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Original Investigation
October 2017

Effectiveness of Psychological and/or Educational Interventions in the Prevention of Anxiety: A Systematic Review, Meta-analysis, and Meta-regression

Author Affiliations
  • 1Research Unit, Primary Care District of Málaga-Guadalhorce, Málaga, Spain
  • 2Prevention and Health Promotion Research Network, Málaga, Spain
  • 3Institute of Biomedical Research in Málaga, Málaga, Spain
  • 4Sant Joan de Déu Research Foundation, Barcelona, Spain
  • 5Network for Biomedical Research on Epidemiology and Public Health, Biomedical Research Networking Center for Epidemiology and Public Health, Madrid, Spain
  • 6School of Pharmacy, University of Barcelona, Barcelona, Spain
  • 7Service of Community Health, Public Health Agency of Barcelona, Barcelona, Spain
  • 8Department of Personality, Evaluation, and Psychological Treatment, Universidad de Málaga, Málaga, Spain
  • 9Department of Psychology, University Loyola Andalucía, Seville, Spain
  • 10Department of Biostatistics, University of Granada, Granada, Spain
  • 11Primary Care Center of Marquesado, Área Nordeste de Granada, Granada, Spain
  • 12Primary Care Center of San José, Linares, Jaén, Spain
  • 13Primary Care Center of Federico del Castillo, Jaén, Spain
  • 14Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, St Boi de Llobregat, Spain
  • 15Primary Care Center of El Palo, Málaga, Spain
  • 16Department of Preventive Medicine, Public Health and Psychiatry, University of Málaga, Málaga, Spain
JAMA Psychiatry. 2017;74(10):1021-1029. doi:10.1001/jamapsychiatry.2017.2509
Key Points

Question  Are psychological and/or educational preventive interventions for anxiety effective in varied populations?

Findings  This systematic review and meta-analysis of 29 randomized clinical trials (36 comparisons) including 10 430 patients from 11 countries on 4 continents showed a small, but statistically significant, effect size of psychological and/or educational preventive interventions for anxiety. Sensitivity analyses and adjustment for publication bias confirmed that the results were robust.

Meaning  Although the benefit of psychological and/or educational interventions in the prevention of anxiety is modest, the results suggest that psychological and/or educational preventive interventions for anxiety should be further developed and implemented.


Importance  To our knowledge, no systematic reviews or meta-analyses have been conducted to assess the effectiveness of preventive psychological and/or educational interventions for anxiety in varied populations.

Objective  To evaluate the effectiveness of preventive psychological and/or educational interventions for anxiety in varied population types.

Data Sources  A systematic review and meta-analysis was conducted based on literature searches of MEDLINE, PsycINFO, Web of Science, EMBASE, OpenGrey, Cochrane Central Register of Controlled Trials, and other sources from inception to March 7, 2017.

Study Selection  A search was performed of randomized clinical trials assessing the effectiveness of preventive psychological and/or educational interventions for anxiety in varying populations free of anxiety at baseline as measured using validated instruments. There was no setting or language restriction. Eligibility criteria assessment was conducted by 2 of us.

Data Extraction and Synthesis  Data extraction and assessment of risk of bias (Cochrane Collaboration’s tool) were performed by 2 of us. Pooled standardized mean differences (SMDs) were calculated using random-effect models. Heterogeneity was explored by random-effects meta-regression.

Main Outcomes and Measures  Incidence of new cases of anxiety disorders or reduction of anxiety symptoms as measured by validated instruments.

Results  Of the 3273 abstracts reviewed, 131 were selected for full-text review, and 29 met the inclusion criteria, representing 10 430 patients from 11 countries on 4 continents. Meta-analysis calculations were based on 36 comparisons. The pooled SMD was −0.31 (95% CI, −0.40 to −0.21; P < .001) and heterogeneity was substantial (I2 = 61.1%; 95% CI, 44% to 73%). There was evidence of publication bias, but the effect size barely varied after adjustment (SMD, −0.27; 95% CI, −0.37 to −0.17; P < .001). Sensitivity analyses confirmed the robustness of effect size results. A meta-regression including 5 variables explained 99.6% of between-study variability, revealing an association between higher SMD, waiting list (comparator) (β = −0.33 [95% CI, −0.55 to −0.11]; P = .005) and a lower sample size (lg) (β = 0.15 [95% CI, 0.06 to 0.23]; P = .001). No association was observed with risk of bias, family physician providing intervention, and use of standardized interviews as outcomes.

Conclusions and Relevance  Psychological and/or educational interventions had a small but statistically significant benefit for anxiety prevention in all populations evaluated. Although more studies with larger samples and active comparators are needed, these findings suggest that anxiety prevention programs should be further developed and implemented.