Cognitive-Behavioral Therapy for Childhood Anxiety and Depression

For both depression and anxiety disorders in youths, there is increasing evidence of clinical benefit from cognitive-behavioral therapy (CBT).

Anxiety disorders

Both SSRIs and CBT individually have been shown to be effective in the treatment of children with anxiety disorders. A recent large randomized controlled trial examined the combined efficacy of these treatments in 488 children and adolescents (aged 7 to 17 years) who had anxiety disorder (separation anxiety disorder, social phobia, or generalized anxiety disorder).¹

Patients were randomized to receive sertraline, CBT, sertraline and CBT, or placebo for 12 weeks. Combination treatment was significantly superior to either sertraline or CBT alone. Response rates were 81% for combination treatment, 60% for CBT, 55% for sertraline, and 24% for placebo. The effect size for combination treatment was 0.86 compared with 0.45 for sertraline and 0.31 for CBT. The investigators concluded that children and adolescents who receive combination treatment for anxiety disorders can consistently expect a significant reduction in anxiety severity.

Is CBT effective for young children with anxiety disorders? Typically, anxiety studies include children older than 8 years. Recently, Freeman and colleagues² compared the efficacy of family-based CBT with family-based relaxation treatment for children aged 5 to 8 years who have ob-sessive-compulsive disorder (OCD). The 12-session CBT treatment was tailored to younger children to address their developmental stage. CBT had a moderate treatment effect (0.53). Half of the children who received CBT obtained clinical remission compared with 20% in the relaxation treatment group. The authors recommended family-based CBT as an important component when addressing early childhood–onset OCD.

School-based CBT has been shown to be effective in reducing symptoms of anxiety in children.³ Sixty-one children, aged 7 to 11 years, were randomized to receive group CBT for children, group CBT for children plus parent training, or no treatment for 9 weeks. After a 12-month follow-up period, those who received CBT had significantly less anxiety severity than those in the control group. The authors noted that treatment effects of CBT can be maintained for a 12-month period in children who have anxiety.

Depression

The Treatment for Adolescents With Depression Study4 showed that rates of response after 12 weeks of treatment were highest with fluoxetine plus CBT (71%). This compares with rates of 61% with fluoxetine alone, 43% with CBT alone, and 35% with placebo. Similarly, remission rates were higher in those who received fluoxetine plus CBT (37%). This rate compares with 23% for fluoxetine, 16% for CBT, and 17% for placebo.⁵ For those adolescents who did not achieve a sustained response by 12 weeks, subsequent sustained response rates through week 36 were higher with combined treatment (80%) than with fluoxetine alone (62%) or CBT alone (77%).⁶ The investigators concluded that most depressed adolescents who do not have a sustained response to acute treatment will respond to continuation and maintenance treatments.

The benefit of CBT in preventing relapse in depressed youths (aged 11 to 18 years) treated with antidepressants was recently shown.⁷ In this pilot study, 46 youths who had a positive response to 12 weeks of fluoxetine treatment were randomized to continue either fluoxetine or fluoxetine plus CBT for 6 months. Those who received fluoxetine alone had an 8-fold greater risk of relapse than did those who received fluoxetine plus CBT. At 36 weeks, the estimated probability for relapse was 37% in the fluoxetine group and 15% in the fluoxetine plus CBT group. The investigators suggested that sequential treatment-ie, starting with an antidepressant to achieve clinical response and then adding CBT-may be an effective method for preventing relapse in youths with major depression. Further research is needed to determine the optimal time to add CBT to a depressed youth’s treatment regimen.

The addition of CBT was shown to increase treatment response rates for adolescents with treatment-resistant major depression.⁸ A total of 334 adolescents with major depression who had failed to improve with SSRI treatment (minimum duration, 2 months) were randomized to receive alternative antidepressant medication treatment either with or without CBT. Response rates were higher for those adolescents who received CBT plus alternative antidepressant medication than for controls (55% vs 41%, respectively). Based on the results of this study, it can be expected that more than half of adolescents with moderate to severe depression who do not respond to initial medication treatment will have a positive response to a switch in antidepressant medication combined with CBT.

Unlike anxiety studies, most controlled trials of depression have examined the benefits of CBT in adolescent populations. It will be impor-tant to determine whether there is similar efficacy of CBT for depressed children.

Implications

There is mounting evidence to support CBT as an important component of the treatment regimen for anxiety and depression in youths. Unfortunately, the availability of adequately trained cognitive-behavioral therapists in the community is quite limited. Typically, the CBT administered in treatment studies is provided by individuals who receive training in specific manualized treatment as well as supervision; their sessions are recorded for training purposes. To generalize the results of studies of the efficacy of CBT, clinicians would need similar training.

It is important that residency training programs-particularly in child and adolescent psychiatry-include CBT as an essential component. Ideally, child psychiatry residents should develop equal expertise in pharmacotherapy and in CBT. It is clear from our evidence-based treatments that CBT has become a core skill for clinicians who treat youths with anxiety or depressive disorders.

References:

References

1.

Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety.

N Engl J Med.

2008;359:2753-2766.

2.

Freeman JB, Garcia AM, Coyne L, et al. Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach.

J Am Acad Child Adolesc Psychiatry.

2008;47:593-602.

3.

Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups.

J Am Acad Child Adolesc Psychiatry.

2008;47:1039-1047.

4.

March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.

JAMA.

2004;292:807-820.

5.

Kennard B, Silva S, Vitiello B, et al; TADS Team. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS).

J Am Acad Child Adolesc Psychiatry.

2006;45:1404-1411.

6.

Rohde P, Silva SG, Tonev ST, et al. Achievement and maintenance of sustained response during the Treatment for Adolescents With Depression Study continuation and maintenance therapy.

Arch Gen Psychiatry.

2008;65:447-455.

7.

Kennard BD, Emslie GJ, Mayes TL, et al. Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder.

J Am Acad Child Adolesc Psychiatry.

2008;47:1395-1404.

8.

Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial.

JAMA.

2008;299:901-913.