Journal of Anxiety Disorders 39 (2016) 44–64

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Review

Efficacy of group psychotherapy for social anxiety disorder: A

meta-analysis of randomized-controlled trials
Sarah Barkowski a , Dominique Schwartze a , Bernhard Strauss a , Gary M. Burlingame b ,
Jürgen Barth c , Jenny Rosendahl a,∗
a
Jena University Hospital, Institute of Psychosocial Medicine and Psychotherapy, Stoystrasse 3, 07740 Jena, Germany
b
Brigham Young University, Department of Psychology, 238 TLRB, Provo, UT 84602, USA
c
University Hospital Zurich and University of Zurich, Institute for Complementary and Integrative Medicine, Rämistrasse 100, 8091 Zurich, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Group psychotherapy for social anxiety disorder (SAD) is an established treatment supported by find-
Received 13 May 2015 ings from primary studies and earlier meta-analyses. However, a comprehensive summary of the
Received in revised form 15 January 2016 recent evidence is still pending. This meta-analysis investigates the efficacy of group psychotherapy for
Accepted 8 February 2016
adult patients with SAD. A literature search identified 36 randomized-controlled trials examining 2171
Available online 10 February 2016
patients. Available studies used mainly cognitive-behavioral group therapies (CBGT); therefore, quanti-
tative analyses were done for CBGT. Medium to large positive effects emerged for wait list-controlled
Keywords:
trials for specific symptomatology: g = 0.84, 95% CI [0.72; 0.97] and general psychopathology: g = 0.62,
Social anxiety disorder
Group psychotherapy
95% CI [0.36; 0.89]. Group psychotherapy was also superior to common factor control conditions in alle-
Randomized controlled trials viating symptoms of SAD, but not in improving general psychopathology. No differences appeared for
Format equivalence direct comparisons of group psychotherapy and individual psychotherapy or pharmacotherapy. Hence,
Meta-analysis group psychotherapy for SAD is an efficacious treatment, equivalent to other treatment formats.
© 2016 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.1. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.2. Data collection and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.2.1. Coding of outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.2.2. Coding of moderators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.2.3. Coding of risk of bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.3. Summary measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.4. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.1. Study inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.2. Characteristics of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.3. Risk of bias within studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.4. Group psychotherapy vs. wait list control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.4.1. Specific symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.4.2. General psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3.5. Group psychotherapy vs. active treatment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.5.1. Specific symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.5.2. General psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.6. Inclusion of non-CBT studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

∗ Corresponding author. Fax: +49 3641 936546.

E-mail address: jenny.rosendahl@med.uni-jena.de (J. Rosendahl).

http://dx.doi.org/10.1016/j.janxdis.2016.02.005
0887-6185/© 2016 Elsevier Ltd. All rights reserved.
 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64 45

3.7. Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.8. Drop-out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4.1. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.2. Implications for clinical practice and research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

1. Introduction elicit, as well as from the experience of mutual support (Tefikow

et al., 2012; Yalom & Leszcz, 2005). Therefore, this format of therapy
Social anxiety disorder (SAD) is one of the most common men- administration for SAD patients has received some attention, with
tal disorders in Western countries, showing a lifetime prevalence usually positive appraisal of group therapy in literature reviews
between 7% and 13% (Furmark, 2002). Typically, it occurs early in (Burlingame et al., 2004; Heimberg, 2002).
life and turns into a chronic condition if no treatment is sought Furthermore, several meta-analyses on psychological treatment
(Wittchen & Fehm, 2003). The core symptomatology is character- for SAD included group treatment in their analyses (Acarturk,
ized by a persistent fear and avoidance of social and performance Cuijpers, van Straten, & de Graaf, 2009; Aderka, 2009; Mayo-Wilson
situations (see DSM-5 criteria, American Psychiatric Association, et al., 2014; Powers, Sigmarsson, & Emmelkamp, 2008) and there
2013). This often leads to considerable impairment because it inter- is one meta-analysis that specifically focused on the controlled
feres with social and occupational participation (Dahl & Dahl, 2010; efficacy of CBGT (Wersebe, Sijbrandij, & Cuijpers, 2013). While
Fehm, Pelissolo, Furmark, & Wittchen, 2005). Consequently, SAD is group psychotherapy was consistently evaluated as being supe-
also associated with high economic expenses primarily stemming rior to wait list control groups with effect sizes ranging from 0.64
from indirect non-medical costs such as lower productivity and (Wersebe et al., 2013) to 0.92 (Mayo-Wilson et al., 2014), the evi-
absenteeism (Acarturk, Smit et al., 2009; Lipsitz & Schneier, 2000). dence on comparisons to active control conditions and alternative
Therefore, providing efficient treatment options should be of high treatment approaches is still scarce and provides an unclear pic-
priority (Egger et al., 2015). ture. Aderka (2009) found higher effect sizes for studies treating
Psychotherapy in a group format constitutes one of the patients in an individual format as compared to the group format,
treatments available for individuals suffering from SAD. Most while other meta-analyses did not detect significant differences
prominent in the research literature is cognitive-behavioral group (Acarturk, Cuijpers et al., 2009; Powers et al., 2008). Wersebe et al.
therapy (CBGT), usually consisting of exposure, cognitive restruc- (2013) reported significant positive effects of group therapy in
turing and homework assignment. Individual components of the comparison to active control groups such as placebo and treatment-
cognitive-behavioral therapy (CBT) approach, such as exposure, as-usual.
are administered separately as well. The CBGT model suggested The most recent review by Mayo-Wilson et al. (2014) regarded
by Heimberg and colleagues (Heimberg, 1991; Heimberg & Becker, CBGT in a network meta-analysis and found that it is superior
2002) in particular, has been investigated in a number of con- to wait list control groups, while no differences to psychological
trolled clinical trials and has gained widespread acceptance as the placebo or other forms of psychological treatment were detected.
gold standard group treatment for SAD Burlingame, MacKenzie, Consequently, individual CBT, which, in contrast to group therapy,
& Strauss, 2004; Hofmann & Bögels, 2006). In addition, the cog- was superior to psychological placebo and some other psychologi-
nitive model by Clark and Wells (1995) has been adapted to cal interventions, was recommended as first-line treatment in the
the group setting (e.g., Stangier, Heidenreich, Peitz, Lauterbach, study (as well as in the NICE clinical guidelines; NICE, 2013). How-
& Clark, 2003) as have non-CBT approaches, such as interper- ever, it should be considered that no statistical difference between
sonal psychotherapy (Huang & Liu, 2011) and psychodynamic the two delivery formats of CBT was detected.
therapy (Gawlytta, Tefikow, & Strauss, 2013; Knijnik, Kapczinski, Although these results from comprehensive meta-analyses
Chachamovich, Margis, & Eizirik, 2004). exist, there is a paucity of meta-analyses on SAD, which specifically
These options present important treatment alternatives to indi- aim to evaluate treatment delivered in a group format. These would
vidual psychotherapy, as group psychotherapy can potentially be beneficial considering that comprehensive reviews usually have
provide a more economic way of treatment (c.f. the studies of Otto, to limit their analyses and therefore leave some specific questions
Pollack, and Maki, 2000, and Roberge, Marchand, Reinharz, and unanswered. For example, the aim of the network meta-analysis
Savard, 2008, related to panic disorders). Because the time needed by Mayo-Wilson et al. (2014) was to evaluate and compare com-
per patient is reduced, group psychotherapy can facilitate access to monly used treatment options. However, the effect of the specific
treatment for a greater number of individuals. delivery format was only investigated for full CBT treatments, while
Although the specific characteristics of SAD seem to conflict effects of other psychotherapeutic approaches (e.g., exposure ther-
with the group environment (i.e., groups elicit anxiety and are apy alone and psychodynamic therapy) were not differentiated by
therefore avoided), additional therapeutic factors are introduced format. Additionally, all inferences made on the differential effects
by treating patients in the specific setting. These include for exam- of group psychotherapy and other active treatments (Acarturk,
ple in-session exposure to social situations and the ability to work Cuijpers et al., 2009; Aderka, 2009; Mayo-Wilson et al., 2014;
with a wider range of interpersonal behavior (compare Heimberg Powers et al., 2008) were derived from information that stemmed
& Becker, 2002; Sank & Shaffer, 1984; Tefikow, Bormann, & Strauss, at least partly from between-study comparisons and might be con-
2012). Socially anxious patients might especially benefit from the founded by differing study characteristics.
sense of belonging and self-validation that well-functioning groups
46 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64
It should also be noted that only two reviews considered het-
erogeneity between group psychotherapy studies. However, one of
them included studies published before 2007 only, leaving out any
recent studies (Acarturk, Cuijpers et al., 2009) while the other was
limited to studies comparing CBGT to a control condition (Wersebe
et al., 2013).
Therefore, our aim was to provide a comprehensive review of
the efficacy of group psychotherapy for SAD, concentrating on the
specific format of treatment delivery. We raise questions tailored
to the group format by exploring the influence of specific setting
variables and the treatment type, and discussing heterogeneity
between group psychotherapy studies in general. By aligning our
inclusion criteria to the specific research question, we expect to
be able to include more ample evidence on the particular therapy
option.
Standardized mean differences will be provided for wait list-
controlled studies as well as comparisons to active treatment
alternatives such as common factor control groups, individual psy-
chotherapy, and pharmacotherapy. Between-study heterogeneity
and publication bias will be carefully considered, and explorative
moderator analyses focusing on methodological variables and spe-
cific characteristics of the group psychotherapy will be conducted.
Objectives, inclusion criteria, and methods were pre-specified in
a review protocol (Rosendahl, Barkowski, Schwartze, Koranyi, &
Strauss, 2013).
2. Methods
2.1. Selection of studies
All randomized-controlled trials were considered for inclusion,
regardless of publication status and language. Study inclusion cri-
teria were specified according to the PICOS guideline,1 proposed by
the PRISMA statement for preferred reporting items for systematic
reviews and meta-analyses (Moher, Alessandro, Tetzlaff, & Altman,
2009). The following eligibility criteria were applied:
a. Publication date from 1990 onwards. The criterion was adopted
in order to ensure the use of current treatment approaches
and state-of-the-art methodology and has been applied in pre-
vious meta-analyses (Westen & Morrison, 2001). Furthermore,
Burlingame et al. (2004), reported in a systematic review of small
group treatment that in this time span an increasing number of
group psychotherapy studies related to specific disorders was
published and that these studies were methodologically more
rigorous than previously conducted studies.
b. Sample of adult patients with a primary diagnosis of SAD accord-
ing to DSM or ICD criteria. Populations of mixed anxiety diagnoses
were eligible if the results for SAD patients were reported sepa-
rately.
c. Group treatment, based on a formal change theory postulating
psychological principles as the agent of change. One or more ther-
apists led groups of at least three patients, providing five or more
sessions. Only interventions aiming at changing the primary psy-
chopathology of SAD were considered. We excluded conditions
in which group psychotherapy was provided in combination with
study-administered concurrent individual or pharmacological
treatment. However, it was not required that studies prohibited
patients to take psychopharmacological medication prescribed
outside the study regimen.
1
The PICOS guideline defines participants, interventions, comparisons,
outcomes, and study design as important domains to be considered for designing
inclusion criteria and addressing important questions in the review.
d. Comparison to wait list or an active treatment or control group
(common factor control group, individual psychotherapy, or
pharmacotherapy). Analogous to Baskin, Callen Tierney, Minami,
and Wampold’s (2003) definition of placebo treatment, com-
parison conditions were considered as “common factor control
groups” if they were “used in an attempt to control for psy-
chotherapy’s common factors by providing a treatment devoid of
specific ingredients” (Baskin et al., 2003; p. 975). This included,
for example, supportive group treatments or relaxation groups.
Self-help and internet-based interventions were not eligible as
comparison conditions.
e. Patient assignment to treatment condition was random. Cluster
randomization was eligible, as well as consecutive assignment if
the first assignment was random.
f. The study reported outcomes of SAD symptomatology or general
psychopathology, such as depression or anxiety for at least one
time point after treatment completion.
In the initial study protocol, we additionally intended to inves-
tigate economic outcomes and to compare group psychotherapy to
standard care (treatment-as-usual). However, none of the studies
provided the required data.
The databases CENTRAL, Medline (Ovid), PsycINFO, and Web of
Science were searched according to a search strategy that specified
terms referring to the patient population (e.g., phobi*, social* anxi*),
treatment (e.g., group therap*, group-delivered), and study design
(e.g., random*, control group$1). The search strategy was developed
with consideration of validated search strategies for retrieving ran-
domized controlled trials (Lefebvre, Manheimer & Glanville, 2011).
The database searches were last updated on August 19, 2015. It
was complemented by manual searches of the reference sections
of recent reviews and meta-analyses published on the efficacy of
psychological interventions for anxiety disorders, as well as by
searching references of included primary studies. In order to iden-
tify unpublished studies, we used the ProQuest Dissertations and
Theses Full Text Database and contacted the authors of relevant
studies asking for information about unpublished data. The final
search strategy for Medline as well as the list of manually searched
reviews and meta-analyses can be retrieved from the international
prospective register of systematic reviews, PROSPERO.2
Inclusion of studies was conducted in a two-step process, exe-
cuted by one of the two raters (DS, SB). Studies that were eligible
according to the information in the title and the abstract were read
in full text before the final decision on inclusion. Discussions in
team meetings (with BS and JR) resolved unclear cases.
2.2. Data collection and management
Information was retrieved according to a coding manual
(Appendix A, Table A1) including variables on characteristics of the
study, the participants, the intervention condition, the comparison
condition and the outcome, as well as data necessary to calculate
effect sizes and the rating for methodological quality of the stud-
ies. The variables describe the data on different levels of the study
design. We refer to the study level with a lower case n, to the level
of comparisons between a group psychotherapy and a comparison
condition with a lower case k and to the level of single experi-
mental conditions (i.e., group psychotherapies and/or comparison
conditions) with a lower case i.
In a pilot phase, five studies were double-coded independently
by the first and second author (DS, SB). An analysis of inter-rater
agreement on these studies yielded a mean Cohen’s Kappa of
2
Available from http://www.crd.york.ac.uk/PROSPERO/display record.
asp?ID=CRD42013004419.
 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64
 = 0.88 for categorical variables with a range between  = 0.66 and
 = 1.0 and a mean single-score intra-class correlation coefficient
of ICC = 0.98 for metric variables with a range between ICC = 0.67
and ICC = 1.0. These suggest good to excellent interrater agreement
(Altman, 1991; Cicchetti, 1994). Reasons for discrepancies were dis-
cussed, a consensus found and, where necessary, the instructions
in the coding manual were adapted. Data of all further studies were
obtained by a single coder (DS or SB). Ambiguous cases (i.e., cases
to which the pre-specified criteria did not apply) were brought for-
ward by the respective coder and were discussed between the two
coders. If no consensus was found, a decision was made in team
meetings (with BS and JR). If none of the coders was familiar with
the publication language, we consulted a translator and conducted
the rating cooperatively. Since no translator for Farsi was available
on the expense of reasonable resources, one study was excluded
(Dadashzadeh, Yazdandoost, Gharraee, & Asgharnejad farid, 2012).
2.2.1. Coding of outcomes
As a primary outcome domain, we were interested in the
specific symptomatology of SAD. Outcome measures were sum-
marized under this domain provided they assessed symptoms that
are distinctive of SAD, such as fear of public speaking (compare
Appendix B, Table B1 for allocation of single measures to domains).
As a secondary outcome domain, general psychopathology was
investigated. This domain addresses all outcomes measuring psy-
chological symptoms not specific to the diagnosis of SAD, such as
depression and general anxiety. All outcomes derived from assess-
ments with published measures were included in the analyses,
regardless of whether they were self- or observer-reported. One of
the two raters (DS or SB) and JR double-coded the type of extracted
outcome and the type of statistical parameters. Considered time
points were post-treatment (first assessment after the last ses-
sion and within one week of program termination), short-term
follow-up (≤6 months after the intervention), mid-term follow-up
(6–18 month after the intervention), and long-term follow-up (≥18
months after the intervention).
2.2.2. Coding of moderators
For moderator analyses, we focused on the effect of various
characteristics of group psychotherapy on treatment outcome.
We planned to differentiate between the psychotherapeutic
approaches. Similar to a dismantling procedure, full CBGT was com-
pared to group exposure alone. This distinction has already been
made in previous meta-analyses (e.g., Feske & Chambless, 1995)
since the two treatments are the most frequently evaluated in
the relevant literature. Number of group psychotherapy sessions,
length of group psychotherapy sessions, number of sessions per
week, and the number of patients per group were investigated as
continuous variables. Further categorical moderator variables were
therapist profession (professional vs. student), type of leadership
(single-led vs. co-led), manualization of the treatment (manualized
with adherence check vs. manual- or model-based but no adher-
ence check), and presence of an individual preparatory session (yes
vs. no).
2.2.3. Coding of risk of bias
Studies were evaluated for presence of a risk of bias threaten-
ing internal validity using the Cochrane Risk of Bias Tool (Higgins,
Altman, & Sterne, 2011). We assessed risks of selection bias (ade-
quate randomization procedure and concealment of allocation),
reporting bias (complete outcome reporting), detection bias (blind-
ing of outcome assessors for observer-reported outcomes), and
attrition bias (handling incomplete outcome data). In addition, bias
introduced by the implementation quality of the group therapy
condition was evaluated according to a rating proposed by Barth
et al. (2011) for quality ratings in psychotherapy studies. A high
47
implementation quality was given if studies ensured treatment
completion according to the protocol, either by providing specific
training and regular supervision or by conducting adherence checks
for fidelity to a manual.
We assigned categories to each of the risk of bias variables, indi-
cating whether a study had a low risk of bias (i.e., implemented
adequate measures to minimize the risk of bias) or a high risk of
bias on the respective variable. Studies that did not give sufficient
information to make an informed decision were rated unclear. Two
separate independent coders (a student assistant at master’s level
and JR) rated methodological quality in duplicate for all studies.
Consensus across all studies was excellent with a mean Cohen’s
Kappa of  = 0.90 and a range between  = 0.80 and  = 1.0. Risk of
bias was examined within moderator analyses and subgroup analy-
ses differentiating between studies without any judgement of high
risk of bias and all other studies.
2.3. Summary measures
Between-group effect sizes Hedges’ g (Hedges, 1981) were cal-
culated within the Comprehensive Meta-Analysis software (CMA,
Biostat, Inc., Version 2) for reported outcomes that matched one of
the selected outcome domains. Raw population data (M, SD, N) were
preferred over test results (p-value, F-value, etc.) and, where pos-
sible, pre-test data were gathered and implemented in the effect
size calculation. If available, intention-to-treat data were chosen
over completer data. The magnitude of Hedges’ g was interpreted
within the same framework as Cohen’s d, regarding 0.20, 0.50, and
0.80 as small, medium, and large effect sizes, respectively (Cohen,
1992). Positive effect sizes indicate a superiority of the group psy-
chotherapy, while negative effect sizes suggest a superiority of
the comparison condition. Whenever effect size information was
missing but a reasonable approximation was possible (e.g., by mea-
suring means and standard deviations from figures or estimating
post-treatment sample sizes from pre-treatment sample sizes),
approximated values were used. Furthermore, all non-significant
effects reported without statistical parameters were entered into
the analyses by setting effect sizes to zero. We employed this
approach to ensure consideration of all available information.
Since the majority of studies reported multiple outcomes per
outcome domain, effect sizes were subsequently aggregated within
domains for each unit of analysis (i.e., comparison of group psy-
chotherapy and comparison condition) using the “agg”-function
provided by the “MAd” package version 0.8-1 (Del Re & Hoyt, 2014)
for R statistical computing language and environment version 3.1.1
(R Core Team, 2014). The agg-function accounts for between-
outcome correlations within one study and estimates the variance
of the aggregate effect size accordingly (Borenstein, 2009; Gleser &
Olkin, 1994; cited by Del Re and Hoyt, 2014). If correlations between
outcomes were not given by study authors, the correlations were
taken from validation studies or were set to 0.50 (for further infor-
mation on this approach, compare Wampold et al., 1997). Thus, only
one effect size estimate per comparison was added to the analysis
of a specific outcome domain.
2.4. Data synthesis
All eligible comparisons from included studies were considered
for analysis. If a study provided for multiple comparisons and one
of the reported experimental groups was shared between several
comparisons, we divided the sample size of this group by the num-
ber of times it was included (Higgins, Deeks, & Altman, 2011). All
other statistical parameters remained constant.
We computed pooled standardized mean differences separately
for comparisons to wait list control groups and for comparisons
to active comparison conditions. The latter was further stratified
48 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64
by type of comparison (common factor control group, individual
psychotherapy, and pharmacotherapy).
Analyses were conducted in R, version 3.1.1 (R Core Team,
2014) for all subgroups and outcome categories, using the
package “metafor,” version 1.9-4 (Viechtbauer, 2010b). We per-
formed all meta-analyses according to the random-effects model
(Hedges & Vevea, 1998) and estimated heterogeneity with the
DerSimonian–Laird-method (DerSimonian & Laird, 1986). Pooled
standardized mean differences Hedges’ g are reported along with
their 95%-confidence intervals and the p-value. Heterogeneity was
tested with the Q-statistic and quantified using I2 , which gives
the amount of between-study variability that cannot be explained
by chance alone. I2 values of 25%, 50% and 75% are commonly
interpreted as low, moderate and high amounts of heterogene-
ity, respectively (Borenstein, Hedges, Higgins, & Rothstein, 2009;
Higgins, Thompson, Deeks, & Altman, 2003). Effect sizes of single
comparisons were considered outliers, and were eliminated from
further analyses if the effect size’s confidence interval did not over-
lap with the confidence interval of the pooled standardized mean
difference (see Cuijpers et al., 2014).
Publication bias was assessed for specific symptomatology via
visual examination of the funnel plot, looking for asymmetry that
might suggest specific omission of non-significant results. Egger’s
regression test was executed for each funnel plot to statistically
analyze the relationship between study effect size and standard
error (Egger, Smith, Schneider, & Minder, 1997). When funnel plot
asymmetry was detected, a trim-and-fill analysis was carried out
that added potentially missing studies to the meta-analytic model
(Duval & Tweedie, 2000).
In order to test whether our findings were biased by decisions
taken during the meta-analytic process, we conducted a number of
sensitivity analyses (i.e., meta-analyses on selected subsamples of
effect sizes) for specific symptomatology. Two of these were per-
formed on subsamples of outcome measures, restricting included
outcomes to standard self-report measures or non-estimated effect
sizes (i.e., effect sizes that were not calculated from approximated
parameters or zero effects), respectively. Standard self-report mea-
sures for SAD symptomatology were chosen according to relevant
reviews on the subject (Antony, 1997; Hart, Jack, Turk, & Heimberg,
1999: SADS, SPS, SIAS, FQ-SP, SPAI, and (B)FNE; abbreviations
defined in Table B1). Further sensitivity analyses were confined to
studies ensuring adherence to the treatment manual, studies ban-
ning concurrent psychopharmacological medication treatment and
studies with professional non-student group leaders.
We investigated the influence of potential effect modifiers in
mixed-effects meta-regression analyses for continuous variables
(Viechtbauer, 2010a). In these models, moderator variables are
entered into regression analyses as potential predictors of the
effect size Hedges’ g, and their ability to explain heterogeneity is
investigated. The models provide beta coefficients and a test of
moderator significance on the Q-statistic. The amount of variance
explained by the moderator is reported as R2 . Dichotomous mod-
erators as well as subgroup analyses were investigated by testing
for significant differences in effect sizes between two subsets of the
studies. Again, a mixed-effects model was used by fitting random-
effects models separately for the subgroups and comparing the
resulting effect size estimates within a fixed effects model with
moderators.
3. Results
3.1. Study inclusion
A total of 5894 references were identified by means of database
searches and another 220 references from manual search. After an
initial screening of the title and the abstract, a full-text assessment
was conducted for 610 articles, which resulted in the inclusion of 36
studies fulfilling all pre-specified inclusion criteria. These studies
were reported on in 40 articles altogether. As the database search
was designed to extract studies on anxiety disorders in general, 19
studies related to panic disorder with or without agoraphobia or
generalized anxiety disorder were eliminated in the last step and
are listed accordingly within the study flow (Fig. 1).
3.2. Characteristics of studies
Table 1 contains a summary of the characteristics of all included
studies. Besides n = 33 studies published in journals, three unpub-
lished dissertations were included (Filion-Rosset, 2004; Heideman,
2008; McDougall, 1999). Included studies reported on k = 50 dif-
ferent comparisons of a group psychotherapy to a comparison
condition, composed of i = 45 group psychotherapies and i = 41
comparison conditions. The majority of group psychotherapies
(i = 36, 80.0%) followed the full cognitive-behavioral regimen,
usually incorporating exposure, cognitive restructuring, and home-
work assignment. Some groups added supplemental components
such as social skills training (Davidson et al., 2004), atten-
tion retraining (Rapee, Abbott, Baillie, & Gaston, 2007), imagery
(McDougall, 1999) or mindfulness and acceptance (Kocovski,
Fleming, Hawley, Huta, & Antony, 2013). Most of these treat-
ments (i = 13) were guided by the treatment protocol developed
by Heimberg and colleagues or adapted versions (Heimberg, 1991;
Heimberg & Becker, 2002). Two studies (4.4%) followed an adapted
version of the cognitive therapy model by Clark and Wells (1995).
Other treatment approaches were exposure alone (i = 6, 13.3%),
social skills training alone (i = 1), interpersonal psychotherapy
(i = 1), and psychodynamic psychotherapy (i = 1, 2.2% each). Further
information on characteristics of the group psychotherapies can be
found in Table 2. As most of them followed a cognitive-behavioral
approach or used cognitive-behavioral elements as main ther-
apeutic technique, we conducted the statistical meta-analyses
including CBT approaches only. However, the two additional stud-
ies (one interpersonal and one psychodynamic) were included in
the review nevertheless and are discussed and analyzed in Section
3.6.
The majority of comparison conditions were wait list control
groups (i = 24, 58.5%), followed by common factor control groups
(i = 6, 14.6%), pharmacotherapies (i = 6, 14.6%), and individual psy-
chotherapies (i = 5, 12.2%). Usage of treatment-as-usual was minor
and considerably heterogeneous. Therefore, we allocated the two
such-labeled comparison conditions consistent with their content
to pharmacotherapy (Mörtberg, Clark, Sundin, & Aberg Wistedt,
2007) and common factor control groups (Cottraux et al., 2000),
respectively.
Across all trials, 1187 patients were treated with group psy-
chotherapy and 984 were assigned to a comparison condition. On
average, the percentage of male and female patients was evenly dis-
tributed (Mdn = 50% female, Interquartile range (IQR) = 14.13) and
the distribution of mean age across all studies showed a median
of 34 (IQR = 5, n = 35). The most frequent exclusion criteria were a
diagnosis of psychosis or substance abuse, followed by a diagnosis
of bipolar disorder or depression, suicidality and concurrent psy-
chotherapeutic or medication treatment. Usual comorbidities were
another anxiety or mood disorder (reported by n = 12 studies, each).
Seven studies reported on comorbid avoidant personality disorder
and eight on comorbid substance abuse, with one study includ-
ing exclusively patients with SAD and comorbid alcohol problems
(Heideman, 2008). Only one study (Anderson et al., 2013) reported
absence of any comorbidity for the majority of patients (76%).
Table 1
Study characteristics of included studies.

Study Country Population Group treatment n No. of No. of ses- Comparison n Drop-out Recruitment Diagnostic Concurrent Outcome Assessment
patients sions/length treatment (%) strategy instrument medication category times
per group in minutes

Alden Canada Generalized Interpersonal 31 5–7 12/120 WL 25 10.7 Referred/ ADIS-IV Yes, if Spec Post
and SAD cognitive- recruited stable
Taylor behavioral group
(2011) treatment
Anderson USA SAD Exposure group 39 Up to five 8/n.r. a) WL 28 22.7 Referred/ SCID for Yes, if Spec, Gen Post
et al. therapy (Hofmann, recruited DSM-5 stable
(2013) 2004)
b) IP: virtual 30
reality exposure
Bjornsson USA SAD CBGT (shorter 22 5–7 8/120 ComFC: 23 13.3 Recruited SCID No Spec, Gen Post
et al. version of the non-specific

S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64

(2011) Heimberg model) elements of
group
psychotherapy
(Yalom & Leszcz,
2005), designed
to be both
credible and
structurally
equivalent
Blanco USA SAD CBGT (Heimberg 34 4–6 12/150 Med: phenelzine 35 30.5 Referred/ n.r. No Spec, Gen Post
et al. model) recruited
(2010)
Cottraux France SAD Group social skills 32 4–6 6/120 ComFC: 35 17.9 Recruited Structured No Spec, Gen Post
et al. training, supportive interview
(2000) administered after therapy,
6 weeks baseline practiced “as
treatment of usual”, after 6
individual weeks of the
cognitive therapy same baseline
treatment
Davidson USA Generalized Comprehensive 60 5–6 14/n.r. Med: fluoxetine 57 28.5 Recruited SCID No Spec, Gen Post
et al. SAD CBGT with
(2004) exposure, cognitive
and restructuring and
Ledley social skills
et al. training
(2005)
D’El Rey Brasil Generalized CBGT (Heimberg 16 ca. 5 12/120 WL 16 3.1 Recruited SCID-I No Spec, Gen Post
et al. SAD model, adapted)
(2008)
Dogaheh Iran SAD CBGT (adapted 14 n.r. 12/n.r. IP: individual 14 21.4 Recruited Clinical n.r. Spec, Gen Post
et al. mainly from cognitive- interview
(2011) Heimberg model) behavioral
treatment
Erickson Canada Mixed CBGT for 14a 9–13 11/120 WL 14a 42.1 Referred SCID-IV Yes Gen Post
et al. anxiety diagnostically
(2007) diagnoses heterogeneous
groups

49
 50
Table 1 (Continued)

Study Country Population Group treatment n No. of No. of ses- Comparison n Drop-out Recruitment Diagnostic Concurrent Outcome Assessment
patients sions/length treatment (%) strategy instrument medication category times
per group in minutes

Filion- Canada SAD CBGT 32 n.r. 13/120 WL 36 34.6 Recruited SCID Yes, if Spec, Gen Post
Rosset stable
(2004)
Furmark Sweden SAD CBGT (Heimberg 6 6 8/180 a) Med: 6 0.0 Recruited SCID No Spec Post
et al. model) citalopram
(2002)
b) WL 6

S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64

Gruber USA SAD a) CBGT (Heimberg 18 n.r. 12/150 WL 18 14.8 Recruited ADIS-R Yes, if Spec, Gen Post
et al. model) stable
(2001)
b) Short CBGT 18 n.r. 8/150
facilitated by a
hand-held
computer
Heideman USA SAD and CBGT (Heimberg 9 n.r. 6/60-75 WL 9 22.2 Recruited ADIS-IV, Yes, if Spec Post
(2008) alcohol model), after SCID-I stable
problems attending one
individual BASICS
feedback session
for drinking
behavior
Heimberg USA SAD CBGT 25 4–7 12/120 ComFC: 24 18.4 Recruited ADIS n.r. Spec, Gen Post,
et al. educational- 6-month
(1990, supportive fu, 5-year
1993) psychotherapy fu
comparison
group, credible
placebo control
Heimberg USA SAD CBGT 36 5–7 12/150 a) Med: 31 19.5 Referred/ ADIS-R n.r. Spec, Gen Post
et al. phenelzine recruited
(1998)
b) ComFC: 33
educational-
supportive group
therapy
Hofmann USA SAD a) CBGT (Heimberg 30a 5–7 12/n.r. WL 30a N.r. Referred ADIS-IV-L n.r. Spec Post
(2004) model)
b) Exposure group 30a 5–7 12/n.r.
therapy
Hope USA SAD a) CBGT (Heimberg 18 6–7 12/120-150 WL 11 17.5 Referred ADIS-R Yes, if Spec Post
et al. model) stable
(1995)
b) Exposure alone 11 n.r. 12/120-150
(developed for the
study to match
CBGT)
Huang China SAD a) Group 15 15 8/120 WL 15 6.7 Recruited n.r. n.r. Spec Post
and Liu interpersonal
(2011) psychotherapy
b) CBGT 15 15 8/120

S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64

Knijnik Brazil Generalized Psychodynamic 15a 7–8 12/90 ComFC: credible 15a 25.0 Referred/ SCID-I No Spec, Gen Post
et al. SAD group therapy placebo control recruited
(2004) group (Heimberg
et al., 1990)
Kocovski Generalized a) Mindfulness and 53 n.r. 12/120 WL 31 27.0 Recruited SCID Yes, if Spec, Gen Post
et al. SAD acceptance based stable
(2013) group therapy
b) CBGT 53 n.r. 12/120
Mácia- Spain Generalized CBGT (Heimberg 17 8–9 12/150 WL 16 0.0 Recruited ADIS-IV-L No Spec Post
Antòn SAD model)
et al.
(2012)
McDougall Canada SAD a) Cognitive- 20 3–8 10/150 WL 17 27.1 Referred/ ADIS-IV Yes Spec, Gen Post
(1999) behavioral plus recruited
imagery group
treatment
b) CBGT 22 3–8 10/150
Mörtberg Sweden SAD Intensive group 35 6–7 16/a 3-h a) IP: individual 32 28.0 Recruited SCID No Spec, Gen 4-, 8-,
et al. cognitive morning cognitive therapy 12-month
(2007, treatment (adapted session and (Clark & Wells, fu, 5-year
2011) from Clark & Wells, a 2-h 1995) fu
1995) afternoon
session
b) Med: flexible, 33 4-, 8-,
predominantly 12-month
SSRIs fu
Mörtberg Sweden SAD Intensive CBGT 13 6–8 16/154 WL 13 7.7 Referred SCID, Yes Spec, Gen Post, 3-,
et al. SCID-II 6-month fu
(2006)
Newman USA SAD Performance-based 18 6 8/120 WL 18 8.3 Recruited SCID No Spec, Gen Post
et al. exposure
(1994) treatment, speech
phobia manual

51
 52
Table 1 (Continued)

Study Country Population Group treatment n No. of No. of ses- Comparison n Drop-out Recruitment Diagnostic Concurrent Outcome Assessment
patients sions/length treatment (%) strategy instrument medication category times
per group in minutes

S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64

Nortje South Generalized a) Cognitive 15 7–8 12/150 WL 14 0.0 n.r. ADIS-IV Yes, if Spec, Gen Post,
et al. Africa SAD restructuring plus stable 3-month fu
(2008) exposure (CR + E)
combined in CBGT
(Heimberg model)
b) Exposure alone 15 7–8 12/150
(EA), taken from
CBGT (Heimberg
model)
Olivares Spain Generalized Intervention in 10 5 12/90 WL 10 0.0 Recruited ADIS-IV-L No Spec Post, 6-,
et al. SAD adolescents with 12-month
(2009) social phobia fu
(CBGT)
Otto, USA SAD CBGT (Heimberg 20 3–8 12/150 Med: 25 33.3 Referred/ SCID for No Spec, Gen Post
Pollack, model) clonazepam recruited DSM-III-R
Gould
et al.
(2000)
Pishyar Australia SAD Standard CBGT, 16 n.r. N.r. WL 16 0.0 Recruited Telephone n.r. Spec, Gen Post
et al. developed for the screening
(2008) study interview
and
follow-up
assessment
Rapee Australia SAD Standard group 59 n.r. 10/120 WL 52 21.0 Referred/ ADIS-IV Yes, if Spec Post
et al. treatment; recruited stable
(2007) components
included cognitive
restructuring of
negative evaluation
beliefs, exposure to
feared social
situations, realistic
feedback of social

S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64

performance, and
attention training.
Rapee Australia SAD a) Enhanced 71 Approx. 6 12/120 ComFC: 58 17.9 Referred/ ADIS-IV Yes, if Spec Post
et al. treatment (CBGT non-specific recruited stable
(2009) with additional stress
treatment management
techniques: e.g.
performance
feedback, attention
retraining)
b) Standard 66 Approx. 6 12/120
treatment (CBGT,
purely cognitive
restructuring and
in vivo exposure,
loosely based on
other models, such
as Heimberg)
Salaberría Spain SAD a) Self-exposure 24 n.r. 8/150 WL 23 15.5 Referred/ ADIS-R n.r. Spec, Gen 4-month fu
Irízar and in vivo recruited
Echeburúa
Odriozola
(1995)
b) Self-exposure 24 n.r. 8/150
and cognitive
restructuring
following Beck
Schmidt USA Mixed False Safety 17 4–6 10/120 WL 16 4.2 Self- SCID Yes, if Spec Post
et al. anxiety Behavior presented stable
(2012) diagnoses Elimination
Therapy (F-SET)

53
 54
Table 1 (Continued)

Study Country Population Group treatment n No. of No. of ses- Comparison n Drop-out Recruitment Diagnostic Concurrent Outcome Assessment
patients sions/length treatment (%) strategy instrument medication category times

S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64

per group in minutes

Scholing Netherlands Generalized CBGT with three 36 5–7 14/150 IP: cognitive- 37 19.2 Referred/ ADIS-R Yes Spec, Gen Post, 3-,
and SAD treatment options: behavioral recruited 18-month
Emmelkamp exposure alone, individual fu
(1993, cognitive therapy therapy with the
1996) and exposure same three
separated in two treatment
blocks, integrated options
cognitive-
behavioral
treatment
Stangier Germany SAD Group cognitive 26 4–7 15/120 a) IP: individual 24 8.5 Referred/ SCID for No Spec, Gen Post,
et al. therapy based on cognitive therapy recruited DSM-5, 6-month fu
(2003) the model and (Clark & Wells, SCID-II
approach of Clark 1995)
and Wells, 1995
b) WL 21
Wong China SAD CBGT (Heimberg 17 8–9 10/150 WL 17 0.0 Referred/ n.r. Yes Spec Post
and Sun model, adapted for recruited
(2006) improving cultural
relevance)

Note: SAD = social anxiety disorder, n = sample size (randomized if not stated otherwise), CBGT = cognitive-behavioral group therapy, * = evaluated were the data available for our analyses, not if any results on an ITT-based
sample were provided, a = completer sample, WL = wait list, ComFC = common factor control group, IP = individual psychotherapy, Med = medication treatment, SCID = Structured Clinical Interview for DSM, ADIS = Anxiety Disorder
Interview Schedule for DSM, Spec = specific psychopathology, Gen = general psychopathology, Post = post treatment, fu = follow-up.
 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64 55

Fig. 1. Flow chart displaying the process of study inclusion.

Table 2
Characteristics of the group treatment (total i = 45 group treatments).

Median IQR i

No. of patients per group 6 1.4 34

No. of sessions 12 2.5 44
Length of sessions (min) 120 30 39
No. of sessions per week 1 0 41

Category k %

Type of treatment Cognitive-behavioral 36 80.0

Exposure 6 13.3
Interpersonal 1 2.2
Psychodynamic 1 2.2
Social skills training 1 2.2

Therapist profession Students (graduate and undergraduate) 7 15.6

Professional or mixed 31 68.9
n.r. 7 15.6

Leadership Single-led 6 13.3

Co-led 35 77.8
n.r. 4 8.9

Individual session Yes 8 17.8

No/n.r. 37 82.2

Manualization Manualized and adherence checked 28 62.2

Manual-/model-based 17 37.8

Note: n.r. = not reported, IQR = interquartile range, i = number of treatment groups.

3.3. Risk of bias within studies 3.4. Group psychotherapy vs. wait list control

A lack of reporting impeded the evaluation of risk of bias espe-
cially for selection bias and reporting bias where more than half of
the studies did not allow for an informed decision. There was little
evidence for an implementation bias to be present in the included
studies with most of the studies fulfilling the requirements for low
risk of bias. However, we observed a high level of attrition bias;
only a minority of studies reported on intention-to-treat samples
(Fig. 2).
3.4.1. Specific symptomatology
A meta-analysis of 28 comparisons of group psychotherapy
versus wait list control groups revealed an average effect size of
g = 1.05 (95% CI [0.81; 1.29], p < 0.001). However, heterogeneity
was high with I2 = 72.9% (Q = 99.79, df = 27, p < 0.001). After elim-
ination of three outliers (D’El Rey, Lacava, Cejkinski, & Mello, 2008;
Olivares, Rosa-Alcázar, Olivares-Olivares, & Rosa-Alcázar, 2009;
Pishyar, Harris, & Menzies, 2008; g > 2.50), the effect size was
56 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64
Fig. 2. Distribution of risk of bias in included studies.
reduced to g = 0.84 (95% CI [0.72; 0.97], p < 0.001, k = 25). For results
of included studies see Fig. 3. Heterogeneity of the model with-
out outliers was non-significant, with I2 = 0.0% (Q = 15.80, df = 24,
p = 0.895).
3.4.1.1. Publication bias and sensitivity analyses. Egger’s regression
test for funnel plot asymmetry did not indicate missing studies
(t = −0.72, df = 23, p = 0.477) and neither did visual examination of
the funnel plot (Appendix C, Fig. C1). Furthermore, the robustness
of results was tested against the influence of decisions undertaken
during the meta-analytic process (i.e., study inclusion, selection
of outcomes, effect size calculation). Deductions from results did
not change after confining sensitivity analyses to results from
non-estimated effect sizes, group psychotherapies where manual
adherence was adequately ensured and reported, or group psy-
chotherapies led by non-student professional therapists (compare
Table 3). Slightly smaller effects resulted from standard self-report
scales and for comparisons of studies not allowing for concurrent
medication, but significance was maintained.
Fig. 3. Forest plot of study effect sizes and overall standardized mean difference for comparisons to wait list.
3.4.1.2. Clinical and methodological diversity. Because statistical
heterogeneity was zero for comparisons to wait list controls, mod-
erator analyses were not indicated from a statistical viewpoint.
Nevertheless, some important clinical and methodological diver-
sity was assumed between studies, and regarded in subgroup
analyses. Subgroup analyses on differences between full CBGT
(g = 0.83 [0.70; 0.97], p < 0.001, k = 20, Q = 13.27, df = 19, p = 0.825,
I2 = 0.0%) and exposure group treatment alone (g = 0.91 [0.61; 1.20],
p < 0.001, k = 5, Q = 2.33, df = 4, p = 0.676, I2 = 0.0%) revealed no signif-
icant difference (z = −0.46; p = 0.648). Studies without high risk of
bias on any of the risk of bias variables showed a significantly larger
treatment effect (z = 2.06, p = 0.040; g = 1.03 [0.81; 1.25], p = < 0.001,
k = 6, Q = 1.97, df = 5, p = 0.854, I2 = 0.0%) compared to the remain-
ing studies (g = 0.76 [0.61; 0.90], p ≤ 0.001, k = 19, Q = 9.61, df = 18,
p = 0.944, I2 = 0.0%).
3.4.2. General psychopathology
Fourteen studies compared the effect of group psychotherapy
with wait list control groups regarding general symptomatology.
In line with the results on specific symptomatology, a large rela-
tive effect of group psychotherapy emerged (g = 0.80 [0.43; 1.17],
p < 0.001, k = 14). Again, heterogeneity was high (Q = 43.36, df = 13,
p < 0.001, I2 = 70.0%) and one outlier was eliminated from further
analyses (Pishyar et al., 2008; g = 3.24). Analyses on the reduced
sample produced a moderate treatment effect of g = 0.62 (95%
CI [0.36; 0.89], p < 0.001, k = 13) and a considerably smaller het-
erogeneity (Q = 19.42, df = 12, p = 0.079, I2 = 38.2%). None of the
pre-specified moderator variables of treatment setting or risk of
bias explained further heterogeneity. However, eliminating D’El
Rey et al. (2008) (g = 2.12) from the analyses reduced heterogeneity
in the remaining sample to I2 = 0.0% (Q = 6.71, df = 11, p = 0.22) and
resulted in a standardized mean difference of g = 0.50 (95% CI [0.29;
0.71], p < 0.001, k = 12).
Analyses on this sample (k = 12) were stratified by type of treat-
ment and high versus low risk of bias. No significant subgroup
differences occurred (type of treatment: z = −0.14, p = 0.890; risk
of bias: z = 1.38, p = 0.167). Nevertheless, treatment effects were
somewhat larger for exposure treatments (g = 0.54 [−0.00; 1.07],
 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64 57

Table 3
Statistics of the meta-analyses and sensitivity analyses on specific symptomatology.

Comparisons to wait list control Comparisons to active treatment groups

Heterogeneity Heterogeneity
2
k g 95% CI (g) p(Q) I (%) k g 95% CI(g) p(Q) I2 (%)

Overall 28 1.05 0.81; 1.29 <0.001 72.9 15 0.06 −0.19; 0.31 0.656 76.5

Without outlier 25 0.84 0.72; 0.97 0.895 0.0 14 0.15 −0.03; 0.33 0.012 52.1
Without outlier, including non-CBT 26 0.86 0.74; 0.98 0.774 0.0 15 0.15 −0.02; 0.32 0.097 48.5

Sensitivity analyses
Non-estimated ES 19 0.79 0.65; 0.93 0.241 17.5 8 0.14 −0.12; 0.39 0.022 57.1
Standard self-report scales 20 0.70 0.55; 0.85 0.982 0.0 12 0.01 −0.20; 0.21 0.043 45.6
Manual adherence ensured and reported 17 0.85 0.70; 1.00 0.732 0.0 9 0.22 0.06; 0.38 0.263 20.2
No concurrent psychotropic medication 4 0.73 0.41; 1.05 0.531 0.0 7 −0.09 −0.30; 0.12 0.228 26.3
Professional non-student therapists 20 0.86 0.72; 1.00 0.862 0.0 8 0.18 −0.08; 0.44 0.007 64.2

Note: k = number of comparisons included in the analysis, g = Hedges’ g, 95% CI(g) = 95% confidence interval for g, p(Q) = level of significance for the Q-statistic, I2 = proportion
of heterogeneity not explained by within-study variance, CBT = cognitive-behavioral therapy, ES = effect size.

p = 0.052, k = 2, Q = 0.68, df = 1, p = 0.410, I2 = 0.0%) compared to full
CBGT (g = 0.49 [0.27; 0.72], p < 0.001, k = 10, Q = 6.01, df = 9, p = 0.739,
I2 = 0.0%), and for studies without high risk of bias (g = 0.93 [0.29;
1.57], p = 0.005, k = 2, Q = 0.08, df = 1, p = 0.777, I2 = 0.0%) compared
to the remaining studies (g = 0.45 [0.23; 0.67], p < 0.001, k = 10,
Q = 4.72, df = 9, p = 0.858, I2 = 0.0%).
3.5. Group psychotherapy vs. active treatment conditions
3.5.1. Specific symptomatology
Fifteen comparisons of group psychotherapy to an active treat-
ment condition reported outcomes specific to the diagnosis of social
phobia. A meta-analysis across all these comparisons resulted
in a standardized mean difference of g = 0.06, not significantly
different from zero (95% CI [−0.19; 0.31], p = 0.656). High hetero-
geneity was observed (Q = 59.61, df = 14, p < 0.001, I2 = 76.5%) and
one negative outlier was identified (Heimberg et al., 1998; CBGT
vs. pharmacotherapy; g = −1.48). The standardized mean differ-
ence across the remaining studies was g = 0.15 (95% CI [−0.03;
0.33], p = 0.097). Heterogeneity for the model remained moder-
ate at I2 = 52.1% (Q = 27.13, df = 13, p = 0.012). For results of primary
studies, see Fig. 4.
3.5.1.1. Publication bias and sensitivity analyses. Egger’s regression
test did not indicate publication bias (t = 0.54, df = 12, p = 0.598) and
there were no studies added in trim-and-fill analyses (Appendix
C, Fig. C2). Sensitivity analyses are displayed in Table 3. For two
subgroups of comparisons, confining analyses to the new sample
changed the result in a meaningful way. Comparisons to group
treatments for which adherence to the manual was checked yielded
a significant positive effect size. In contrast, comparisons from stud-
ies that did not allow for concurrent medication treatment showed
a negative effect size, albeit still non-significant.
3.5.1.2. Subgroup analyses stratified by type of comparison condition.
Since a number of different comparison conditions were collapsed
under the label of active treatment groups, subgroup analyses
were computed. Group psychotherapy was significantly superior to
treatment in a common factor control group (g = 0.31 [0.14; 0.48],
p < 0.001, k = 6), while no difference to pharmacotherapy (g = −0.15
[−0.44; 0.15], p = 0.335, k = 4) or individual psychotherapy (g = 0.23
[−0.17; 0.63], p = 0.261, k = 4) was found (Fig. 4). Heterogene-
ity reached a moderate but non-significant level for comparisons
to individual psychotherapy (Q = 6.18, df = 3, p = 0.103; I2 = 51.4%),
while dropping to a low level for comparisons to pharmacotherapy
(Q = 4.99, df = 3, p = 0.173, I2 = 39.8%) and even to zero for compar-
isons to common factor control groups (Q = 4.64, df = 5, p = 0.461,
I2 = 0.0%).
3.5.1.3. Clinical and methodological diversity. Given the limited data
in the stratified samples, no further moderator analyses were
conducted. However, in order to address issues of clinical and
methodological diversity, results for subgroups of full CBGT stud-
ies and studies without judgment of high risk of bias are reported.
We provide results for only one subgroup instead of contrasting the
two opposing groups since the number of studies per subgroup is
too small to allow for informative subgroup analyses.
With regard to the subgroup of full CBGT studies, unchanged
results were obtained for comparisons to both common factor con-
trol groups (g = 0.31 [0.11; 0.51], p = 0.002, k = 5, Q = 4.62, df = 4,
p = 0.328, I2 = 13.4%), and individual psychotherapy (g = 0.26 [−0.36;
0.88], p = 0.407, k = 3, Q = 6.13, df = 2, p = 0.047, I2 = 67.4%). The analy-
sis relative to pharmacotherapy was already exclusively comprised
of full CBGT studies.
The subgroup of studies without high risk of bias showed consis-
tent results with respect to comparisons to common factor control
groups (g = 0.49 [0.23; 0.74], p < 0.001, k = 2, Q = 0.10, df = 1, p = 0.746,
I2 = 0.0%) and comparisons to individual psychotherapy (g = 0.23
[-0.20; 0.67], p = .296, k = 1). The two comparisons to pharmacother-
apy were significantly in favor of pharmacotherapy (g = −0.36
[−0.66; −0.07], p = 0.017, k = 2, Q = 0.08, df = 1, p = 0.779, I2 = 0.0%).
3.5.2. General psychopathology
The pooled standardized mean difference for comparisons to
active treatments on general psychopathology was negative but
non-significant (g = −0.34 [−0.86; 0.17], p = 0.190, k = 10). Hetero-
geneity was high at I2 = 88.9% (Q = 81.16, df = 9, p < 0.001). The
pattern of results did not change after removing one study iden-
tified as negative outlier (Heimberg et al., 1998; CBGT vs. common
factor control group; g = −3.55). The new standardized mean dif-
ference lay at g = −0.06 (95% CI [−0.38; 0.27], p = 0.726, k = 9),
and heterogeneity dropped to a moderate level (Q = 28.65, df = 8,
p < 0.001, I2 = 72.1%).
With regard to general psychopathology, there were no signif-
icant effects for comparisons of any of the subgroups to group
psychotherapy (common factor control group: g = 0.29 [−0.06;
0.64], p = 0.100, k = 2; individual psychotherapy: g = 0.15 [−0.18;
0.47], p = 0.378, k = 3; pharmacotherapy: g = −0.41 [−0.95; 0.13],
p = 0.140, k = 4). High heterogeneity only emerged for comparisons
to pharmacotherapy (Q = 15.19, df = 3, p = 0.002, I2 = 80.3%), while it
dropped to I2 = 0% for common factor control groups (Q = 0.01, df = 1,
p = 0.922) and to I2 = 1.7% for individual psychotherapy (Q = 2.03,
df = 2, p = 0.362).
58 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64
Fig. 4. Forest plot of study effect sizes and overall standardized mean differences for comparisons to active treatments stratified by comparison condition.
3.6. Inclusion of non-CBT studies
Analyses were repeated under inclusion of the two non-CBT
studies. One study that investigated interpersonal group psy-
chotherapy (Huang & Liu, 2011) provided for wait list-controlled
effect sizes for specific symptomatology (g = 1.69 [0.83; 2.55]). A
study of psychodynamic group psychotherapy (Knijnik et al., 2004)
supplied data on both outcome domains for comparisons to a
common factor control group (specific symptomatology: g = 0.10
[−0.57; 0.76]; general psychopathology g = −0.24 [−0.93; 0.46]).
The confidence intervals of these effect sizes overlapped with
those of the standardized mean differences across all other stud-
ies. Results did not change after inclusion of the two studies to the
meta-analyses (Table 3).
3.7. Follow-up
Eight studies provided follow-up data. Group psychotherapy
remained consistently superior to wait list control groups over all
outcome categories at short-term follow-up. (Table 4). Only one
study provided for data on specific symptomatology at mid-term
follow-up (Olivares et al., 2009; g = 3.91 [2.66; 5.15]). Comparisons
to active treatment groups did not gain significance at either of the
follow-up time points or outcome categories. Results on long-term
follow-up were reported by only two studies and did not indicate
differential effects for group psychotherapy and individual psy-
chotherapy or common factor control groups (results are available
upon request).
3.8. Drop-out
The weighted drop-out rate3 in a meta-analysis across all
included experimental groups was 15.2% (95% CI [12.6%; 17.7%],
i = 79). Separate subgroup analyses for the type of experimental
3
Drop-out was conceptualized by contrasting randomized and post-treatment
completer sample sizes. More patients may have finished the treatment without
providing data at post-assessment or some may have provided post-assessment
data without finishing the treatment. This approximation was necessary as studies
defined drop-out in various ways and often did not differentiate between treatment
and assessment drop-out.
group revealed drop-out rates of 17.1% [13.5%; 20.7%] for group
psychotherapy (i = 41), 14.5% [8.6%; 20.3%] for individual psy-
chotherapy (i = 5), 29.5% [18.4%; 40.5%] for pharmacotherapy (i = 6),
15.8% [7.2%, 24.3%] for common factor control groups (i = 5), and
7.8% [4.5%; 11.0%] for wait list control groups (i = 22).
Direct comparisons of drop-out rates in the group psychother-
apy condition and the comparison condition within the same
studies resulted in non-significant relative risks for comparisons
to wait list (RR = 1.28 [0.95; 1.71], p = 0.101, k = 30), common factor
control groups (RR = 1.05 [0.58; 1.90], p = 0.872, k = 5), and individ-
ual psychotherapy (RR = 1.50 [0.91; 2.47], p = 0.108; k = 5). A trend
in favor of group psychotherapy emerged for comparisons to phar-
macotherapy (RR = 0.76 [0.55; 1.05], p = 0.095; k = 6).
4. Discussion
In the present meta-analysis, group psychotherapy obtained
large positive effects compared to wait list control groups
and demonstrated equivalence to alternative treatment options.
The results were consistent across different outcome domains,
except for comparisons to common factor controls, where
group psychotherapy was superior in alleviating the specific
SAD symptomatology, but did not differ for effects on general
psychopathology. The robustness of the results was generally con-
firmed by sensitivity analyses and absence of publication bias.
The effect size that we obtained for wait list-controlled trials of
group psychotherapy is similar to that of efficacy measures from
other meta-analyses examining psychotherapeutic treatments for
SAD in general (Powers et al., 2008: g = 0.84), as well as to those
including only CBGT (Mayo-Wilson et al., 2014: g = 0.92).
Our analyses extend the existing knowledge on the differential
effects of group psychotherapy compared to other treatment for-
mats, providing results that were exclusively derived from direct
comparisons within studies. Generally, they are in accordance with
findings from Mayo-Wilson et al. (2014), who found non-significant
effects for comparisons of CBGT and other psychotherapeutic and
pharmacologic treatment options in their network meta-analysis.
While, in their analyses no differences were detected in relation to
“psychological placebo,” our results suggest that group psychother-
apy is superior to common factor controls in reducing specific
 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64 59

Table 4
Meta-analyses on follow-up data for specific symptomatology and general psychopathology stratified by comparison conditions.

Short-term follow-up Mid-term follow-up

Heterogeneity Heterogeneity
2
k g 95% CI(g) p(Q) I (%) k g 95% CI(g) p(Q) I2 (%)

Wait list Specific 7 1.09 0.63; 1.55 0.009 65.1 1 3.91 2.66; 5.15
General 6 0.73 0.44; 1.02 0.625 0.0 –
Active comparisons Specific 5 −0.01 −0.37; 0.35 0.037 60.9 3 −0.06 −0.55; 0.43 0.029 71.7
General 5 −0.10 −0.36; 0.15 0.678 0.0 3 −0.20 −0.69; 0.29 0.070 62.5
Common factor control Specific 1 0.43 −0.07; 0.93 –
General 1 −0.09 −0.74; 0.57 –
Individual therapy Specific 3 −0.24 −0.72; 0.23 0.058 65.0 2 −0.22 −0.89; 0.44 0.038 76.9
General 3 −0.18 −0.53; 0.17 0.239 30.2 2 −0.35 −1.03; 0.33 0.048 74.4
Pharmacoththerapy Specific 1 0.15 −0.32; 0.62 1 0.22 −0.18; 0.63
General 1 0.00 −0.58; 0.58 1 0.08 −0.42; 0.58

Note: k = number of comparisons included in the analysis, g = Hedges’ g, CI(g) = 95% confidence interval for g, p(Q) = level of significance for the Q-statistic, I2 = proportion of
heterogeneity not explained by within-study variance.

symptomatology. Explanations for this divergence could be the dif-
ferent sample of included studies or the different methodology
between network meta-analyses and traditional meta-analyses.
Network meta-analyses have an advantage over traditional meta-
analyses because the evidence base is larger since they allow for
comparisons across studies (Mayo-Wilson et al., 2014). However,
different characteristics between studies and comparisons are at
risk of biasing the effect (Jansen & Naci, 2013). In contrast, our
results are in accordance with moderate positive effect sizes found
by Wersebe et al. (2013). Non-significant effects in comparison to
common factor control groups emerged for outcomes of general
psychopathology in our analyses. This might be due to charac-
teristics of the comparison conditions, which have demonstrated
considerable effects in previous meta-analyses (Baskin et al., 2003;
Wampold, Minami, Callen Tierny, Baskin, & Bhati, 2005).
Compared to previous meta-analyses that investigated group
psychotherapy for SAD, our results are based on an especially wide
spectrum of evidence, since studies were included regardless of
any treatment approach, comparison condition, or publication lan-
guage. We were able to examine data from 18 additional studies
that were not included in the meta-analysis by Mayo-Wilson et al.
(2014). At the same time, ten group psychotherapy studies included
in the network meta-analysis were not eligible for our analyses due
to missing or non-eligible comparison conditions. We also added
26 studies to the sample analyzed by Wersebe et al. (2013).
Additionally, our study considers several factors of risk of bias
and characteristics of the group psychotherapy with respect to
their influence on the relative treatment effect. Surprisingly, stud-
ies without high risk of bias consistently reported larger effect sizes
than all other studies. This result suggests that our analyses are
unlikely to be biased by low quality studies. However, it is in con-
tradiction to most findings on the effects of methodological quality,
which usually report smaller effect sizes for high quality studies
(Cuijpers, van Straten, Bohlmeijer, Hollon, & Andersson, 2010; Jüni,
Altman, & Egger, 2001). Nevertheless, a specific direction of the bias
was not universally confirmed and usually depends on the type
of quality assessment and the assessed sample of included stud-
ies (Jüni et al., 2001). Larger effects for high quality studies might
be explained, assuming that high methodological quality is paired
with high intervention quality. However, all conclusions on the
impact of methodological quality should be treated with caution,
considering that the reporting quality for the relevant variables was
poor.
No differential effects between CBGT and group exposure
therapy were detected. These findings are in line with earlier
meta-analyses, which found that exposure produced equivalent
outcomes to full CBT (Feske & Chambless, 1995; Mayo-Wilson et al.,
2014; Powers et al., 2008) for SAD. Evidence for further treat-
ment approaches was scarce, which reveals the need for more
well-controlled efficacy studies. It would be informative to com-
pare CBGT and group exposure treatments to non-CBT treatment
approaches. However, our sample did not contain enough data
to allow for meaningful analyses. Even so, single study results
from studies administering alternative treatment approaches did
not show noticeably different effects and including them in over-
all analyses did not change the findings but instead marginally
reduced heterogeneity.
With regard to the design of future primary studies, it should
be noted that both the wait list-controlled treatment effect and the
effect relative to active comparisons was reduced if only studies
were included that prohibited concurrent psychotropic medica-
tion. Nevertheless, this change was too minor to influence the
deductions made from the results. Information from primary stud-
ies on the actual medication use per experimental condition was
scarce and did not allow for any informed conclusions. There-
fore, it remains unclear how the effect might have emerged and
whether it was meaningful. This is a question that should be
addressed in future research. There is one study on treatment of
complicated grief that reports treatment-specific effects of con-
current medication with higher response and completion rates
for patients receiving concurrent medication while showing dif-
ferent effect magnitudes for complicated grief targeted therapy
and interpersonal psychotherapy (Simon et al., 2008). Similar
treatment-specific effects might have been relevant in our included
studies.
The effect was also marginally reduced if only standard self-
report scales were considered, but again this did not change
deductions. Lower effects for self-report scales have been reported
in the literature (Feske & Chambless, 1995).
Findings of higher attrition within group psychotherapies com-
pared to the individual format reported in a previous meta-analysis
on SAD (Aderka, 2009), were not confirmed in our sample of
included studies. This is in line with reviews related to drop outs
in different psychotherapy settings (Swift & Greenberg, 2012).
Instead, a trend for higher drop-out in pharmacotherapy was found
and indicates less treatment acceptance for these conditions, pos-
sibly due to the side effects of psychopharmacological medication.
Together with reported higher relapse rates for pharmacotherapy
(Liebowitz et al., 1999), this trend should be considered when inter-
preting the somewhat higher post-treatment effect sizes of the
condition. However, power was probably an issue within these
analyses. Therefore, analyses on larger study pools of direct com-
parisons should be conducted before conclusions can be drawn.
60 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64
4.1. Limitations
A number of limitations are worth noting when interpreting the
results from the present study. First, although we wanted to include
group psychotherapy studies regardless of the theoretical orienta-
tion, the sample is mainly based on CBT approaches (i.e., 80.0% use
full CBGT, 95.6% have CBT elements as main therapeutic technique)
and main analyses were therefore restricted to this approach. This
is a common problem within efficacy research (Burlingame, 2010)
and further primary studies on non-CBT interventions are needed
for conclusions about differential effects.
Second, we decided to exclude statistical outliers from subse-
quent analyses even though the introduced heterogeneity could
be meaningful. This procedure was adopted because heterogeneity
was largely due to these single studies, and there was a high likeli-
hood of getting chance findings in moderator analyses. This is less
problematic for wait list-controlled trials, where all outliers were
positive, and thus the estimate without outliers provided a more
conservative value. However, for comparisons to active treatment
groups, a negative outlier was identified and eliminating the com-
parison from the analysis changed the effect size in favor of group
psychotherapy. Notably, this change was not pronounced enough
to alter deductions from the results.
Third, we could not investigate all of the pre-specified mod-
erator variables due to limited variability between studies and
generally low statistical heterogeneity. Additionally, reporting on
methodological quality was poor. Therefore, results of our analy-
ses rely on uncertainty as to the quality of some studies, where
poor reporting might not always accurately reflect poor qual-
ity. Although heterogeneity was low, the consideration of further
moderators might be beneficial. Based upon the observation that
the diagnosis of SAD is often described as heterogeneous (e.g.,
Hofmann, 2010), with differentiation of a generalized subtype and
proximity to avoidant personality disorder, taking into account
diagnostic aspects might be promising.
Fourth, heterogeneity remained even after moderator and sub-
group analyses for some analyses, i.e., comparisons to individual
psychotherapy and pharmacotherapy, where only small study
pools were available. Heterogeneity for these analyses relied
heavily on the analyzed outcome domain, possibly due to the dif-
ferent subsamples of studies. High heterogeneity remained for
comparisons to pharmacotherapy when regarding general psy-
chopathology and moderate but non-significant heterogeneity for
comparisons to individual psychotherapy when regarding specific
symptomatology. In these cases, results between single stud-
ies were contradicting with respect to the observed direction of
the effect. One possible explanation could be an effect of biased
researcher allegiance that has previously been discussed within
the context of head-to-head comparisons (Luborsky et al., 1999;
Munder, Gerger, Trelle, & Barth, 2011). Another possible reason
for the divergence might be that group psychotherapies that are
adapted from individual treatment approaches might lack a trans-
position accounting for the use of specific therapeutic factors in a
group, thus resulting in poorer outcomes (Strauss & Burlingame,
2012). It would be of interest to regard the impact of these char-
acteristics as statistical moderators. However, the small study pool
did not allow for further analyses.
Finally, although a comprehensive search strategy was con-
ducted, we may have missed some existing evidence from studies
that were not found, unpublished, or published after completion of
our final search. One study (Dadashzadeh et al., 2012) could not be
included due to limited resources for translation.
4.2. Implications for clinical practice and research
Currently, the 2013 NICE clinical guideline 159 for SAD discour-
ages treatment providers from administering group psychotherapy
instead of individual psychotherapy and states that “it is less clin-
ically and cost effective than individual CBT” (p. 19). However,
in accordance with findings from other meta-analyses (Acarturk,
Cuijpers et al., 2009; Powers et al., 2008; Wersebe et al., 2013) our
results advocate that group psychotherapy for patients with SAD
should be considered as a valid treatment option. To date, most
evidence acknowledges an equivalent efficacy of group psychother-
apy compared to treatment alternatives (Burlingame et al., personal
communication, June 5, 2015).
Additionally, group psychotherapy can provide an economic
way of treating a greater number of patients, which is impor-
tant especially as the prevalence of anxiety disorders increases
(Kessler & Greenberg, 2002) and public financing of psychoso-
cial interventions gets increasingly difficult in some countries.
Randomized-controlled studies that explicitly investigate eco-
nomic outcomes of group psychotherapy for SAD would be
desirable.
The data reveal a considerable lack of randomized-controlled
studies that examined approaches other than CBGT. Given the sub-
stantial amount of patients that do not recover after CBGT (compare
Knijnik et al., 2008; Stangier et al., 2003), developing and evalu-
ating alternative treatment approaches such as interpersonal or
psychodynamic psychotherapy should be of high priority.
4.3. Conclusions
Group psychotherapy for SAD is efficacious and shows equiva-
lent effect sizes to other treatment formats. However, additional
evidence and clarification is needed especially for non-CBT
approaches and direct comparisons to alternative formats. Further
analyses should investigate the differential efficacy of the vari-
ous approaches of group psychotherapy as well as the differential
suitability for distinct patient populations, such as those with gen-
eralized SAD or comorbid avoidant personality disorder.
Funding
The work was funded by the German Federal Ministry of Edu-
cation and Research (FKZ 01KG1216). The funding source was not
involved in content-related decisions that led to the preparation of
this article.
Acknowledgements
We kindly thank Anna Lindner and Rahel Klatte for their help
with the coding of methodological quality and the literature search,
and Xin Chang, Stefanie Kern, and Swetlana Philipp for their support
with translations.
 S. Barkowski et al. / Journal of Anxiety Disorders 39 (2016) 44–64 61

Appendix A Appendix C

Table A1
Data coding manual.
Information Variables
Study characteristics Author; publication year; publication status; language;
country of study performance
Participant Sample size; age; gender; ethnicity; previous treatment or
characteristics hospitalization; concurrent treatment; recruitment method
(referred, recruited etc.); diagnostic manual (DSM, ICD
versions); diagnostic instrument; duration of disorder;
comorbidity; exclusion criteria
Intervention group Theoretical orientation (CBT, psychodynamic, interpersonal
characteristics etc.); group composition regarding gender and disorder
(homogeneous or mixed); treatment setting (inpatient,
outpatient, day treatment); treatment location (university
counseling center, state hospital, private practice etc.),
duration (number and length of sessions) and frequency of
treatment (number of sessions per week); number of patients
per group; manualization of treatment; group membership
(open, closed, etc.); therapists profession (graduate level,
doctoral level, professional level etc.); group leadership
(single-led, co-led); booster sessions (yes/no); preparatory
individual sessions (yes/no)
Control group Type of control group (wait list, common factor control, Fig. C1. Funnel plot for effect sizes and their standard errors regarding specific
characteristics treatment as usual, individual therapy, pharmacotherapy); symptomatology compared to wait list control groups.
bona fide treatment
Outcome Type of analyses (ITT or completer); length of follow-up; type
characteristics of outcome measure (specific symptomatology, general
psychopathology, remission/response); outcome inventory;
outcome form (continuous, dichotomous); outcome source
(self-reported, observer-reported)
Effect size related Statistical parameters (M, SD, p-values, t-values, F-values,
information sample size etc.); effect direction, estimation by approximation
Study quality Sequence generation; allocation concealment; selective
reporting; implementation quality; blinding of outcome
assessment, handling of incomplete outcome data

Appendix B

Table B1
Allocation of outcome measures to domains.

Specific symptomatology General psychopathology

Measures ADIS-IV Fear/Avoidance, BAIo , BDIp , FQ-Depression

ADIS-IV Severity, BSPSa , CGIb ,
FNE/BFNEc , FQd -SP, FQ-Main
Fear, IASe , LSASf , PRCSg , SADSh ,
SIASi , SPAIj , SPINk , SPSl , SPSQm ,
SPWSSn , Social Phobic
Disorders Severity and Change
Form, study-specific composite
scores of SAD symptomatology
Anxiety, FQ-Disability, HAMAq ,
HAMDr , SCL-90s , STAIt
Fig. C2. Funnel plot for effect sizes and their standard errors regarding specific
symptomatology compared to active treatment groups.
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