Combination Therapy for Childhood Anxiety Disorders

Anxiety disorders are among the most common diagnoses in children and adolescents. Anxiety problems that begin in childhood are often quite damaging, leading to low self-esteem, social isolation, inadequate social skills, academic difficulties, and physical manifestations such as headaches and stomachaches. Actual prevalence rates of anxiety disorders reported in the literature vary, but may, in fact, range from approximately 9% to nearly 20% of pediatric patients. Many children with anxiety disorders become adults with anxiety disorders.

Unfortunately, not all treatment options available for adults with anxiety disorders are available for children and adolescents. Benzodiazepines, common in adult populations, carry a high risk of sedation, dependence, and withdrawal, making them inappropriate choices for first-line therapy in children. The few studies evaluating tricyclic antidepressants in children have yielded conflicting results, and these also carry a risk of unwanted side effects. Several studies report the effectiveness of certain selective serotonin reuptake inhibitors (SSRIs), but still more promote the benefits of cognitive behavioral therapy (CBT). Few studies, however, compare the two, or evaluate the effectiveness of combined therapy.

A new study in the New England Journal of Medicine reports that a combination of CBT and the SSRI sertraline (Zoloft) is more effective than either therapy alone. The researchers assessed nearly 500 children between the ages of 7 and 17 years who had a diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia. More than three-quarters of the patients had diagnoses of 2 or more anxiety disorders. The study population was evenly divided between boys and girls, and most of the children were white and middle-class. The severity of anxiety was examined over 12 weeks using the Clinical Global Impression-Improvement scale and the Pediatric Anxiety Rating Scale, and the children were randomized to receive either 14 sessions of CBT, a daily dose of sertraline, a combination of CBT and sertraline, or a placebo pill.

More than 80% of the children who received combination therapy reported that their anxiety was improved at the end of the study. This was significantly better than either therapy alone. CBT alone produced nearly 60% improvement rates, and sertraline alone produced nearly 55% improvement. All therapies were superior to placebo. Adverse events were reported with the same frequency in the sertraline and the placebo group. As expected, there was less insomnia, fatigue, sedation, and restlessness associated with CBT than sertraline. Sertraline, along with the other SSRIs bears a black-box warning regarding the increased risk of suicide in adolescents, but this risk has not been present in this or many other studies evaluating the safety of sertraline.

There are many considerations in choosing the right therapy for anxiety disorders, especially for pediatric patients. The family’s treatment preferences, as well as availability, cost, and time commitments, need to be weighed by the patient, family, and health care provider. All 3 options — drug therapy, CBT, or a combination of both — are safe and effective interventions for children with anxiety disorders. No matter what treatment option is chosen, however, early identification and intervention are critical to improve immediate and long-term outcomes for children with anxiety disorders.

References

(2004). Cognitive-Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents With Obsessive-Compulsive Disorder: The Pediatric OCD Treatment Study (POTS) Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 292 (16), 1969-1976 DOI: 10.1001/jama.292.16.1969

Juliette Liber, Brigit van Widenfelt, Arnold Goedhart, Elisabeth Utens, Adelinde van der Leeden, Monica Markus, Philip Treffers (2008). Parenting and Parental Anxiety and Depression as Predictors of Treatment Outcome for Childhood Anxiety Disorders: Has the Role of Fathers Been Underestimated? Journal of Clinical Child & Adolescent Psychology, 37 (4), 747-758 DOI: 10.1080/15374410802359692

M. A. Rynn (2001). Placebo-Controlled Trial of Sertraline in the Treatment of Children With Generalized Anxiety Disorder American Journal of Psychiatry, 158 (12), 2008-2014 DOI: 10.1176/appi.ajp.158.12.2008

Van Roy B, Kristensen H, Groholt B, Clench-Aas J. Prevalence and characteristics of significant social anxiety in children aged 8-13 years : A Norwegian cross-sectional population study. Soc Psychiatry Psychiatr Epidemiol. Nov 8 2008.

J. T. Walkup, A. M. Albano, J. Piacentini, B. Birmaher, S. N. Compton, J. T. Sherrill, G. S. Ginsburg, M. A. Rynn, J. McCracken, B. Waslick, S. Iyengar, J. S. March, P. C. Kendall (2008). Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety New England Journal of Medicine, 359 (26), 2753-2766 DOI: 10.1056/NEJMoa0804633