Medication and Cognitive Behavioral Therapy for Pediatric Anxiety Disorders

Abstract

Anxiety disorders are among the most prevalent pediatric behavioral health conditions, affecting roughly 32% of youths prior to adulthood, and associated with impaired functioning that can continue into adulthood and increase in severity. 1,2 In this issue of JAMA Pediatrics, Wang et al 3 report an updated meta-analysis evaluating the comparative efficacy of cognitive behavioral therapy (CBT) and pharmacotherapy for pediatric anxiety disorders. Results supported the efficacy of CBT, selective serotonin reuptake inhibitors (SSRIs), and their combination; limited support was provided for serotonin-norepinephrine reuptake inhibitors (SNRIs). We briefly review the evidence followed by implementation issues.Results of the meta-analysis indicate that CBT and SSRIs were each more likely to result in diagnostic remission/treatment response compared with wait list/no treatment and pill placebo, respectively. Combined CBT and medication led to greater improvements in anxiety symptoms compared with CBT alone (2 studies) or medication alone (1 study). Comparison of CBT and SSRIs (2 studies) indicated greater declines in anxiety (symptoms and diagnostic remission) among CBT-treated vs SSRI-treated children. 4,5 Some, but less, support was found for SNRIs on a few outcomes in some trials; there was no support for tricyclic medications, benzodiazepines, or buspirone. Adverse events and treatment dropout were more common during pharmacotherapy compared with CBT, although SSRIs and pill placebo did not statistically differ in dropout rates, dropout due to adverse events, or any specific adverse events. With regard to psychiatric adverse events, no suicide deaths or attempts were reported in any study and suicidal behavior appeared to be less than in

Cost-effectiveness of Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care

“… 47 Our results build on prior research suggesting that youths with anxiety and/or depression can be successfully treated with a brief transdiagnostic psychosocial intervention. 6 , 7 , 8 , 9 , 10 , 11 Although these results are promising, to our knowledge, few evidence-based interventions for either anxiety or depression are available in health care settings. 15 , 16 , 17 One barrier has been a lack of information about the budgetary impact of programs and their long-term effects on health care costs.…”

“…[3][4][5] Several evidence-based treatments are available for youth anxiety and/or depression, including medication, cognitive behavioral therapy, and interpersonal psychotherapy. [6][7][8][9][10][11] However, less than 50% of youths with these conditions receive any mental health service. 12 Youths with anxiety and depression also often experience physical symptoms that require extensive testing and treatment and thus lead to avoidable costs.…”

“…Without treatment, many youths continue to experience substantial burden, and increased severity and chronicity are associated with decreased treatment responsiveness and increased costs. 13,14 Despite availability of efficacious treatments for anxiety and depression, [6][7][8][9][10][11] usual care services often do not offer evidence-based approaches specifically targeting anxiety or depression. [15][16][17] Health systems experience barriers to providing services with the strongest evidence base, 18 including a lack of information about the immediate budgetary impact of introducing programs as well as their longer-term effects on costs.…”

“…Despite availability of efficacious treatments for anxiety and depression, 6 , 7 , 8 , 9 , 10 , 11 usual care services often do not offer evidence-based approaches specifically targeting anxiety or depression. 15 , 16 , 17 Health systems experience barriers to providing services with the strongest evidence base, 18 including a lack of information about the immediate budgetary impact of introducing programs as well as their longer-term effects on costs.…”

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

“…Empirical evidence contributing to individualized treatment regimens based on tailoring variables, treatment history, and current response status will have the added advantage of supporting shared decision-making by the child and parents with an empirically-informed clinician [ 65 , 66 ], ideally improving patient satisfaction, treatment motivation [ 67 ], and clinical outcomes [ 68 , 69 ]. This study will also explore the effects of treatment on long-term patient and family-centered outcomes, such as symptom recurrence, subjective distress and well-being, social relationships, family and school functioning, and potential adverse treatment effects [ 20 , 70 ]. The findings of this study will therefore inform decisions among patients, families, clinicians, and healthcare leaders about improvements that can be expected in the short- and long-term when treating pediatric anxiety disorders with CBT, medication, or their combination in real-world settings, providing information needed when making critically important treatment choices for individual patients, with a much-needed emphasis on children from underserved and minority populations.…”