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Table of Contents
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 71-74

Effectiveness of cognitive behavioral therapy on generalized anxiety disorder in college and graduate students: Literature review

Department of Physiotherapy, Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission19-Oct-2019
Date of Decision25-Nov-2019
Date of Acceptance30-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Nandakumar
Department of Physiotherapy, Ramaiah Medical College, New BEL Road, MSIRT Nagar, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_75_19

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There has been a significant increase in the incidence of mental disorders in young adults and often been neglected due to social stigma. However, due to the increased awareness, there has been increased demand for services and counseling centers which often have long waiting lists. Due to the limited resources available, the effectiveness of the therapy method to provide “best” available treatment is needed. In this literature review, the effectiveness of cognitive behavioral therapy (CBT) on generalized anxiety disorder in college and graduate students, a systematic review and meta-analysis of randomized controlled trials (RCTs) and two RCTs are included. The selected studies suggested significant improvement in general anxiety disorder in college or graduate students by providing CBT. The literature reviewed indicates improvement in generalized anxiety in graduate students' population by CBT, limited studies have been conducted specifically to this population, and since young adults constitute majority of the world population suggesting economic growth, there is a need for more research on the effectiveness of the therapy in this specific population per se.

Keywords: Cognitive behavioral therapy, College or graduate students, Generalized anxiety disorder

How to cite this article:
Donadkar S, Nandakumar. Effectiveness of cognitive behavioral therapy on generalized anxiety disorder in college and graduate students: Literature review. Indian J Phys Ther Res 2019;1:71-4

How to cite this URL:
Donadkar S, Nandakumar. Effectiveness of cognitive behavioral therapy on generalized anxiety disorder in college and graduate students: Literature review. Indian J Phys Ther Res [serial online] 2019 [cited 2023 Oct 1];1:71-4. Available from: https://www.ijptr.org/text.asp?2019/1/2/71/273729

  Introduction Top

Mental disorders are often neglected because of its nonspecificity in diagnosis, indefinite clinical presentations, long-term and varied treatment, various myths, and belief systems associated with the social stigma.[1] Depression and anxiety are among the most frequent mental disorders. Mental disorders have received increasing global attention because of their negative effects on working ability and the performance of people, as the core of the health system in all countries.[2] The etiology of generalized anxiety disorder (GAD) is not well understood. There are several theoretical models, each with varying degrees of empirical support. An underlying theme to several models is the dysregulation of worry. Emerging evidence suggests that patients with GAD may experience persistent activation of areas of the brain associated with mental activity and introspective thinking following worry-inducing stimuli.[3] Patients with GAD generally present with excessive anxiety about ordinary, day-to-day situations. The anxiety is intrusive, causes distress or functional impairment, and often encompasses multiple domains (e.g., finances, work, and health). The anxiety is often associated with physical symptoms, such as sleep disturbance, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches.[4]

GAD is one of the most common psychiatric disorders among college students, with 7% prevalence in 14,175 students across 26 college campuses and universities in America.[5] Onset occurs at approximately 20 years of age for most individuals.[6] These numbers reflect the difficulties young people might experience in entering higher education, including academic pressure, managing social demands and developmental changes that might give rise to mental health difficulties.[7] Counseling center directors report that there has been an increase in recent years in the number of students seeking help for serious psychological problems, and current mental health resources on campus often do not adequately address the needs of the student population.[8] Due to the increased demand for services, counseling centers often have long waiting lists.[9] In addition, many students with mental health issues do not seek services; the primary barriers include stigma, lack of time, and scheduling concerns.[10]

CBT is defined as a therapy in which the therapist focuses on the impact that a patient's present dysfunctional thoughts affect current behavior and functioning.[11] CBT helps patients or clients to evaluate, challenge, and modify their dysfunctional beliefs, in part to promote behavioral change and improve their functioning. The origins of CBT can be traced back in part to the theories of early researchers like B. F. Skinner and Joseph Wolpe, who pioneered the behavioral therapy movement in the 1950s. Behavioral therapy proposes that changing behaviors leads to change in emotions and cognitions such as appraisals. Since its introduction, behavioral therapy has evolved to include cognitive psychotherapy, pioneered by the early work of psychologists such as Beck et al.[12] Therapists use a psychoeducational approach, and teach patients new ways to cope with stressful situations; however, CBT therapists emphasize homework assignments and outside-of-session activities, through the method of collaborative empiricism, to directly experience the value of proposed changes within therapy sessions.

  Need for the Literature Review Top

Over the past years, many different rehabilitation techniques have been put forward to alleviate, reduce, or remediate GAD. The need for literature review on the effect of cognitive behavioral therapy (CBT) on GAD in college students is to know the effectiveness of the therapy method to provide “best” available treatment. It allows us to be updated with the state of research in the field of anxiety disorder and the challenging findings of other research studies. The literature review will determine the need to replicate a prior study in different settings, study populations, and sample sizes to check the effectiveness of the therapy in different scenarios. As we explore the effect of CBT, we get a perspective on different areas that it can be applied. Since there have been conflicting opinions previously over the therapy effects, literature review is required to resolve the conflicts among seemingly contradictory previous studies.

  Methodology Top

Research question - does CBT symptomatically improve GAD in college and graduate students?

Inclusion criteria

  • Articles in the English language
  • Articles with GAD in college or graduate students
  • CBT as a compulsory intervention
  • GAD as one of the major components being studied
  • Articles published after 2014.

Exclusion criteria

  • Article evaluating participants who had undergone previous treatment for the same
  • Articles that used qualitative methodology
  • Articles used an observational design.


  • The topic was selected and framed
  • Research question was formed
  • The inclusion and exclusion criteria were decided
  • Search engines such as Google Scholar, PubMed, and Pedro were used
  • Keywords such as CBT, GAD, college or graduate students
  • The articles which met the study topic were chosen for this study.

The literature review of three articles that were found matching the above-mentioned criteria are considered and elaborated below:

  • Palacios et al. conducted an open, nonrandomized feasibility trial published in December 2018. The objective of this study was to assess feasibility, acceptability, effectiveness, and satisfaction of a supported iCBT intervention offering three programs on depression, anxiety, and stress to university students. Participants were recruited from three counseling centers at a large Midwestern University in the United States. Those agreeing to take part chose 1 of 3 iCBT programs – space from depression, space from Anxiety, or space from stress – all comprised eight modules of media-rich interactive content. Participants were supported throughout the trial by a trained professional. The Patient Health Questionnaire 9 (PHQ-9), GAD-7 questionnaire and stress subscale of the Depression Anxiety and Stress Scale-21 were completed at baseline, 8 weeks, and 3-month follow-up. Satisfaction with treatment (SAT) questionnaire was completed at 8 weeks, and qualitative interviews were completed by a subsample of participants at 3 months. A total of 102 participants were recruited, with 52 choosing space from anxiety, 31 choosing space from depression, and 19 choosing space from stress. Mixed-effects models showed a significant decrease in symptoms of depression, anxiety, and stress over time across all three programs. The major decrease in PHQ-9 scores at 8 weeks was among participants who chose the space from depression and space from stress program at 3 months. The major decrease in GAD-7 scores was among those who chose the Space from anxiety program. Most (37/53, 69%) participants found that the program was helpful or very helpful and liked the convenience and flexibility of the intervention. Qualitative interviews (n = 14) indicated the intervention met students' expectations, and they saw it as a valuable complement to face-to-face treatment [13]
  • Huang et al. conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), published in September 2018, with an objective to conduct a systematic review and meta-analysis of RCTs examining interventions for Common Mental Health Problems among university and college students and to estimate their postintervention effect size (ES), as well as follow-up ES, for depression, anxiety disorder, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) separately. Meta-analytic procedures were conducted in accordance with PRISMA guidelines. Studies meeting the following inclusion criteria were selected for the meta-analysis: (1) target population were university or college students; (2) health conditions intervened included: depression, anxiety disorder, OCD or PTSD; (3) RCT design; (4) control was no treatment, waitlist or placebo control; (5) outcomes (depression, anxiety, OCD, PTSD) were assessed with a validated instrument; (6) a minimum of 10 participants in each experimental group; (7) being written in English and published between January 2000 and May 2018. Reviewed 7768 abstracts from which 331 full-text articles were reviewed and 51 RCTs were included in the analysis. Moderate ESs for both depression (Hedges' g = −0.60) and anxiety disorder (Hedges' g = −0.48) were noted. For interventions with high number of papers, subgroup analysis was performed, and it was observed that CBT and mindfulness-based interventions were effective for both depression and GAD, and attention/perception modification was effective for GAD; other interventions (i.e., art, exercise, and peer support) had the highest ES for both depression and GAD among university and college students [14]
  • Fitzpatrick et al. conducted a randomized control trial, with an objective to determine the feasibility, acceptability, and preliminary efficacy of a fully automated conversational agent to deliver a self-help program for college students who self-identify as having symptoms of anxiety and depression. An unblinded trial, 70 individuals age 18–28 years were recruited online from a university community social media site and were randomized to receive either 2 weeks (up to 20 sessions) of self-help content derived from CBT principles in a conversational format with a text-based conversational agent (Woebot) in an instant messenger app (n = 34) or were sent a link to the National Institute of Mental Health ebook on depression among college students as an information-only control group (n = 36). All participants completed Web-based versions of the 9-item PHQ-9, the 7-item GAD-7, and the positive and negative affect scale at baseline and 2–3 weeks later (T2). No significant differences existed between the groups at baseline, and 83% (58/70) of participants provided data at T2 (17% attrition). Intent-to-treat univariate analysis of covariance revealed a significant group difference on depression such that those in the Woebot group significantly showed reduction in their symptoms of depression over the study period as measured by the PHQ-9 while those in the information control group did not. In an analysis of completers, participants in both groups significantly reduced anxiety as measured by the GAD-7.[15]

  Discussion Top

In our literature review, all the three articles selected, suggested a significant improvement in general anxiety disorder in college or graduate students by providing CBT. The study conducted by Fitzpatrick et al. was inconsequential since the results were to be viewed with caution of limitations such as the limited number of participants received a relatively short intervention due to issue of feasibility, and no follow-up data were available to assess whether gains were sustained. The small number of participants meant that a formal mediator analysis was not possible, hence were not able to formally test a theorized relationship between engagement and outcome. However, the effectiveness of CBT in Woebot group significantly reduced their symptoms of depression over the study period. The nonrandomized trial conducted by Palacios et al. the iCBT programs tested in the study appeared to be feasible, acceptable, and effective in a university environment. Participants described the benefits of having a flexible, supported Web-based intervention available on campus, but it lacked a control group and follow-up data on a sizable portion of the initial sample. Without a control group, we cannot be sure that decrease in symptoms were because of the intervention rather than the natural course of symptoms over time. A systematic review and meta-analysis of randomized control trials conducted by Huang et al. exhibited moderate intervention effects of CBT and mindfulness for both depression and anxiety among college and university students. Other interventions, i.e., art, exercise, peer support, etc., had the highest ES for both depression and GAD.

  Conclusion Top

After going through above literature, a conclusion is drawn that even though the literature reviewed indicates improvement in generalized anxiety in graduate students' population by CBT, limited studies have been conducted specifically to this population and since young adults constitute majority of the world population suggesting economic growth, there is a need for more research on the effectiveness of the therapy in this specific population per se. Doing so will help plan treatment strategies, which will have a profound impact on the quality of lives of the students with anxiety disorder and will enable them to cope with their daily living activities effectively.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kishore J. National Health Programs of India. 11th ed. New Delhi: Century Publications; 2014.  Back to cited text no. 1
Mao Y, Zhang N, Liu J, Zhu B, He R, Wang X. A systematic review of depression and anxiety in medical students in China. BMC Med Educ 2019;19:327.  Back to cited text no. 2
Paulesu E, Sambugaro E, Torti T, Danelli L, Ferri F, Scialfa G, et al. Neural correlates of worry in generalized anxiety disorder and in normal controls: A functional MRI study. Psychol Med 2010;40:117-24.  Back to cited text no. 3
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.  Back to cited text no. 4
Eisenberg D, Hunt J, Speer N. Mental health in American colleges and universities: Variation across student subgroups and across campuses. J Nerv Ment Dis 2013;201:60-7.  Back to cited text no. 5
Brown TA, O'Leary TA, Barlow DH. Generalized anxiety disorder. In: Barlow DH, editor. Clinical Handbook of Psychological Disorders: A Step by Step Treatment Manual. 3rd ed. New York: Guilford Press; 2001. p. 154-208.  Back to cited text no. 6
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593-602.  Back to cited text no. 7
Gallagher R. The International Association of Counseling Services, Inc., National Survey of College Counseling Centers; 2014. Available from: http://d-scholarship.pitt.edu/28178/1/survey_2014.pdf. [Last accessed on 2019 Nov 11].  Back to cited text no. 8
Eisenberg D, Golberstein E, Gollust SE. Help-seeking and access to mental health care in a university student population. Med Care 2007;45:594-601.  Back to cited text no. 9
Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: A systematic review. BMC Psychiatry 2010;10:113.  Back to cited text no. 10
Kaczkurkin AN, Foa EB. Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. Dialogues Clin Neurosci 2015;17:337-46.  Back to cited text no. 11
Beck AT, Rush AJ, Shaw BF, Emery G. The Cognitive Therapy of Depression. New York (NY): Guilford Press; 1979.  Back to cited text no. 12
Palacios JE, Richards D, Palmer R, Coudray C, Hofmann SG, Palmieri PA, et al. Supported internet-delivered cognitive behavioral therapy programs for depression, anxiety, and stress in university students: Open, non-randomised trial of acceptability, effectiveness, and satisfaction. JMIR Ment Health 2018;5:e11467.  Back to cited text no. 13
Huang J, Nigatu YT, Smail-Crevier R, Zhang X, Wang J. Interventions for common mental health problems among university and college students: A systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res 2018;107:1-0.  Back to cited text no. 14
Fitzpatrick KK, Darcy A, Vierhile M. Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (Woebot): A randomized controlled trial. JMIR Ment Health 2017;4:e19.  Back to cited text no. 15


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