Initiation of Pharmacotherapy Following CBT in Anxious Youth: Results From the Child/Adolescent Anxiety Multimodal Study (CAMS)

J Clin Psychiatry 2023;84(1):22m14524

ABSTRACT

Objective: To describe youth with anxiety disorders who initiate pharmacotherapy following cognitive-behavioral therapy (CBT) in a prospective, randomized trial and to identify predictors of the decision to use pharmacotherapy.

Methods: Data from CBT-treated youth (aged 7–17 years, N = 139) in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multisite, randomized controlled trial that examined the efficacy of CBT, sertraline, their combination, and placebo for pediatric anxiety disorders (DSM-IV criteria), were evaluated. Initiation of pharmacotherapy following acute CBT treatment was examined over a 24-week period; the study was conducted from December 2002 through May 2007. Logistic regression models identified features associated with initiating pharmacotherapy, including symptom severity (scores on the Pediatric Anxiety Rating Scale [PARS] and the Screen for Child/Adolescent Anxiety Related Disorders [SCARED]), parent and child treatment expectations, Clinical Global Impressions–Improvement/Severity of Illness (CGI-I/S) scores, and clinical and demographic characteristics.

Results: CBT non-remitters (CGI-S score > 2) who began pharmacotherapy (n = 10) and those who did not (n = 80) were similar in age (P = .445), sex (P = .324), race (P = .242), and symptom severity based on CGI-S (P = .753), PARS (P = .845), or SCARED (P = .678) scores. Mean ± SD improvement (CGI-I score) at week 12 did not differ between patients who initiated pharmacotherapy (3.00 ± 0.82) and those who did not (2.69 ± 0.89, P = .798). However, in the logistic regression, age (P = .003), race (P = .021), and parents’ treatment expectation (P = .037) were significantly associated with the likelihood of initiating pharmacotherapy. Beginning pharmacotherapy in CBT non-remitters was associated with a significant improvement in CGI-S score (mean ± SD decline: −0.99 ± 0.46; 95% credible interval [CrI], −0.088 to −1.89; P = .035) from week 12 to week 36 compared to patients who did not begin pharmacotherapy.

Discussion: Very few CBT non-remitters initiated pharmacotherapy, although beginning medication produced significant improvement. Younger and racial and ethnic minoritized patients as well as those with lower expectations for CBT were less likely to begin medication.

Trial Registration: ClinicalTrials.gov identifier: NCT00052078

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

References (26)

Strawn JR, Lu L, Peris TS, et al. Research review: pediatric anxiety disorders—what have we learnt in the last 10 years? J Child Psychol Psychiatry. 2021;62(2):114–139. PubMed CrossRef
Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359(26):2753–2766. PubMed CrossRef
Bushnell GA, Compton SN, Dusetzina SB, et al. Treating pediatric anxiety: Initial use of SSRIs and other antianxiety prescription medications. J Clin Psychiatry. 2018;79(1):16m11415. PubMed CrossRef
Ginsburg GS, Kendall PC, Sakolsky D, et al. Remission after acute treatment in children and adolescents with anxiety disorders: findings from the CAMS. J Consult Clin Psychol. 2011;79(6):806–813. PubMed CrossRef
Walkup J, Labellarte M, Riddle MA, et al; Research Units on Pediatric Psychopharmacology Anxiety Study Group. Treatment of pediatric anxiety disorders: an open-label extension of the research units on pediatric psychopharmacology anxiety study. J Child Adolesc Psychopharmacol. 2002;12(3):175–188. PubMed CrossRef
Piacentini J, Bennett S, Compton SN, et al. 24- and 36-week outcomes for the child/adolescent anxiety multimodal study (CAMS). J Am Acad Child Adolesc Psychiatry. 2014;53(3):297–310. PubMed CrossRef
Strawn JR, Mills JA, Suresh V, et al. Combining selective serotonin reuptake inhibitors and cognitive behavioral therapy in youth with depression and anxiety. J Affect Disord. 2022;298(Pt A):292–300. PubMed CrossRef
Brown AM, Deacon BJ, Abramowitz JS, et al. Parents’ perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders. Behav Res Ther. 2007;45(4):819–828. PubMed CrossRef
Stevens J, Wang W, Fan L, et al. Parental attitudes toward children’s use of antidepressants and psychotherapy. J Child Adolesc Psychopharmacol. 2009;19(3):289–296. PubMed CrossRef
Compton SN, Walkup JT, Albano AM, et al. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health. 2010;4(1):1. PubMed CrossRef
Kendall PC, Compton SN, Walkup JT, et al. Clinical characteristics of anxiety disordered youth. J Anxiety Disord. 2010;24(3):360–365. PubMed CrossRef
Guy W. CGI Clinical Global Impressions. ECDEU Assessment Manual. 1976:217–222.
The Pediatric Anxiety Rating Scale (PARS): development and psychometric properties. J Am Acad Child Adolesc Psychiatry. 2002;41(9):1061–1069. PubMed CrossRef
Strawn JR, Mills JA, Sauley BA, et al. The impact of antidepressant dose and class on treatment response in pediatric anxiety disorders: a meta-analysis. J Am Acad Child Adolesc Psychiatry. 2018;57(4):235–244.e2. PubMed CrossRef
Suresh V, Mills JA, Croarkin PE, et al. What next? a Bayesian hierarchical modeling re-examination of treatments for adolescents with selective serotonin reuptake inhibitor-resistant depression. Depress Anxiety. 2020;37(9):926–934. PubMed CrossRef
Ge H, Xu K, Ghahramani Z. Turing: a language of flexible probabilistic inference: proceedings of the twenty-first international conference on artificial intelligence and statistics. Proceedings of Machine Learning Research. 2018;84:1682–1690.
Gelman A, Carlin JB, Stern HS, et al. Bayesian Data Analysis. 2nd ed. CRC Press; 2003.
Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997;36(4):545–553. PubMed CrossRef
Peterson BS, West AE, Weisz JR, et al. A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders. BMC Psychiatry. 2021;21(1):323. PubMed CrossRef
Gunlicks-Stoessel M, Mufson L, Bernstein G, et al. Critical decision points for augmenting interpersonal psychotherapy for depressed adolescents: a pilot sequential multiple assignment randomized trial. J Am Acad Child Adolesc Psychiatry. 2019;58(1):80–91. PubMed CrossRef
Radovic A, Reynolds K, McCauley HL, et al. Parents’ role in adolescent depression care: primary care provider perspectives. J Pediatr. 2015;167(4):911–918. PubMed CrossRef
Richardson LP, Lewis CW, Casey-Goldstein M, et al. Pediatric primary care providers and adolescent depression: a qualitative study of barriers to treatment and the effect of the black box warning. J Adolesc Health. 2007;40(5):433–439. PubMed CrossRef
Cummings JR, Ji X, Lally C, et al. Racial and ethnic differences in minimally adequate depression care among medicaid-enrolled youth. J Am Acad Child Adolesc Psychiatry. 2019;58(1):128–138. PubMed CrossRef
Nong P, Raj M, Creary M, et al. Patient-reported experiences of discrimination in the US health care system. JAA Netw Open. 2020;3(12):e2029650. PubMed CrossRef
Boulware LE, Cooper LA, Ratner LE, et al. Race and trust in the health care system. Public Health Rep. 2003;118(4):358–365. PubMed CrossRef
Armstrong K, Putt M, Halbert CH, et al. Prior experiences of racial discrimination and racial differences in health care system distrust. Med Care. 2013;51(2):144–150. PubMed CrossRef