Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety

Abstract

Background Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. Methods In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. Results The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. Conclusions Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)

Prefrontal Reactivity to Social Signals of Threat as a Predictor of Treatment Response in Anxious Youth

“…This rate is higher than response rates observed in large randomized controlled trials of CBT and SSRI in anxious youth (Walkup et al, 2008), likely because the current study focused only on youth who completed treatment and posttreatment clinical measures. Though this design allowed us to examine predictors of response to comparable doses of treatment, additional research is needed to evaluate whether neural measures may be useful in predicting whether individuals will remain engaged in treatment and may be more likely to tolerate one type of treatment over another.…”

“…Separation, social, and generalized anxiety disorder (GAD) are particularly common among youth, with relatively early ages of onset and high rates of co-occurence with each other (Mohatt et al, 2014;Verduin and Kendall, 2003). Although both pharmacological (ie, selective serotonin reuptake inhibitors (SSRIs)) and cognitive behavioral therapy (CBT) are effective in treating pediatric anxiety disorders, approximately 40-45% of youth fail to show significant improvement in symptoms (Mohatt et al, 2014;Walkup et al, 2008), raising the need to identify predictors of treatment response.…”

Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review

“…Some aspects of methodological quality were widely ignored; for example, only one study specifically addressed and reported possible adverse effects of psychological treatment (Walkup et al, 2008).…”

Pediatric anxiety disorders: from neuroscience to evidence-based clinical practice

“…In clinically referred samples, comorbidity is often the rule rather than the exception, 108 with more than half of the patients having more than one anxiety disorder. In community samples, anxiety also increases the chance of having additional psychiatric diagnoses such as major depression (odds ratio [OR] = 8.2; 95%CI 5.8-12), ADHD (OR = 3.0; 95%CI 2.1-4.3), and oppositional defiant disorder/conduct disorder (OR = 3.1; 95%CI 2.2-4.6).…”

“…108,168 For non-OCD anxiety disorders, the CBT+sertraline combined treatment was more effective than both monotherapy conditions and the placebo condition. 108 For OCD, the combined treatment was more effective than the sertraline monotherapy and the placebo conditions, but there was no difference between the combined treatment and the CBT monotherapy.…”