THERAPEUTIC INTERVENTIONS FOR ANXIETY DISORDERS: AN INTEGRATIVE REVIEW

Background: Anxiety disorders are characterized by excessive emotional responses that generate major disturbances, causing cognitive and behavioral changes and triggering somatic manifestations. Therapeutic interventions show relevance and significant results for the treatment of anxiety. Aim: To identify therapeutic interventions used in the treatment of anxiety disorders. Method: A search for publications indexed in three electronic databases was conducted from January to March 2021. Titles, abstracts, and full-text reading by two independent reviewers were analyzed and classified by level of evidence developed by the Oxford Centre for Evidence-Based Medicine. Results: It resulted in 27 studies that observed the following therapeutic interventions: Psychoeducation; Mindfulness; Evidence-Based Behavioral Therapy; Applied Relaxation; Transdiagnostic CBT; Dialectical Behavioral Therapy; Positive Activity Techniques; Individual and Group CBT; Transcendence Technique Multifaceted Spiritually Based Intervention; Unified Protocol for Transdiagnostic Treatment of Emotional Disorders; Positive Activity Intervention Protocol; and Art Therapy. Conclusions: Of the therapeutic interventions used for the treatment of anxiety disorders, Mindfulness and Psychoeducation were the interventions of greater choice among the studies, which bring large benefit and autonomy to patients, considering that the implementation of these interventions can be performed by nurses and a multidisciplinary team in primary care services, also enabling the reduction of costs to the health system. The etiology of the ADs is considered multifactorial. Although the neurobiology of individual anxiety disorders is broadly unknown, generalizations have been identified for most of them, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis, and genetic factors. 1,3 In addition, general risk factors for anxiety disorders include female gender and family history of anxiety, although disorder-specific risk factors have also been identified. An environment permeated with instability and adversity, such as financial difficulties, family quarrels, or stress at work can be a risk factor for the development of an anxiety condition. A greater change in Experiential Avoidance (EA) across treatment significantly predicted change in worry (PSWQ) and quality of life (QOLI) across both treatments. These results contribute to the body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches. services. Zimmermann et al. 28 report in their study that a nurse-led psychoeducation intervention, implemented as a collaborative care model, increased perceived self-efficacy in patients with anxiety symptoms. This German study also validated the belief that a nurse aide can successfully complement the work of a general practitioner by supporting the self-management of patients with psychosomatic symptoms and psychosocial needs. An important aspect to note is about the care setting. The studies that reported the level of complexity of care were mostly conducted in mental health centers. 23,25,27,31,46 However, it is possible to note that the effectiveness of the interventions delivered does not differ from the outcomes of the interventions delivered in non-specialized mental health settings, such as in a PHC center 37 , in which the participants had a significant improvement in quality of life and relief of psychological symptoms of common mental disorders when receiving the CBT, corroborating another study that reinforces that the PHCs have the potential to act in improving mental health, in addition to promoting a short-term economic benefit for patients with mild to moderate anxiety and depression. 56 In the study by Ejeby et al. 37 , Yoshinaga et al. 42 , and Zimmermann et al. 28 , interventions delivered by non-specialist nurses and with different CBT techniques, such as individual CBT (CBT based on Clark and Mells’ model), transdiagnostic and psychoeducation, showed significant reduction in anxiety. In previous studies, CBT intervention techniques performed by non-specialist nurses, but with adapted training for anxiety, evidenced anxiety symptom reduction, showing no differentiation in outcomes from interventions performed by specialist nurses. 56-60 Zimmermann et al. 28 validated that a nurse aide can successfully complement the work of a general practitioner by supporting the self-management of patients. This finding should be taken into consideration, since the prevalence of anxiety disorders is significant 2 and that patients affected with these disorders have functional impairments 61 and seek more health services. 62 The implementation of a model of care performed by a nurse with education or training to perform mental health interventions in primary health care (PHC), individually and/or in groups, may minimize the problems listed.


INTRODUCTION
Anxiety disorders (AD) are characterized by excessive emotional responses that generate major disturbances, causing cognitive and behavioral changes and triggering somatic manifestations. They constitute one of the leading causes of disability around the world, with excessive and persistent fear as one of the main characteristics involved in these disorders. 1 According to the DSM-V 1  It is estimated that around the world, about 264 million people suffer from some type of anxiety disorder, which means an average of 3.6% of the world population. 2 In Brazil, specifically, this data is even more worrisome, as 18 million Brazilians suffer from this disabling condition, which represents 9.3% of the population, being classified as the country with the highest number of anxiety cases in the world. 3 The etiology of the ADs is considered multifactorial. Although the neurobiology of individual anxiety disorders is broadly unknown, generalizations have been identified for most of them, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis, and genetic factors. 1,3 In addition, general risk factors for anxiety disorders include female gender and family history of anxiety, although disorder-specific risk factors have also been identified. 3 An environment permeated with instability and adversity, such as financial difficulties, family quarrels, or stress at work can be a risk factor for the development of an anxiety condition. 1 Regarding social costs, anxiety disorders are directly associated with a significant increase in health care expenses 4 , since individuals with AD have decreased productivity and frequently seek public health services, such as emergency rooms, medical appointments, and examinations. 5,3 In addition, it is important to highlight that, although ADs cause the individuals complications in their daily, social, and work activities 6 , it is estimated that only 23% of the individuals diagnosed with AD have access to specialized services with psychiatrists, psychologists or nurses specialized in mental health. 4,7 Thus, despite their importance to public health, the vast majority of the ADs continue undetected and untreated by health systems, even in economically advanced countries. If untreated, these disorders are usually chronic, with recurrent symptoms or partial remission. The impairments associated with the ADs range from limitations in role functioning to severe impairments, such as the patient's inability to leave home as an attempt to avoid anxiogenic situations. 3,8 Specifically, the treatment for ADs can be accomplished through psychopharmaceuticals and psychotherapies. And, for the choice of the therapeutic modality, one should consider specific diagnosis, response to previous treatments, availability of treatment, cost-effectiveness, patient preference, psychiatric comorbidities, clinical comorbidities, and patient goals. 9 As the first choice for the pharmacological treatment of ADs, antidepressants are the most indicated, such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). 10, 11 Benzodiazepine medications also demonstrate efficacy in the treatment for AD and are considered second-or third-line medicinal products for the treatment. 11 For treating anxiety, psychosocial therapies that show relevance and significant results are also presented. According to the National Alliance on Mental Illness 12 , these therapies collaborate in training the individual to develop vocational, social, and psychological skills to control anxiety, improving their quality of life and well-being. In addition, it comprises from individual aspects to the recognition of the importance of interpersonal relationships in the stability of well-being, ensuring an integrative vision of health and demonstrating, according to studies, that the application of psychosocial treatments is effective, presenting short-and long-term improvements, with similar or superior responses to the pharmacological treatment. 13,14 However, one of the main difficulties for the development of more effective therapeutic proposals in mental health in health services has been the insufficient number of professionals properly trained and supervised to provide mental health care. 15 4 Given the context of the importance of caring for patients with AD, this review study is justified with the purpose of deepening the knowledge about therapeutic interventions performed for the ADs.
Moreover, it is considered that therapeutic techniques have been occupying a prominent place, as they have evidenced assertive responses in benefiting the health of the population suffering from moderate mental disorder. 16 This study aims to identify the therapeutic interventions used in the treatment of anxiety disorders.

MATERIALS AND METHODS
This is an integrative review, in which a synopsis of the literature is presented, based on a specific concept or content thematic area, generating synthesis, analysis, and the conclusions. 17 The steps are: construction of the review question, search on databases and selection of primary studies, data extraction, evaluation of the included studies, synthesis of the results, and presentation of the review. 18 To define the research question, the acronym PICO (Patient, Intervention, Comparison, Outcome) was used. The following question was proposed: For the treatment of anxiety disorder (P), which therapeutic interventions (I) are used (O)? It was chosen to omit the definition of C (control) because of the limited evidence from comparative studies. The definition of control (C) would complicate the evaluation of the research question for which the best available evidence in the literature was sought.
Based on the guiding question, the search for articles was conducted in the National Library of Medicine (PubMed), Virtual Health Library (VHL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science (WoS) databases, using the following search strategy with Health Science Descriptors (DeCS/MeSH): ("Anxiety disorder*" OR anxiety) AND (Therapeutic* OR "Therapeutic* Approache*" OR Treatment*) NOT ("pharmaceutical preparations" OR pharmacoloy OR drog*) AND (anxiolytic* OR antidepressant*) AND (children* OR teenager*), from January to March 2021.
Then, using the Rayyan® platform, we excluded duplicate articles and read the titles and abstracts in pairs independently, in accordance with the inclusion criteria, the exclusion criteria, and the guiding question. Inclusion criteria were adults aged 18 to 65 years, free full articles, intervention studies (comparative or not, randomized or not), clinical or structured diagnosis of anxiety, articles published in the last 10 years in Portuguese, English, and Spanish. Secondary studies and articles involving patients with chronic diseases, Covid-19, palliative care, patients taking anxiolytic drugs, interventions involving the use of apps, internet and/or cellphones were excluded.
The delimitation of the articles included in this integrative review occurred through the resolution of disagreements between the authors by a third reviewer. The articles were classified by level of evidence according to the recommendations proposed by the Oxford Centre for Evidence-based Medicine 19 : 1Asystematic review of randomized controlled trials; 1Brandomized controlled trial with narrow confidence interval; 1Call-or-nothing therapeutic outcomes; 2Asystematic review of cohort studies; 2Bcohort study (including lower quality randomized controlled trial); 2Cobservation of There was evidence that acceptance-based behavioral therapy for GAD has significant effects on the unique targets of intervention highlighted in several prominent theoretical models of GAD. CT and IPT led to considerable improvements that were maintained one year after treatment; CT was more efficacious than was IPT in reducing social phobia symptoms.
Effectiveness of guided self-help for depression and anxiety disorders in primary care: A pragmatic randomized controlled trial

Seekles et al. (2011) Psychiatry Res Netherlands
To evaluate the effectiveness of (guided) self-help in primary care for patients with a diagnosis of mood and/or minor or major anxiety disorder.
For patients with an anxiety disorder only, the anxiety symptoms decreased significantly compared to the careas-usual group. Self-help seems only slightly superior to care-as-usual and therefore might not be an effective tool in general practice. Cognitive Behavioral Therapy (CBT) with diagnosis-specific CBT for panic disorder (PD), social anxiety disorder (SAD), and Generalized Anxiety Disorder (GAD).
The efficacy of Transdiagnostic CBT for anxiety disorder is as strong as that of specific CBT, with the benefit of facilitating the dissemination of and increasing access to evidence-based treatments for anxiety. To test whether a spiritually based intervention has greater efficacy than a nonspecific control condition in generalized anxiety disorder.
A nondenominational spiritually based intervention has greater efficacy than a rigorous control in improving symptoms of GAD and enhancing spiritual well-being.
A preliminary study of individual cognitive behavior therapy for social anxiety disorder in Japanese clinical settings: A single-arm, uncontrolled trial A 14-week individual CBT program seems feasible and may achieve favorable treatment outcomes for SAD in Japanese clinical settings.
Decentering as a potential common mechanism across two therapies for generalized anxiety disorder Hayes-Skelton et al. (2013) To examine whether a treatment combining mindfulness (Applied Relaxation) and acceptance-based strategies with behavioral approaches would improve outcomes in Generalized Anxiety Disorder RCT 1B Acceptance-Based Therapy (ABBT); Applied Relaxation (AR).
ABBT is a viable alternative for the treatment of GAD. GAD patients, half with comorbid major depression, evidenced statistically, and clinically meaningful improvements in symptom severity, impairment, quality of life, and in model-related outcomes including emotional/motivational intensity, mindful attending/acceptance, decentering, and cognitive reappraisal. Patients maintained gains across the threeand nine-month follow-up periods.

RECISATEC -REVISTA CIENTÍFICA SAÚDE E TECNOLOGIA
Decentering as a potential common mechanism across two therapies for generalized anxiety disorder Hayes In this sample, results suggest that increased decentering was associated with decreases in anxiety and that changes in decentering appear to precede changes in symptoms within both ABBT and AR, indicating that decentering may be an important common mechanism of action.
Effectiveness of a tailored implementation programme to improve recognition, diagnosis and treatment of anxiety and depression in general practice: A cluster randomised controlled trial  A complex, nurse-led intervention, implemented as a collaborative care model, increased perceived selfefficacy in patients with symptoms of anxiety, depression or somatization compared to control patients. For the first time in the German healthcare system, the trial validated the belief that a nurse can successfully complement the work of a general practitioner -particularly in supporting self-management of patients with psychosomatic symptoms and their psychosocial needs. UP produces symptom reduction equivalent to standard evidence-based psychological treatments for anxiety disorders with less stress. Thus, it may be possible to use one protocol rather than multiple SDPs to treat more efficiently the most commonly occurring depressive and anxiety disorders. CBGT and MBSR produced similar trajectories showing decreases in social anxiety and increases in reappraisal (changing the way of thinking) and mindfulness (mindful attitude). Compared to MBSR, CBGT produced greater increases in disputing anxious thoughts/feelings and reappraisal success. Compared to CBGT, MBSR produced greater acceptance of anxiety and acceptance success. Granger Causality analyses revealed that increases in weekly reappraisal and reappraisal success predicted subsequent decreases in weekly social anxiety during CBGT (but not MBSR), and that increases in weekly mindful attitude and disputing anxious thoughts/feelings predicted subsequent decreases in weekly social anxiety during MBSR (but not CBGT). This examination of temporal dynamics identified shared and distinct changes during CBGT and MBSR that both support and challenge current conceptualizations of these clinical interventions. The PAI group displayed significantly larger improvements in positive affect and psychological well-being from pre-to posttreatment compared to the waitlist group. The PAI regimen also resulted in significantly larger reductions in negative affect, as well as anxiety and depression symptoms, compared to the waitlist group.

RECISATEC -REVISTA
Anxiety reduction through art therapy in women. Exploring stress regulation and executive To verify anxiety reduction in women with anxiety disorders, treated with Art Therapy (AT).

RCT
1B Anthropophosic Art Therapy. AT improves heart rate and resting heart rate variability and daily behavioral and cognitive performance aspects of executive functioning. Both analyses suggested a larger decrease in agoraphobic symptoms in the experimental treatment than in the waitlist condition. The effect size was small. The completers analyses showed additional beneficial effects in two of three autonomy-connectedness components, as well as psychoneuroticism, anxiety, and depression, which disappeared after correcting for multiple testing. AET may alleviate agoraphobic symptoms in a patient sample with severe anxiety.  (ABBT) and Applied Relaxation (AR) were applied in three studies. [32][33][34] Dialectical Behavioral Therapy (DBT) was the intervention used in three studies. 30,35,36 Transdiagnostic Cognitive Behavioral Therapy (CBT) was described in two studies. 24,37 Positive activity techniques were applied in two studies. 38,39 Individual and group CBT were used in three studies. [40][41][42] Two studies 35,36 used the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (PU), and one study 39 used the Positive Activity Intervention Protocol. Art therapy (AT) was an intervention tool in two studies. 43,44 The transcendence technique multifaceted spiritually based intervention (SBI) was identified in only one study. 45  noting that in some studies more than one intervention was applied in order to obtain effective results for anxiety reduction. 22,24,25,27,28,31,32,34,37,41 With reference to the setting, five studies 23,25,27,31,46 took place in Specialized Mental Health Centers; three studies 35,40,42 were conducted in General Outpatient Clinics; two studies 43,44 took place in 25 private art therapy clinics spread across the Netherlands; and one study 37

was held in a Primary
Health Care (PHC) Center. The remaining studies did not report the care settings for AD.
In the study by Koszycki et al. 45 , which aimed to evaluate the acceptability and initial effectiveness of an SBI intervention, the intervention was applied to patients from diverse religious and spiritual backgrounds, with basic teachings found in many religious traditions as opposed to teachings of a specific faith group. The intention-to-treat analysis revealed that the SBI and the CBT demonstrated comparable effectiveness in reducing anxiety, excessive worry, and depressive symptoms. Hayes-Skelton et al. 34 examined decentralization as a potential mechanism of action in two treatments for generalized anxiety disorder compared to ABBT and AR interventions; in another study, Hayes-Skelton et al. 33 examined whether an empirically and theoretically derived treatment combining mindfulness and acceptance-based strategies with behavioral approaches would improve outcomes in the treatment of generalized anxiety disorder (GAD) compared to an empirically supported treatment.
In both studies it was noted that there was no significant difference during the follow-up, indicating maintenance of gains with both interventions. In the study that addressed the Acceptance Therapy In two studies that addressed Anthroposophic Art Therapy as an intervention, Abbing, Sonneville et al. 44 explored possible working mechanisms of anxiety reduction in women with AD, treated with art therapy (AT), evidenced improvement in heart rate and resting heart rate variability and daily behavioral aspects. Abbing, Baars et al. 43 , in a second study, which verified the effectiveness of AT on anxiety in adult women, showed that AT is effective in reducing anxiety symptoms, improving quality of life and aspects of emotional regulation.
Regarding the two studies in which the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) was used 35,36 as an intervention tool, it was evidenced that the UP provides efficacy in reducing anxiety, playing an important role for emotional disorders. In a third study, Taylor et al. 39 used the Positive Activity Intervention Protocol, which suggests that positive emotions, negative emotion reduction, and positive activity interventions can be valuable for increasing social connection in individuals with anxiety or depression.
Taking into consideration the characteristics of the studies and their aggregated results, the quality of evidence produced in this review was analyzed in the research design, using the Oxford Centre for Evidence-Based Medicine 19 Classification, with the presentation of grade of recommendation "A" and level of evidence 1B, as visualized in Table 1.

DISCUSSION
Understanding the importance of a multidisciplinary team for the treatment of people with AD, in this integrative review, no restrictions were made regarding the specialty of the professionals who performed the therapeutic interventions for AD. Regardless of the training of the professionals presented, whether they were specialists in mental health and psychiatry or not, it was identified among the studies that the therapeutic interventions presented showed a reduction in anxiety levels.
In the studies in which the practices were carried out by non-specialist professionals, they had a brief training in specific CBT techniques with the supervision of professionals experienced in the techniques of the chosen interventions. The treatments varied among the studies, demonstrating, however, that common therapeutic intervention practices among them evidenced that the choice of one approach does not exclude the others, according to numerous clinical trials and meta-analyses that demonstrated the effectiveness of psychotherapies in various disorders. 49 In the studies that addressed AD with women, Abbing, Sonneville et al. 44 and Abbing, Baars et al. 43 identified the reduction of anxiety levels and the improvement of health and quality of life, which is in line with other studies that emphasize the relevance of actions for prevention and treatment, preventing ATs from raising the rates of comorbidities and morbidities. 50,51,52 It is worth noting that although the studies refer that the interventions were performed by professionals specialized in anthroposophic art therapy, no references were found in the literature indicating the need for specialization in art therapy intervention.
In this research, only one study addressed spirituality as an intervention 45 , through the SBI intervention that, in conjunction with the CBT, obtained significant improvements in GAD, contemporizing with previous study 53 , which demonstrated how religious psychotherapy can increase spiritual well-being, contributing to positive mental health outcomes. 45 However, it is known that this study was incipient, as it is not aware of the interaction mechanisms, being corroborated by the study of Oliveira and Junges 53 , which noted the absence of evidence that the SBI would present differentiation compared to any other psychotherapy.
Among the most commonly performed interventions in the studies 22-28 , psychoeducation stood out, with effective resolution for the AD, associated with the application of the mindfulness approach, with diaphragmatic breathing exercises, muscle relaxation, management technique to promote selfmanagement, problem-solving technique, and empowerment and self-confidence activity. Nogueira, Crisostomo, Souza, and Prado 54 reinforce that psychoeducation is a relevant CBT technique, with significant improvement in the domains of autonomy, leisure, and interpersonal relationships. According to Beentjes, Gaal, Achterberg, and Goossens 55 , the script for building a self-care intervention should be considered an essential model of care in supporting self-management for people with mental health problems. 19 An important aspect to note is about the care setting. The studies that reported the level of complexity of care were mostly conducted in mental health centers. 23,25,27,31,46 However, it is possible to note that the effectiveness of the interventions delivered does not differ from the outcomes of the interventions delivered in non-specialized mental health settings, such as in a PHC center 37 , in which the participants had a significant improvement in quality of life and relief of psychological symptoms of common mental disorders when receiving the CBT, corroborating another study that reinforces that the PHCs have the potential to act in improving mental health, in addition to promoting a short-term economic benefit for patients with mild to moderate anxiety and depression. 56 In the study by Ejeby et al. 37 , Yoshinaga et al. 42 , and Zimmermann et al. 28 , interventions delivered by non-specialist nurses and with different CBT techniques, such as individual CBT (CBT based on Clark and Mells' model), transdiagnostic and psychoeducation, showed significant reduction in anxiety. In previous studies, CBT intervention techniques performed by non-specialist nurses, but with adapted training for anxiety, evidenced anxiety symptom reduction, showing no differentiation in outcomes from interventions performed by specialist nurses. [56][57][58][59][60] Zimmermann et al. 28 validated that a nurse aide can successfully complement the work of a general practitioner by supporting the selfmanagement of patients. This finding should be taken into consideration, since the prevalence of anxiety disorders is significant 2 and that patients affected with these disorders have functional impairments 61 and seek more health services. 62 The implementation of a model of care performed by a nurse with education or training to perform mental health interventions in primary health care (PHC), individually and/or in groups, may minimize the problems listed.

LIMITATIONS
A limiting aspect of this study, when searching the databases, was the scarcity of national publications that explore the use of therapeutic interventions, presenting only the reference of one study pertinent to the theme, which may be related to the fact that, in the last 10 years, the application of therapeutic interventions has been recent in Brazil.

CONCLUSION
The therapeutic interventions used for the treatment of ADs that were identified in this study proved to be effective in reducing anxiety symptoms. Among the interventions, Mindfulness and