Exposure-based cognitive behavioral therapy delivered by assertive community treatment teams for severe mental...

Individuals with severe mental illnesses (SMIs) experience anxiety that impairs functioning and quality of life. This cluster randomized trial evaluated exposure-based cognitive behavioral therapy (ebCBT) integrated into assertive community treatment (ACT) teams to reduce anxiety.

Fifteen ACT teams were allocated to ebCBT + ACT (k = 8, n = 50) or ACT-only (k = 7, n = 43). The intervention followed four steps: situation identification, four-component analysis (behavior, cognition, emotion, physical symptoms), psychoeducation, and graded exposure. Staff received 50 h training and bimonthly supervision over 12 months. Co-primary outcomes were trait and social anxiety; secondary outcomes were psychiatric symptoms, functioning, quality of life, and recovery.

The ebCBT + ACT group showed significant improvements in State-Trait Anxiety Inventory-Trait scores at 12 months (AMD = -5.30, 95% CI = -8.71 to -1.90, p = 0.002, d = -0.64) and 18 months (AMD = -7.22, 95% CI = -12.1 to -2.34, p = 0.004, d = -0.60). Brief Fear of Negative Evaluation scores showed near-significant improvement at 18 months (AMD = -3.70, 95% CI = -7.44 to 0.04, p = 0.052, d = -0.40). Secondary outcomes, including global functioning, recovery, and quality of life, also improved. Cost-effectiveness analyses indicated favorable cost-effectiveness for anxiety outcomes.

Embedding ebCBT within ACT services may reduce anxiety-related fear and avoidance and enhance recovery-related outcomes in individuals with SMI. These findings support the feasibility and clinical value of integrating structured psychological interventions into intensive community-based outreach services.