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Psychological treatment for anxiety in people with traumatic brain injury

  1. Cheryl Soo1,*,
  2. Robyn L Tate2

Editorial Group: Cochrane Injuries Group

Published Online: 18 JUL 2007

DOI: 10.1002/14651858.CD005239.pub2

How to Cite

Soo C, Tate RL. Psychological treatment for anxiety in people with traumatic brain injury. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005239. DOI: 10.1002/14651858.CD005239.pub2.

Author Information

  1. 1

    University of Sydney and Royal Rehabilitation Centre Sydney, Rehabilitation Studies Unit, Ryde, New South Wales, Australia

  2. 2

    The University of Sydney, Rehabilitation Studies Unit, Northern Clinical School, Sydney Medical School, Ryde, New South Wales, Australia

*Cheryl Soo, Rehabilitation Studies Unit, University of Sydney and Royal Rehabilitation Centre Sydney, PO Box 6, Ryde, New South Wales, 1680, Australia.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 JUL 2007


Characteristics of included studies [ordered by study ID]

MethodsRCT comparing CBT and SC.
Follow up: post-treatment and six months.

Participants24 participants with mild TBI (8 males, 16 females). Acute Stress Disorder criteria met.

Interventions1. Cognitive Behavioural Therapy (CBT, n = 12).
(CBT: education, progressive muscle training, imaginal exposure to traumatic memories, cognitive restructuring, and graded in vivo exposure to avoided situation).

2. Supportive counselling (SC; n = 12).
(SC: education about trauma and general problem solving skills).
- Each group received five 90 min individually administered weekly sessions.
- Post-treatment and six-month follow ups.

Clinician administered PTSD scale (CAPS), Impact of Event Scale (IES), Beck Anxiety Inventory (BAI).

Beck Depression Inventory (BDI).


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

MethodsRCT comparing IPR and no psychological intervention.
Follow up: post-treatment and one month (however, 1-month follow-up data was not analysed due to small sample size).

Participants16 participants with TBI (13 males, three females).
Severity of TBI not indicated.

Interventions1. Interpersonal process recall (IPR, n = 8)
IPR session consisted of 10-15 min videotaped interaction between the participant and a staff member. The next 45-50 min of the session was spent reviewing and processing the tape. This included feedback to the participant as to why and how skills were deficit and mutually developing more adaptive and/or appropriate ways of interaction.

2. Controls, individual sessions involving no feedback with regard to interpersonal functioning (n = 8).
- Each group met for 20 hours (one hour per day).
- Post-treatment only.
(one month follow-up data were not analysed due to small n).

State-Trait Anxiety Inventory (STAI).

Tennessee Self-concept Scale (TSCS), Interpersonal Communication Inventory (ICI), Interpersonal Relationship Rating Scale (IRRS), independent observer report scale, video tape analysis of interpersonal interaction.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

MethodsRCT comparing CBT/neurorehabilitation (NR) and no psychological intervention.
Follow up: post-treatment, one month and three month.

Participants20 participants with mild to moderate TBI (nine males, 11 females).

Interventions1. Combination of CBT and NR (n = 11).
CBT component focused on helping the participant: (1) increase the use of effective coping behaviours, (2) reduce levels of stress, (3) teach skills for preventing relapse, and (4) cope with feelings of loss related to decreased cognitive and physical functioning.
NR component focused on remediation of attention, information processing and memory difficulties. Organisation and problem solving skills were also addressed.

2. No psychological intervention controls (n = 9).
Controls were placed on a waitlist for treatment .
- Treatment group met three times weekly for 11 weeks.

- Control group met with principal investigator for 45 minutes or spoke on the telephone 2 or 3 times over the course of 11 weeks

- Follow up at post-intervention, 1 month and 3 months.

Anxiety subscale of the Symptoms Checklist -90R (SCL-90R).

Global Severity Index of the SCL - 90R, Depression subscale of the SCL - 90R, Somatization subscale of the SCL -90R, Paced Auditory Serial Addition Test (PASAT), Rey Auditory Verbal Learning Test (RAVLT), Attention Questionnaire (AQ), Assessment of Client Functioning Inventory (ACFI), Coping Response Inventory (CRI), Community Integration Questionnaire (CIQ).


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ackerman 2004Not RCT.

Adelbratt 2000Not TBI.

Bedard 2003Not RCT.

Drummond 1988Not RCT.

Gurr 2001Not RCT.

Hodgson 2005Not TBI.

Holland 1999Not RCT.

Johnson 1987aNot RCT.

Johnson 1987bNot RCT.

King 2002Not RCT.

Ko 1997Not RCT.

Koder 1998Not TBI.

Lysaght 1990Not RCT.

Mateer 2005Not RCT.

McGrath 1997Not RCT.

McGrath 1999Not TBI.

McMillian 1991Not RCT.

McMillian 1996Not RCT.

McNeil 1996Not RCT.

Suhr 1999Not TBI.

Takano 2000Not RCT.

Williams 2003aNot RCT.

Williams 2003bNot RCT.

Youngson 1994Not RCT.

Zencius 1990Not RCT.

Table 1. Characteristics of CBT and SC groups (Bryant 2003)


Age29.42 (13.93)33.00 (14.37)

Sex4 males, 8 females4 males, 8 females

Prior psychiatric diagnosis1 major depression, 1 bulimia nervosa1 major depression, 1 attention defict disorder

Pre-treatment Acute Stress Disorder Interview65.42 (10.60)62.42 (14.58)

Pre-treatment IES (Intrusion subscale)27.83 (5.31)24.50 (8.20)

Pre-treatment IES (Avoidance subscale)20.58 (5.02)16.25 (7.24)

Pre-treatment BAI25.58 (11.43)26.83 (13.90)

Table 2. Characteristics of IPR and control groups (Helffenstein 1982)

CharacteristicsIPR groupControl groupNotes

AgeInformation not providedInformation not provided17 to 35 years across both groups

SexInformation not providedInformation not provided13 males, 3 females across both groups

Pre-treatment STAI scoreInformation not providedInformation not providedReviewers contacted authors of this paper requesting mean age, sex and pre-treatment STAI scores across groups, however, no response was provided.

Table 3. Characteristics of CBT/NR and control groups (Tiersky 2005)

CharacteristicsCBT/NRControl group

Age47.55 (11.78)46.00 (9.35)

Sex5 females, 6 males6 females, 3 males

Pre-treatment SCL-90R anxiety subscale0.921 (0.85)1.39 (0.70)

Table 4. Methodology quality assessed by the PEDro scale

CriterionBryant 2003Helffenstein 1982Tiersky 2005

1. Eligibility criteria were specifiedYYY

2. Participants were randomly allocated to interventions (in a crossover study, subjects were randomly allocated an order in which treatments were received)YYY

3. Allocation was concealedNNY

4. The intervention groups were similar at baseline regarding the key outcome measure(s) and most important prognostic indicatorsYNY

5. There was blinding of all participantsNNN

6. There was blinding of all therapists who administered the therapyNNN

7. There was blinding of all assessors who measured at least one key outcomeYYY

8. Measures of at least one key outcome were obtained from more than 85% of the participants initially allocated to groupsYYN

9. All participants for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by "intention to treat"NNN

10. The results of between- intervention group statistical comparisons are reported for at least one key outcomeYNY

11. The study provides both point measures and measures of variability for at least one key outcomeYNY

Total (Items 2-11)6/103/106/10

Table 5. Summary of timing of assessments

StudyTime 1Time 2Time 3Time 4Comments

Bryant 2003baselinepost-treatment6-month follow up

Helffenstein 1982baselinepost-treatment1-month follow upData from 1-month follow up were not analysed due to small sample (n=6)

Tiersky 2005baselinepost-treatment1-month follow up3-month follow upPost-treatment, 1-month and 3-month follow-up assessments were combined and an averaged score was used as outcome score

Table 6. Summary of secondary outcome variables

StudyAffective/selfNeuropsychologicalPsychosocialDaily funct/participMed/service usageTreatment compliance

Bryant 2003BDIN/AN/AN/AN/ANo dropouts

Helffenstein 1982TSCSN/AICI, IRRS, independent observer report scale of interpersonal interaction, videotape analysis of interpersonal interactionN/AN/ANo dropouts

Tiersky 2005SCL-90R Global Severity Index, SCL-90R depression subscale, CRIPASAT, RAVLT, ACFI, AQN/ACIQN/A3 dropouts from treatment group, 6 from the control group