT performed better than placebo, but he closes his abstract with the hard-hitting remark that, essentially, psychotherapy is no different from placebo.

In the introduction of Bandelow's paper, he comments on the National Institute for Health and Clinical Excellence (NICE) and how their views seem to differ from the results he has collated in this paper. It appears to me that this paper is a polemic against "NICE." I also raised an eyebrow when I saw at the very end of the paper, under "Conflict of Interests," that Bandelow and his co-author Wedekind are on boards (speaker boards or advisory boards) for Meiji-Seika, Lundbeck, Pfizer, Servier, AstraZeneca and Essex Pharma, all pharmaceutical companies promoting the drugs that Brandelow's report says are superior to psychotherapy. As we delve further, I wonder if Bandelow obfuscates the details of his approach with technical statistical language?

As I read, I continued to wonder how 234 studies, all using different controls, variables, assessments, samples, pools, measurements, and time frames, could be consolidated into such a succinct headline statement that drugs work and that therapy is no better than placebo. In any case, a couple of interesting tidbits I extracted from the paper include some more knowledge about placebos; I did not realize that pill placebo has changed in effectiveness over time, "from 0.87 in the years 1983–1992 to 1.71 for the years 2003–2013", this was very interesting to me and made me think about the social part of biopsychosocial, how societal belief on pills has dramatically increased their placebo effect. I was also very interested in the section entitled "Active versus control effect sizes." In this section, the authors explain that while their overall meta-analysis shows drugs as superior, these differences go away when they look at direct or head-to-head comparisons between smaller sets of reports. We get varied results, especially with CBT, which shows a superior effect to control in these scenarios, as do relaxation and mindfulness-based techniques, with mixed results.

I was also interested in how Bandelow performed statistical analysis on "allegiance effects," where he attempts to show that even if he and other authors of pharma-based studies do have allegiance, it is not significant in the results. He also then tries to pre-emptively tackle the objection that therapy-based procedures need a longer time to take effect compared to drugs, showing that the mean research period for drugs was ten weeks. In contrast, for therapy, it was 12 weeks, and even 21 weeks for psychotherapy. Bandelow also notes that it could be hard to say because many patients studied in the therapy research could also be on medications. He also notes that patients in drug studies may have had more severe anxiety than those in therapy studies.

After reading this piece, I am grateful to be better informed and equipped about the criticisms volleyed at therapy as an intervention so I may strengthen my ability to deliver well-being in my encounters.