# Translated Article: Metacognitive Therapy vs. Cognitive Behavioral Therapy in Adults with Generalized Anxiety Disorder: A 9-Year Follow-Up Study

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- Last updated: 2026-08-15
- Page title: Translated Article: Metacognitive Therapy vs. Cognitive Behavioral Therapy in Adults with Generalized Anxiety Disorder: A 9-Year Follow-Up Study | Assoc. Prof. Dr. Alişan Burak Yaşar

> Metacognitive therapy and Cognitive Behavioral Therapy are effective and safe approaches for many psychiatric disorders. In addition to depression, many co

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# Translated Article: Metacognitive Therapy vs. Cognitive Behavioral Therapy in Adults with Generalized Anxiety Disorder: A 9-Year Follow-Up Study

October 22, 2021Writings and Talks

[Görsel: Translated Article: Metacognitive Therapy vs. Cognitive Behavioral Therapy in Adults with Generalized Anxiety Disorder: A 9-Year Follow-Up Study]

Metacognitive therapy and Cognitive Behavioral Therapy are effective and safe approaches for many psychiatric disorders. In addition to depression, these approaches are actively used for many anxiety disorders, including Generalized Anxiety Disorder. Below, you can read an article comparing the effectiveness of Cognitive Behavioral Therapy and Metacognitive Therapy, translated and summarized by psychologist Derin Kubilay.

**Metacognitive Therapy vs. Cognitive Behavioral Therapy in Adults with Generalized Anxiety Disorder: A 9-Year Follow-Up Study**

1. **INTRODUCTION**

Generalized anxiety disorder (GAD) is a common problem that follows a relapsing course and has a poor prognosis if left untreated. Cognitive behavioral therapy (CBT) and metacognitive therapy (MCT) are effective treatments. Three randomized controlled trials comparing CBT and MCT for GAD all found MCT to be more effective. One of these studies compared MCT with relaxation exercises, another with the intolerance-of-uncertainty model of CBT, and the third with a general CBT approach. In each study, MCT produced superior outcomes on the primary measures and the vast majority of secondary measures. MCT's superiority was also observed at follow-ups ranging from 6 to 24 months. One study conducted a 30-month follow-up and found that both MCT and CBT maintained clients' gains during this period; however, MCT was observed to produce better outcomes.

Little is known about the durability of MCT treatment effects beyond 30 months. One study investigated whether cognitive behavioral therapy influenced the long-term (8–14 years) outcome of GAD. However, the study had a participation rate of 30–55%, a well-known challenge in long-term follow-up studies. Nevertheless, results from those who participated suggested that the treatment effects persisted, with 30–40% of clients recovering.

In this study, we aimed to evaluate the effects observed at long-term follow-up (8–11 years). In this study, MCT was associated with significantly higher recovery rates (65%) than CBT (38%). The differences favoring MCT were maintained at the 2-year follow-up. We sought to investigate these clients' recovery, relapse, symptom changes, and diagnostic status.

The main hypothesis was that clients treated with MCT would continue to show greater recovery over the long term than those treated with CBT. This hypothesis was based on initial response rates in the original trial, promising long-term outcomes of MCT for depression, and a meta-analysis suggesting that MCT may be more effective than CBT.

**2. METHOD**

**Participants and Procedure**

In this study, 28 clients were randomly assigned to CBT and 32 to the MCT group. At the 2-year follow-up, four participants were missing, two from each condition (total N = 56, retention rate 93.3%). At the 9-year follow-up, a total of 39 clients remained: 17 from the CBT condition and 22 (68.8%) from the MCT condition (an overall participation rate of 65%). We were unable to reach 15 (25%) clients, five clients (8.3%) declined to participate, and one had died. Of the 39 participants, 32 completed both the questionnaires and interviews, five completed only the questionnaires, and two completed only the interviews. The sample's current mean age was 48.06 (11.70), with no significant age difference between the two conditions (p = .52). There was no gender difference (p = .36), and 66.7% were women. Between 8 and 11 years had passed since the clients completed treatment, with a mean of 9.1 (SD = 1.2) years. Interviews took place between January 2018 and June 2019.

Six clinical psychologists trained in both CBT and MCT delivered treatment based on published manuals, with a maximum of 12 weekly 60-minute sessions. Three therapists initially delivered CBT, while the other three delivered MCT during the first half of the trial before switching conditions. CBT consisted of 4 modules: identifying early cues of anxiety and worry, applying relaxation in response to these cues, mentally rehearsing coping strategies through self-control desensitization, and CBT for catastrophic beliefs and worry. MCT consisted of 5 modules: case formulation and socialization, modifying beliefs about the uncontrollability and danger of worry, challenging positive beliefs about the benefits and advantages of worry, implementing alternative coping strategies, and finally, relapse prevention.

Participants were adults who completed an informed consent form and were diagnosed with GAD. The Anxiety Disorders Interview Schedule for DSM was used for the diagnostic interview. For the follow-up interviews, the assessment team did not use the entire interview but selected sections based on the clients' pretreatment diagnoses (Figure 1).

- **Measures**

The Penn State Worry Questionnaire was selected as the primary outcome measure. This scale contains 16 rated items, with higher scores indicating higher levels of worry. The initial study used a range of secondary outcomes, including the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and measures of state anxiety and psychological processes. In this study, we restricted the secondary measures to reduce the burden on clients and facilitate completion.

The BAI is a 21-item self-report inventory assessing anxiety symptoms. The BAI was included as a secondary outcome measure. The BDI is a 21-item self-report depression inventory. The BDI was included as a covariate in the repeated-measures analyses.

- **Statistics**

Of the 39 participants, 32 completed both the questionnaires and interviews. Initial statistical tests compared participants with those who had dropped out, using pretreatment, posttreatment, and 2-year follow-up scores. Chi-square tests and t-tests were used to compare these two groups. A split-plot repeated-measures ANOVA was used to investigate treatment and possible time × condition effects on the PSWQ and BAI (with BDI included as a covariate). Analyses were conducted using complete cases only. Descriptive statistics were used for recovery and relapse rates and diagnostic status.

**3. Results**

- - **Preliminary Analyses**

Clients who participated in the follow-up assessment were compared with those who did not. We found no significant differences between these two groups on the PSWQ and BAI at pretreatment, posttreatment, or the 2-year follow-up (see Table 1). There was also no significant difference between the two groups in posttreatment recovery rates. Furthermore, we found no significant differences between the two groups in age, gender, or number of diagnoses.

- **Symptom Changes**

The results showed a clear effect of time for both measures. Symptoms decreased significantly from pretreatment to posttreatment, with no significant change during the follow-up period. There were time × condition effects for worry and anxiety symptoms, with greater improvement in the MCT condition. BDI was a significant covariate in the PSWQ analysis (p=.031), but not for BAI (p = .204).

- **Recovery and Relapse Rates**

Using complete-case data, recovery rates at the 9-year follow-up were 57.1% for MCT and 37.5% for CBT, while clinical improvement rates were 23.8% for MCT and 31.3% for CBT. At pretreatment, all clients scored above 47 on the PSWQ. Recovery rates were similar at posttreatment and follow-up. However, some maintained their recovery status, others recovered, and some relapsed (14% relapsed following MCT and 19% following CBT).

- **Diagnostic Status at Follow-Up**

Five clients who participated in the follow-up study were not assessed diagnostically because they responded only to the questionnaires. In the CBT group, 23.1% were diagnosed with GAD, compared with 9.5% in the MCT group, where the rate was 9.5%. In the CBT group, 69.2% did not meet the criteria for any diagnosis, compared with 81.0% in the MCT group. Two clients were diagnosed with recurrent depression (one moderate and one in remission), and one with social anxiety disorder. In addition, two clients had comorbid disorders (dysthymia and fibromyalgia).

**4. Discussion**

This study was conducted to investigate the potential long-term effects of CBT and MCT for clients diagnosed with GAD. The participation rate was approximately 65% of the original sample. The long-term recovery rate was 38% for CBT and higher, at 57%, for MCT. Clients in the MCT condition showed greater improvement in both worry and anxiety. Following MCT, 43% maintained their recovery status, and a further 14% recovered. Following CBT, the sustained recovery rate was 13%, with a further 25% recovering.

The follow-up participation rate of 65% is better than in other studies, but this figure means that the overall sample is small, creating uncertainty about the reliability of the findings. Nevertheless, we found no significant differences between participants and nonparticipants on any clinical or demographic variable. This suggests that the follow-up sample is likely to be representative of the sample that completed treatment.

At the 9-year follow-up, MCT's advantage over CBT observed at posttreatment and medium-term follow-up was maintained. Furthermore, this difference appears to have increased when considering the proportions who maintained their recovery status since posttreatment. The difference in outcomes at long-term follow-up may reflect differing degrees of change in the underlying psychological mechanisms. While CBT focuses on developing relaxation skills and challenging the content of worry, MCT has a very different focus. In MCT, the therapist works on challenging beliefs about worry rather than the content of worry and helps the client discover how to regulate worry processes in a way that emphasizes the significance of thoughts. Thus, the better outcome in MCT may be due to greater changes in dysfunctional metacognitions, which form the basis of long-term mental regulation.

The study of MCT and intolerance-of-uncertainty therapy with a 30-month follow-up reported recovery rates of 75% for MCT and 50% for IUT. However, that study used different criteria for recovery. Using the same criteria, the present study has a recovery rate of 67% for MCT and 44% for CBT, and this consistency supports the superiority of the effects observed with MCT. Taken together, the MCT versus IUT trial, other MCT studies, and the current results suggest that MCT should be considered an effective treatment for people with GAD and that its treatment effects are likely to persist over the long term.

The current results are important because they are the first to report a long-term follow-up comparison of MCT and CBT. However, the analysis has major limitations. First, the original sample size, combined with the modest follow-up participation rate, means that the follow-up sample is small and the results may not be reliable. Second, the assessment team did not use the full-length diagnostic interview (or SCID-II interviews), but instead used selected sections of the interview based on clients' pretreatment diagnoses. Previous research suggests that GAD may be replaced by somatization disorders. The current study therefore leaves unanswered the question of how many participants developed new disorders.

In conclusion, this study showed that both CBT and MCT are associated with long-term effects and that the superiority of MCT observed after treatment may become more pronounced at long-term follow-up. Although MCT clients appeared to show greater and more stable recovery than those receiving CBT, this should be confirmed in future studies with larger sample sizes. These results contribute to the growing body of evidence showing that MCT and CBT differ in their effectiveness for GAD and other disorders.

REFERENCE: Solem, S.,Wells, A., Kennair, L. E.O., Hagen, R., Nordahl, H., & Hjemdal,O. (2021). Metacognitive therapy versus cognitive–behavioral therapy in adults with generalized anxiety disorder: A 9-year follow-up study. *Brain and Behavior*, 1–7. [https://doi.org/10.1002/brb3.2358](https://doi.org/10.1002/brb3.2358)

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