International Review of Psychiatry, December 2007; 19(6): 647–654

Prevention of anxiety disorders

O. JOSEPH BIENVENU & GOLDA S. GINSBURG

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

(Received 4 December 2006; accepted 15 April 2007)

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Abstract
Anxiety disorders are very common and burdensome conditions with early onsets. Thus, there has recently been increasing
interest in preventing these illnesses. In this article we review recent prevention studies targeting populations at varying levels
of risk and conclude that prevention using cognitive-behavioural interventions is promising, though establishing longer-term
effects and the cost-effectiveness of such interventions are important next steps for the field. We discuss conceptual and
practical issues with regard to prevention of anxiety disorders and note that theory-based models of prevention which are
based on identified risk and protective factors, address the optimal timing of intervention delivery, and articulate specific
mechanisms of action are greatly needed.

Introduction disorders are also among the most common psychia-

For personal use only.

tric disorders in school-aged children and adoles-

In this article, we provide an overview of considera-
tions related to prevention of anxiety disorders in
children and adults. We do not attempt a systematic
review of the anxiety prevention literature; rather, we
focus on studies and concepts that illustrate trends in
this field. Specifically, we do not address studies
of prevention of single disorders (e.g., panic dis-
order) or prevention of anxiety disorders in specific
contexts (e.g., after trauma); we refer readers to
a recent extensive review that addresses these issues
(Feldner, Zvolensky, & Schmidt, 2004).
Why should we consider prevention of anxiety
disorders? Scope of the problem
Anxiety disorders are the most common mental
illnesses worldwide (Andrews, Henderson, & Hall,
2001; Demyttenaere et al., 2004; Wittchen & Jacobi,
2005). In the recent United States (US) National
Comorbidity Survey Replication (NCS-R), 18% of
general population participants (ages 18 and older)
met DSM-IV criteria for anxiety disorders in the last
year, and 29% met criteria over their lifetimes
(for comparison, the lifetime prevalence of mood
disorders was 21%; that of ‘impulse control dis-
orders’ was 25%; and that of substance use disorders
was 16%) (Kessler et al., 2005; Kessler, Chiu,
Merikangas, Demler, & Walters, 2005). Anxiety
cents, with lifetime prevalence rates averaging
between 8% and 27% (Costello, Egger, & Angold,
2005). In part because of their frequency, early onset,
and chronicity, anxiety disorders impose a substan-
tial burden on society (Greenberg et al., 1999;
Lepine, 2002). Though anxiety disorders as a
group tend to be less severe and costly than mood
disorders on an individual basis, anxiety disorders
may produce an even greater cost burden to
populations than mood disorders because of their
high prevalence (Smit et al., 2006). In addition,
some anxiety disorders, such as panic disorder
and obsessive-compulsive disorder (OCD), tend to
be particularly severe and disabling conditions
(Kessler et al., 2005; Murray & Lopez, 1996).
Adding to the burden of the anxiety disorders is
the fact that these conditions are highly comorbid
with each other and with other ‘internalizing’
conditions (e.g., depressive illnesses) (Kessler et al.,
2005; Krueger, 1999). Importantly, anxiety disorders
typically precede comorbid depressive illnesses tem-
porally; thus, it is possible that prevention or early
treatment of anxiety could prevent the development
of depression in some persons (Wittchen, Beesdo,
Bittner, & Goodwin, 2003).
An additional reason to consider some form of
preventive effort is that, despite available effective
treatments for anxiety disorders, many people do not

Correspondence: O. Joseph Bienvenu, 600 North Wolfe St – Meyer 115; Baltimore, MD 21287, USA. Tel: 410-614-9063; Fax: 410-614-5913;
E-mail: jbienven@jhmi.edu
ISSN 0954–0261 print/ISSN 1369–1627 online ß 2007 Informa UK Ltd.
DOI: 10.1080/09540260701797837
 648 O. J. Bienvenu & G. S. Ginsburg
receive them. For example, in the NCS-R, only 37%
of adults with recent DSM-IV anxiety disorders got
treatment in a healthcare setting, and only 42% used
any type of services (Wang et al., 2005). In that
study, only 34% of persons in treatment for recent
anxiety disorders got minimally adequate treatment.
Similarly, a recent study in a pediatric primary care
setting found that only 31% of anxious youth had
received counselling or medication treatment during
their lifetime (Chavira, Stein, Bailey, & Stein, 2004).
Notably, though, these studies were conducted in the
USA, lack of treatment for mental disorders is
certainly not specific to the USA (Andrews et al.,
2001; Demyttenaere et al., 2004). That is, it is likely
that this unmet treatment need is worldwide.
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When in the life course should we consider
prevention of anxiety disorders?
As mentioned above, anxiety disorders tend to have
early onsets. For example, in the NCS-R, the median
age at onset of anxiety disorders was 11 years
(compared to 20 years for substance use disorders,
and 30 years for mood disorders) (Kessler et al.,
2005). The distribution of onset ages is not
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completely uniform, of course, across the anxiety
disorders. In the NCS-R, the median ages of onset
of different anxiety disorders were as follows: specific
phobia and separation anxiety disorder, 7; social
phobia, 13; obsessive-compulsive disorder, 19; agor-
aphobia without panic, 20; post-traumatic stress
disorder, 23; panic disorder, 24; and generalized
anxiety disorder (GAD), 31. These findings are
broadly consistent with prior epidemiologic and
clinic-based reports, though the median age at
onset for GAD was a bit later than previous studies
(GAD onset is usually between the late teens and late
20s (Kessler, Keller, & Wittchen, 2001)). Overall,
research suggests that, in order to most reduce the
overall burden of anxiety disorders, prevention and
early treatment should occur early in the life course.
While most prevention scientists would agree that
offering preventive interventions early in the life
course makes good sense, deciding how early has yet
to be determined. For instance, because offspring of
anxious, compared to non-ill, parents are 7 times
more likely to develop an anxiety disorder (Beidel &
Turner, 1997), prevention of child anxiety disorders
aimed at anxious and expectant parents may have
the most impact. Alternatively, delivering preventive
interventions when children are very young
(e.g., ages 3–5) to those with early signs of anxiety
or behavioural inhibition may represent the ideal
stage of intervention (Rapee, Kennedy, Ingram,
Edwards, & Sweeney, 2005). Finally, preventive
interventions may be most useful when they are
delivered during high-risk life transitions, such as
the entry to elementary school or transition to middle
school. There is still much to learn about when in the
life course prevention may have its biggest effect.
These decisions are also intimately related to both
for whom prevention may be most appropriate and
how to prevent these disorders (i.e., the specific
strategies).
Prevention how, and in whom?
One of the issues prevention scientists grapple with
is ‘prevention in whom?’ That is, using the language
suggested by the Institute of Medicine (Mrazek &
Haggerty, 1994), preventive efforts could be indi-
cated (targeting persons with symptoms but not
disorder), selective (targeting persons at risk for
a disorder), or universal (targeting a whole popula-
tion). To date, few preventive interventions have
been systematically evaluated at each of these levels
of risk. With respect to ‘how’ to prevent anxiety
disorders, most interventions, beyond simple educa-
tion, have been based on cognitive-behavioural
principles. Next, we describe examples of preventive
interventions targeting each of these three levels
of risk and report on their efficacy.
Indicated prevention
Indicated prevention programmes target individuals
who have begun to evidence early signs of illness.
One of the first examples of this type of intervention
for the prevention of childhood anxiety disorders
was conducted by Dadds and colleagues (Dadds,
Spence, Holland, Barrett, & Laurens, 1997). These
investigators targeted schoolchildren between 7 and
14 years of age who were disorder-free but exhibited
anxious symptomatology, as well as children who
met criteria for an anxiety disorder but were in the
less severe range (early intervention – the most
common anxiety disorders were specific and social
phobias, GAD, and separation anxiety disorder).
After screening, 128 children were randomized to the
intervention or a control condition (i.e., monitoring
only). The intervention was based on Kendall’s
FEAR plan (Kendall, 1994) and involved a group
cognitive-behavioural therapy (CBT) programme in
which children developed their own plans for
graduated exposure to fear stimuli using physiologi-
cal, cognitive, and behavioural coping strategies:
F ¼ feeling good by learning to relax; E ¼ expecting
good things to happen through positive self-talk;
A ¼ actions to take in facing up to fear stimuli; and
R ¼ rewarding oneself for efforts to overcome fear
or worry. Group sessions were held weekly for 10
weeks in school settings and involved 5–12 children
per group. Three parental sessions were held during
the 10-week period, to introduce parents to child

management skills, to illustrate how parents could
model and encourage use of the child intervention
strategies, and to teach parents to use the interven-
tion strategies to cope with their own anxiety. The
results of this study were interesting and encoura-
ging. Immediately post-intervention, improvements
in anxiety symptoms were noted in both groups, and
there were equal rates of children in each group who
had an anxiety disorder (10%). At the 6-month
follow-up, anxiety disorder prevalences were lower in
the intervention group (16% versus 54%), but at the
1-year follow-up there were no differences between
the two groups in anxiety disorder prevalences.
At the final assessment, 24 months, children in the
CBT group were less likely to have an anxiety
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disorder (20% versus 39%). Thus, while the inter-
vention appeared to have effects that varied over
time, overall, the CBT group had a lower burden
of anxiety disorders.
Selective prevention
Selective prevention is aimed at persons who are at
high risk for anxiety disorders based on specific
‘known’ risk factors. Here, we discuss examples of
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selective interventions that have been evaluated in
studies that target persons considered at high risk
on three likely related bases: inhibited temperament,
parental history of anxiety disorder, and pessimistic
attitudes.
Temperament. Rapee and colleagues reasoned that a
number of putative risk factors for anxiety disorders
may be indexed or moderated/mediated by inhibited
temperament (Rapee, 2002; Rapee et al., 2005).
These investigators designed an intervention for
parents of inhibited children to reduce parental
anxiety, environmental support of avoidant coping,
and vicarious and instructional learning of avoid-
ance. They recruited 146 3-5-year-old children who
appeared behaviourally inhibited based on question-
naire and laboratory measures and randomized half
to an intervention group (parental education) and
half into a control group (monitoring). Components
of the intervention included education regarding the
nature of withdrawal and anxiety; information about
the importance of modelling competence and
promoting independence; development of exposure
hierarchies for the child; and practice of gradual
exposure, cognitive restructuring for the parent(s),
and discussion of high risk periods, such as the
commencement of school. Parents in the interven-
tion group attended six 90-minute small-group
sessions over the course of 2.5 months. Diagnostic
assessments were carried out at baseline (before the
intervention or monitoring period began) and one
year later.
Prevention of anxiety disorders 649
In a preliminary report, the intervention seemed
to have a significant effect on inhibited temperament
(per mothers’ ratings but not laboratory assessments)
– with a greater reduction in the intervention group;
there was also a greater reduction in the number
of anxiety disorder diagnoses in the intervention
group (Rapee, 2002) (the most common anxiety
disorder diagnoses were specific and social phobias
and separation anxiety disorder). In a subsequent
report, with 26 more subjects but with a different
analytic method (anxiety disorders and temperament
apparently included simultaneously in a path model),
temperament did not appear to be independently
affected by the intervention, though the number
of anxiety disorders did (Rapee et al., 2005).
Specifically, children whose parents received the
intervention showed a significantly lower prevalence
of anxiety disorders at the 12-month follow-up,
compared to the control group (50% versus 63%).
Family history of anxiety disorder. Ginsburg and
colleagues have an ongoing prevention trial in
children at high risk for anxiety disorders because
of parental anxiety disorder (Ginsburg, 2004). In
contrast to the other studies reviewed here, an
exclusionary criterion for this study is baseline
anxiety disorder. The means employed to potentially
decrease risk for anxiety disorders involve a family-
based intervention that includes psycho-education
(regarding the cognitive-behavioural conceptualiza-
tion of anxiety), contingency management
(rewarding ‘brave’ behaviours and using extinction
techniques to reduce avoidant behaviours), parental
instruction regarding modelling coping behaviours,
strategies to recognize and reduce parental anxiety
levels, and enhancement of specific problem-solving
and communication skills in the family. The
study randomized 40 children of anxious parents
(7–12 years of age) to either a 6-8-week family-based
CBT intervention or a monitoring only control
group. Though the study is not yet completed,
preliminary results are encouraging (Ginsburg,
unpublished data). Specifically, based on indepen-
dent evaluations of diagnostic status with the Anxiety
Disorders Interview Schedule for Children
(Silverman & Albano, 1996), by post-intervention,
30% of the children in the control group (6/20)
developed an anxiety disorder (all three children met
criteria for GAD and were referred for treatment),
compared to zero in the intervention group (0/20).
Pessimistic attitudes. Seligman et al. assessed the
efficacy of an 8-week CBT workshop (eight 2-hour
meetings with 10 to 12 students) designed to
prevent depression and anxiety in university
students at risk because of a consistently pessimistic
attributional style (established via questionnaire)
 650 O. J. Bienvenu & G. S. Ginsburg
(Seligman, Schulman, DeRubeis, & Hollon, 1999).
Prior unpublished studies suggested that such
students were at high risk for depression over the
next few years. Students (n ¼ 231) were randomized
to either the intervention group or a control
(monitoring) group. Topics in the intervention
workshops included the cognitive theory of change;
identifying automatic negative thoughts and under-
lying beliefs; marshalling evidence to question and
dispute automatic negative thoughts and irrational
beliefs; replacing automatic negative thoughts, etc.,
with more constructive interpretations, beliefs, and
behaviours; behavioural activation strategies; inter-
personal skills; stress management; and generalizing
coping skills to new situations. Students were given
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homework between workshop meetings, and they
met with a trainer individually on 6 occasions over
the next 1 to 2 years, to review skills and to have their
questions addressed. The students were followed
over a 3-year period, with repeated assessments
of mental disorders and symptoms.
Results indicated that students in the intervention
group had significantly fewer episodes of GAD and
significantly fewer moderate (but not severe)
episodes of depression. In addition, the students in
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the intervention group also reported significantly
fewer anxiety and depressive symptoms and greater
improvement in explanatory style, hopelessness, and
dysfunctional attitudes (‘cognitive’ measures). As
might be expected, the cognitive changes appeared
to mediate differences between groups on anxiety
and depression. Though effect sizes were moderate,
most of these differences persisted over 3 years
of follow-up.
Universal prevention
Universal prevention targets an entire population
without regard to risk status. Barrett and colleagues
have conducted several universal prevention studies
in children and adolescents in primary and secondary
school settings, employing cognitive-behavioural
techniques (Barrett, Farrell, Ollendick, & Dadds,
2006; Barrett & Turner, 2001; Lock & Barrett, 2003;
Lowry-Webster, Barrett, & Dadds, 2003; Lowry-
Webster, Barrett, & Lock, 2003). Arguments for-
warded for school-based universal interventions
include less interventionist burden (i.e., no need to
screen or recruit, as well as easier retention
of participants), as well as potentially less stigma for
the participants (Barrett et al., 2006). An argument
against universal interventions is that resources
are often limited, so perhaps resources should
be targeted toward those at highest risk. The
interventions evaluated by Barrett and colleagues
involve 10 to 12 classroom sessions for students,
with 4 psychoeducational sessions for parents.
The mnemonic FRIENDS is an acronym for the
different skills taught in the sessions (F ¼ feeling
worried; R ¼ relax and feel good; I ¼ inner helpful
thoughts; E ¼ explore plans; N ¼ nice work, reward
yourself; D ¼ don’t forget to practice; and S ¼ stay
calm for life).
In one of the FRIENDS evaluation studies, 489
children aged 10–12 years were randomly assigned to
one of three conditions, a psychologist-led condition,
a teacher-led condition, or a usual care condition
(Barrett & Turner, 2001). At post-intervention,
children in both teacher-led and psychologist-led
groups reported fewer anxiety symptoms compared
to children in the usual care group. No differences
were found in diagnoses (assessed in a subsample).
Youths with high levels of anxiety symptoms at the
pre-intervention assessment were more likely to
move into the ‘normal’ range if they had an
intervention, compared to usual care. Positive out-
comes for the prevention programme were reported
in replication studies, in which younger children,
females, and those higher in anxiety severity at
baseline benefited most from the intervention
(Lock & Barrett, 2003). While the majority
of children in these Australian studies were White,
Barrett and colleagues also report positive findings in
a similar study including a non-English speaking
migrant sample of youth (from Yugoslavian,
Chinese, and mixed race backgrounds; Barrett,
Sonderegger, & Xenos, 2003).
Though all of these cognitive-behavioural inter-
ventions appear to have been designed to prevent/
treat anxiety in childhood and adolescence (a worthy
goal in itself), it would be of great interest to
know whether or not these interventions have
any longer-term preventive effects (i.e., lasting into
adulthood). Additional research is needed to answer
this question.
Education as a prevention tool
Advertising regarding the nature of and effective
treatments for anxiety disorders is a potential
prevention tool that apparently remains unstudied.
In the US, the public gets some education regarding
anxiety disorders via news outlets (television, radio,
print and Internet media) and ‘direct-to-consumer’
advertising via pharmaceutical companies. We know
of no empirical studies explicitly addressing how
news programmes and pharmaceutical advertising
affect persons’ behaviours with regard to preventing
anxiety disorders, getting early treatment (indicated
prevention), or reducing the burden of disorder
(tertiary prevention in the older terminology),
but our anecdotal clinical experience suggests that
such programmes can facilitate persons’ initiating
psychiatric care. In the US, public health campaigns

have attempted to educate the populace regarding
mood disorders, and this may be facilitating
individuals’ treatment-seeking, to some extent
(Insel & Fenton, 2005). For example, in the 11
years between the original NCS (1990–1992) and the
NCS-R (2001–2003), the proportion of persons with
recent mood disorders who were in treatment in the
healthcare sector increased from 28% to 51%
(Kessler et al., 1999; Wang et al., 2005); this
increase may relate, at least in part, to increased
public awareness. Unfortunately, the lag time
between onset of mood disorder and first treatment
contact was 6 to 8 years in the NCS-R (Wang et al.,
2005). In the period between the original NCS and
the NCS-R, the proportion of persons with recent
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anxiety disorders who were in treatment in the
healthcare sector also increased, from 19% to 37%.
Though this is an impressive increase, the lag time
for treatment contact was even longer for the anxiety
disorders (9 to 23 years) than for mood disorders.
In the NCS-R, the majority of persons with mood
disorders, panic disorder, or GAD eventually got
some treatment; however, the cumulative lifetime
probability of treatment was substantially lower
for PTSD and agoraphobia, and still lower for
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social and specific phobias. An important goal for
future research is to determine the effect of education
on the outcomes of persons with anxiety disorders.
It is worth noting that further education directed at
primary physicians (including pediatricians) about
anxiety disorders seems vital. This is underscored by
a recent study comparing US service sectors used
for mental healthcare (Wang et al., 2006). Wang
et al. noted that, in comparing the NCS and NCS-R,
there was a large increase in the number of persons
who sought psychiatric care exclusively in the
general medical setting. In Australia, most persons
with recent mental disorders sought care, if any,
from/through general practitioners (Andrews et al.,
2001). Educational programmes for primary physi-
cians regarding the prevention and treatment
of anxiety disorders and their effects on patient
outcomes also deserve study.
Discussion
As we have outlined, anxiety disorders are common
and burdensome conditions with early onsets. We
presented evidence regarding the promise of cogni-
tive-behavioural preventive interventions in groups
characterized by varying levels of risk for anxiety
disorders, and we have argued that simple education
merits further study. We now consider several
limitations of this emerging field and suggest avenues
for future research and public health policy.
The most glaring limitation of the prevention
research literature is a dearth of studies. On the
Prevention of anxiety disorders 651
positive side, this means that the field is ripe for
researchers who wish to make significant contribu-
tions. On the negative side, it means that we are
limited in our ability to draw firm conclusions about
whether, how, and in whom anxiety disorders can be
prevented. Most extant studies have had small
sample sizes, which limit power to detect prevention
effects. Also, most have used a narrow range
of assessments (e.g., only self-reports or only anxiety
disorder diagnoses) and have had limited follow-up
periods (i.e., 3 or less years). The last is a particular
disadvantage, given that the impact of preventive
interventions is hypothesized to be long-term, rather
than short-term.
Many additional questions remain about the
prevention of anxiety disorders, including the follow-
ing: Whom should prevention efforts target, and
why? What intervention strategies, delivery formats,
and settings would be most helpful? Finally, how
much does prevention cost, and who will pay for it?
Below we attempt to address these issues as
considerations for future research.
Whom should prevention efforts target, and why?
In order to determine whom to target, a critical need
for the field is further empirical identification of risk
and protective factors for the development of anxiety
disorders. Theoretical models that specify how
prevention might work (i.e., the mechanisms through
which proximal and distal outcomes are expected to
occur) must be articulated and tested. For example,
Table I displays a schematic of a preventive inter-
vention model for offspring of anxious parents
developed by the second author. The Coping and
Promoting Strength Programme (CAPS) is a theore-
tically-derived preventive intervention designed to
change a set of modifiable risk and protective factors
which, based on prior research and theory, are
believed to mediate the development of anxiety
disorders in children. The underlying theory of the
intervention is that programme-induced change in
these mediators (e.g., parenting behaviours and
maladaptive cognitions) will account for the effects
of the programme on reducing anxiety disorders.
The first column lists the modifiable risk factors (in
children and parents); the second column lists the
intervention strategies that target those risk factors;
and columns 3 and 4 list the hypothesized short-term
(proximal) and long-term (distal) impacts of the
intervention. While the development of this model
was informed by existing research, it awaits empirical
validation. We present it here as a heuristic of a
theoretical model of intervention effects, but fully
expect that the model and intervention components
will be refined over time.
 652 O. J. Bienvenu & G. S. Ginsburg
Table I. Conceptual model and intervention strategies for a selective prevention programme.

Modifiable factors Interventions Proximal outcomes Distal outcomes

Child: Child: Child:

1. Anxiety symptoms/avoidant
behaviour
2. Maladaptive cognitions
3. Poor coping/problem-
solving
Parent/family:
1. Modelling anxiety
2. Overprotection
3. Criticism/conflict
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1. Anxiety management and
social engagement
2. Cognitive restructuring
3. Problem-solving skills
Parent/family:
1. Anxiety management
2. Contingency management
3. Communication and
problem-solving
1. Decreased anxiety symptoms
and avoidance
2. Decreased negative thoughts
3. Increased problem- solving/ Fewer anxiety disorders and
coping skills associated impairment
Parent/family:
1. Decreased anxiety modelling
2. Decreased overprotection
3. Decreased criticism/conflict

Related to the identification of risk and protective
factors is an appreciation that these risk and
protective factors may not be stable over time and/
or may be unique to specific developmental stages
or life transitions (e.g., entry into first grade,
parenthood). Thus, identifying what to target might
depend on ‘when’ across the lifespan these risks
occur. Donovan and Spence detail specific risk
factors for anxiety disorders across the life span
(Donovan & Spence, 2000), and Kellam & Van
For personal use only.
and long-term. Dismantling studies and studies
examining theory-based mechanisms of interventions
will facilitate answers to these questions. Also unclear
is whether preventive intervention strategies are most
effective when delivered on a community-wide basis,
as in public service announcements or public
education campaigns, or whether smaller groups
or work with individual families is needed. The
recent success of bibliotherapy (Rapee, Abbott, &
Lyneham, 2006) and web-based formats for treat-

Horn present a prevention model that highlights how
the timing of interventions should account for the
prevalence of risk factors (and disorders) at different
ages, the timing of disorder onset, and the specific
life task demands at different developmental stages
(Kellam & Van Horn, 1997).
Another issue of concern is the utility of specific
diagnostic categories for prevention of anxiety
disorders. That is, it is not clear that the anxiety
disorder diagnoses capture etiologically and patho-
physiologically distinct categories (Krueger, 1999;
Tyrer, 1985). It may be that inhibited temperament
reflects ‘vulnerability to’ anxiety and other ‘inter-
nalizing’ disorders, or it may be that inhibited
temperament is part of a spectrum of difficulties
that includes anxiety and depressive disorders
(Bienvenu & Stein, 2003). Thus, though some
preventive interventions target people who do
not have particular disorders at baseline, it may
be that what most trials have accomplished could be
construed as modifying a disorder-related process
that has already begun.
What intervention strategies, delivery formats, and
settings would be most helpful?
Another goal for future research should be the
clarification of which specific preventive intervention
strategies are most effective. Currently, most inter-
ventions combine a number of cognitive-behavioural
ingredients; thus, it is difficult to determine which
ones may have the most impact - both short-term
ment of anxiety disorders suggest that additional
options may be viable as preventive interventions.
Related to these issues is where to deliver such
interventions. Currently, most preventive interven-
tions for children are delivered in schools. While
there are many advantages to this (e.g., increased
access) there are also disadvantages (e.g., time away
from academics) that need to be weighed.
In addition, involving family members or adults is
often not practical in this milieu. Alternative settings,
such as places of worship, community seminars, and
hospital clinics should also be examined as potential
venues for prevention of anxiety disorders.
How much does prevention cost, and who will pay for
it?
Each of the issues raised above must also be
considered in the context of cost. Few studies have
examined the cost-effectiveness of anxiety disorder
prevention programmes. Indeed, a top priority
for the field is to conduct a cost-benefit analysis for
potential payers of such interventions. Currently,
preventive interventions for anxiety disorders are not
covered by governments or insurance companies.
Data on the cost savings of such interventions would
be useful leverage for soliciting third party payers.
Evidence will be needed about which strategies might
be the most cost-effective in the long run. For
instance, would indicated and selective interventions
be more cost-effective than universal interventions
because they target those at high risk? Whether or not

preventive cognitive-behavioural interventions are
adopted by governments or insurers in the near
future, based on the apparent efficacy of prevention
programmes, some persons may elect to seek these
interventions and pay themselves. Importantly, the
benefits for individuals and their families based on
the scant literature are compelling enough to warrant
further financial support of research.
Acknowledgements
National Institute of Mental Health grants
K23MH064543 and K23MH063427 supported this
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work.
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