Combined antidepressants and psychotherapy most effective for childhood anxiety

Armen Hareyan's picture
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Treatment that combines cognitive behavior therapy (CBT) with an antidepressant medication is most likely to help children with anxiety disorders, but each of the treatments alone is also effective, according to a new study funded by the National Institutes of Health's National Institute of Mental Health (NIMH).

"Anxiety disorders are among the most common mental disorders affecting children and adolescents. Untreated anxiety can undermine a child's success in school, jeopardize his or her relationships with family, and inhibit social functioning," said NIMH Director Thomas R. Insel, MD "This study provides strong evidence and reassurance to parents that a well-designed, two-pronged treatment approach is the gold standard, while a single line of treatment is still effective."

The Child/Adolescent Anxiety Multimodal Study (CAMS) randomly assigned 488 children ages 7 years to 17 years to one of four treatment options for a 12-week period:

* Cognitive behavioral therapy (CBT), a specific type of therapy that, for this study, taught children about anxiety and helped them face and master their fears by guiding them through structured tasks;
* A Selective Serotonin Re-Uptake Inhibitor (SSRI) class antidepressant (sertraline [Zoloft®]);
* CBT combined with sertraline;
* pill placebo (sugar pill).

The children, recruited from six regionally dispersed sites throughout the United States, all had moderate to severe separation anxiety disorder, generalized anxiety disorder or social phobia. Many also had coexisting disorders, including other anxiety disorders, attention deficit hyperactivity disorder, and behavior problems.

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The six CAMS sites were Duke University; New York State Psychiatric Institute/Columbia University Medical Center; Johns Hopkins University; Temple University/University of Pennsylvania; University of California, Los Angeles; and the Western Psychiatric Institute and Clinic/University of Pittsburgh Medical Center.

John Walkup, MD, of Johns Hopkins Medical Institutions, and colleagues found that among those in combination treatment, 81 percent improved. Sixty percent in the CBT-only group, and 55 percent in the sertraline-only group improved. Among those on placebo, 24 percent improved. A second phase of the study will monitor the children for an additional six months.

"CAMS clearly showed that combination treatment is the most effective for these children. But sertraline alone or CBT alone showed a good response rate as well. This suggests that clinicians and families have three good options to consider for young people with anxiety disorders, depending on treatment availability and costs," said Walkup.

Results also demonstrated that the treatments were safe. Children taking sertraline alone showed no more side effects than the children taking the placebo and few children discontinued the trial due to side effects. In addition, no child attempted suicide, a rare side effect sometimes associated with antidepressant medications in children.

CAMS findings echo previous studies in which sertraline and other SSRIs were found to be effective in treating childhood anxiety disorder. The study's results also add more evidence that high-quality CBT, with or without medication, can effectively treat anxiety disorders in children, according to the researchers.

"Further analyses of the CAMS data may help us predict who is most likely to respond to which treatment, and develop more personalized treatment approaches for children with anxiety disorders," concluded Philip C. Kendall, PhD, of Temple University, a senior investigator of the study. "But in the meantime, we can be assured that we already have good treatments at our disposal."

Walkup JT, Albano AM, Piacentini J, et al. Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety disorders: acute phase efficacy and safety. NEJM 2008 Oct;doi:10.1056/NEJMoa0804633. See the full study.

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