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Bushnell GA, Rynn MA, Gerhard T, Keyes KM, Hasin DS, Cerdá M, Nyandege A, Olfson M. Drug overdose risk with benzodiazepine treatment in young adults: Comparative analysis in privately and publicly insured individuals. Addiction 2024; 119:356-368. [PMID: 37816665 PMCID: PMC10838605 DOI: 10.1111/add.16359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND AIMS Benzodiazepines (BZDs) carry a risk for drug overdose and are prescribed alone or simultaneously with selective-serotonin reuptake inhibitors (SSRIs) for the treatment of anxiety and depression in young adults. We aimed to measure risks of drug overdose following BZD treatment initiation, and simultaneous BZD and SSRI initiation, compared with SSRI treatment alone in young adults with depression or anxiety. DESIGN, SETTING, PARTICIPANTS The cohort study used administrative databases covering privately (MarketScan, 1/1/2009-12/31/2018) and publicly (Medicaid, 1/1/2015-12/31/2016) insured young adults (18-29 years) in the United States. Those with depression or anxiety diagnoses newly initiating BZD or SSRI treatment (without BZD or SSRI prescriptions in prior year) were included. Simultaneous "BZD + SSRI" initiation was defined as starting BZD and SSRI treatment on the same day. The cohorts included 604 664 privately insured young adults (BZD = 22%, BZD + SSRI = 10%, SSRI = 68%) and 110 493 publicly insured young adults (BZD = 23%, BZD + SSRI = 5%, SSRI = 72%). MEASUREMENTS Incident medically treated drug overdose events were identified from emergency department and inpatient encounters (ICD poisoning codes) within 6 months of treatment initiation. Crude and propensity-score adjusted cumulative incidence and hazard ratios (HR) were estimated. Sub-analyses evaluated drug overdose intent. FINDINGS Adjusted HRs of drug overdose for BZD vs. SSRI treatment was 1.36 (95% confidence interval [CI]:1.23-1.51) in privately and 1.59 (95%CI:1.37-1.83) in publicly insured young adults. The adjusted HRs of drug overdose for BZD + SSRI treatment vs. SSRI treatment were 1.99 (95%CI:1.77-2.25) in privately and 1.98 (95%CI:1.47-2.68) in publicly insured young adults. CONCLUSIONS Among young adults in the United States, initiating benzodiazepine treatment for anxiety and depression, alone or simultaneously with selective-serotonin reuptake inhibitors (SSRI), appears to have an increased risk of medically treated drug overdose compared with SSRI treatment alone. These associations were observed in publicly and privately insured individuals.
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Affiliation(s)
- Greta A Bushnell
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers University School of Public Health, Piscataway, NJ, USA
| | - Moira A Rynn
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Tobias Gerhard
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Katherine M Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Abner Nyandege
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
| | - Mark Olfson
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
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Wang Z, Fontaine M, Cyr M, Rynn MA, Simpson HB, Marsh R, Pagliaccio D. Subcortical shape in pediatric and adult obsessive-compulsive disorder. Depress Anxiety 2022; 39:504-514. [PMID: 35485920 PMCID: PMC9813975 DOI: 10.1002/da.23261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/22/2022] [Accepted: 04/16/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) implicates alterations in cortico-striato-thalamo-cortical and fronto-limbic circuits. Building on prior structural findings, this is the largest study to date examining subcortical surface morphometry in OCD. METHODS Structural magnetic resonance imaging data were collected from 200 participants across development (5-55 years): 28 youth and 75 adults with OCD and 27 psychiatrically healthy youth and 70 adults. General linear models were used to assess group differences and group-by-age interactions on subcortical shape (FSL FIRST). RESULTS Compared to healthy participants, those with OCD exhibited surface expansions on the right nucleus accumbens and inward left amygdala deformations, which were associated with greater OCD symptom severity ([Children's] Yale-Brown Obsessive-Compulsive Scale). Group-by-age interactions indicated that accumbens group differences were driven by younger participants and that right pallidum shape was associated inversely with age in healthy participants, but not in participants with OCD. No differences in the shape of other subcortical regions or in volumes (FreeSurfer) were detected in supplementary analyses. CONCLUSIONS This study is the largest to date examining subcortical shape in OCD and the first to do so across the developmental spectrum. NAcc and amygdala shape deformation builds on extant neuroimaging findings and suggests subtle, subregional alterations beyond volumetric findings. Results shed light on morphometric alterations in OCD, informing current pathophysiological models.
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Affiliation(s)
- Zhishun Wang
- The Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Martine Fontaine
- The Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Marilyn Cyr
- The Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Moira A. Rynn
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Helen Blair Simpson
- The Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Rachel Marsh
- The Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - David Pagliaccio
- The Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
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Abstract
Objective: There are potential risks and benefits of combining benzodiazepine (BZD) and selective serotonin reuptake inhibitor (SSRI) therapy at anxiety disorder treatment onset. We investigated how often adolescents and young adults with anxiety disorders simultaneously initiate BZD treatment with SSRI treatment and examined whether SSRI treatment duration varies by simultaneous BZD initiation. Methods: In a United States commercial claims database (January 2008-December 2016), we identified adolescents (10-17 years) and young adults (18-24 years) with ICD-9-CM/ICD-10-CM anxiety disorder diagnoses initiating SSRI treatment, without past-year SSRI and BZD treatment. We defined simultaneous initiation as filling a new BZD prescription on the date of SSRI initiation. We estimated time to SSRI treatment discontinuation and used stabilized inverse probability of treatment weighting for adjusted estimates. Results: The study included 94,399 adolescents and 130,971 young adults initiating SSRI treatment with an anxiety disorder. Four percent of adolescents and 17% of young adults simultaneously initiated BZD treatment, varying by age, anxiety disorder, comorbidities, health care utilization, and provider type. Simultaneous BZD initiation among SSRI initiators declined from 2008 to 2016. SSRI treatment duration was similar in initiators of simultaneous therapy vs SSRI monotherapy: ≥ 6 months in adolescents (55% vs 56%, respectively) and in young adults (39% vs 40%). Nine percent of simultaneous initiators continued BZDs for ≥ 6 months. Conclusions: Simultaneous initiation of BZD and SSRI treatment is relatively common in young adults with anxiety disorders and was not associated with longer SSRI persistence. Given risks of BZD treatment, potential benefits and risks of adding a BZD at SSRI treatment initiation must be carefully weighed.
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Affiliation(s)
- Greta A. Bushnell
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ,Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ
| | - Moira A. Rynn
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ
| | - Tobias Gerhard
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ,Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ
| | - Mark Olfson
- Department of Epidemiology, Columbia University Mailman School of Public Health and Department of Psychiatry, Columbia University Irving Medical Center, New York, NY
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Cyr M, Pagliaccio D, Yanes-Lukin P, Goldberg P, Fontaine M, Rynn MA, Marsh R. Altered fronto-amygdalar functional connectivity predicts response to cognitive behavioral therapy in pediatric obsessive-compulsive disorder. Depress Anxiety 2021; 38:836-845. [PMID: 34157177 PMCID: PMC8328961 DOI: 10.1002/da.23187] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/29/2021] [Accepted: 05/22/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Based on findings from adults with obsessive-compulsive disorder (OCD), this study examined alterations in resting-state functional connectivity (rs-fc) between the basolateral amygdala (BLA) and the ventromedial prefrontal cortex (vmPFC) in children and adolescents with OCD. We also assessed whether such BLA-vmPFC connectivity changed with or predicted response to exposure and response prevention (E/RP), the first-line treatment for pediatric OCD, given the involvement of these regions in fear processing, regulation, and extinction learning-a probable mechanism of action of E/RP. METHODS Resting state functional magnetic resonance imaging scans were acquired from 25 unmedicated, treatment-naïve pediatric patients with OCD (12.8 ± 2.9 years) and 23 age- and sex-matched healthy controls (HCs; 11.0 ± 3.3 years). Patients completed a 12-16-week E/RP intervention for OCD. Participants were rescanned after the 12-16-week period. ANCOVAs tested group differences in baseline rs-fc. Cross-lagged panel models examined relationships between BLA-vmPFC rs-fc and OCD symptoms pre- and posttreatment. All tests were adjusted for participants' age, sex, and head motion. RESULTS Right BLA-vmPFC rs-fc was significantly reduced (more negative) in patients with OCD relative to HCs at baseline, and increased following treatment. In patients, more positive (less negative) right BLA-vmPFC rs-fc pretreatment predicted greater OCD symptoms reduction posttreatment. Changes in BLA-vmPFC rs-fc was unassociated with change in OCD symptoms pre- to posttreatment. CONCLUSIONS These results provide further evidence of the BLA-vmPFC pathway as a potential target for novel treatments or prevention strategies aimed at facilitating adaptive learning and fear extinction in children with OCD or subclinical OCD symptoms.
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Affiliation(s)
- Marilyn Cyr
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - David Pagliaccio
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Paula Yanes-Lukin
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Pablo Goldberg
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Martine Fontaine
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Moira A. Rynn
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rachel Marsh
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Pagliaccio D, Cha J, He X, Cyr M, Yanes-Lukin P, Goldberg P, Fontaine M, Rynn MA, Marsh R. Structural neural markers of response to cognitive behavioral therapy in pediatric obsessive-compulsive disorder. J Child Psychol Psychiatry 2020; 61:1299-1308. [PMID: 31889307 PMCID: PMC7326644 DOI: 10.1111/jcpp.13191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cognitive behavioral therapy (CBT) is an effective, first-line treatment for pediatric obsessive-compulsive disorder (OCD). While neural predictors of treatment outcomes have been identified in adults with OCD, robust predictors are lacking for pediatric patients. Herein, we sought to identify brain structural markers of CBT response in youth with OCD. METHODS Twenty-eight children/adolescents with OCD and 27 matched healthy participants (7- to 18-year-olds, M = 11.71 years, SD = 3.29) completed high-resolution structural and diffusion MRI (all unmedicated at time of scanning). Patients with OCD then completed 12-16 sessions of CBT. Subcortical volume and cortical thickness were estimated using FreeSurfer. Structural connectivity (streamline counts) was estimated using MRtrix. RESULTS Thinner cortex in nine frontoparietal regions significantly predicted improvement in Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores (all ts > 3.4, FDR-corrected ps < .05). These included middle and superior frontal, angular, lingual, precentral, superior temporal, and supramarginal gyri (SMG). Vertex-wise analyses confirmed a significant left SMG cluster, showing large effect size (Cohen's d = 1.42) with 72.22% specificity and 90.00% sensitivity in predicting CBT response. Ten structural connections between cingulo-opercular regions exhibited fewer streamline counts in OCD (all ts > 3.12, Cohen's ds > 0.92) compared with healthy participants. These connections predicted post-treatment CY-BOCS scores, beyond pretreatment severity and demographics, though not above and beyond cortical thickness. CONCLUSIONS The current study identified group differences in structural connectivity (reduced among cingulo-opercular regions) and cortical thickness predictors of CBT response (thinner frontoparietal cortices) in unmedicated children/adolescents with OCD. These data suggest, for the first time, that cortical and white matter features of task control circuits may be useful in identifying which pediatric patients respond best to individual CBT.
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Affiliation(s)
- David Pagliaccio
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jiook Cha
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Xiaofu He
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Marilyn Cyr
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Paula Yanes-Lukin
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Pablo Goldberg
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Martine Fontaine
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Moira A. Rynn
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rachel Marsh
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA;,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Cyr M, Pagliaccio D, Yanes-Lukin P, Fontaine M, Rynn MA, Marsh R. Altered network connectivity predicts response to cognitive-behavioral therapy in pediatric obsessive-compulsive disorder. Neuropsychopharmacology 2020; 45:1232-1240. [PMID: 31952071 PMCID: PMC7235012 DOI: 10.1038/s41386-020-0613-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/21/2019] [Accepted: 01/08/2020] [Indexed: 12/12/2022]
Abstract
Obsessive-compulsive disorder (OCD) is commonly associated with alterations in cortico-striato-thalamo-cortical brain networks. Yet, recent investigations of large-scale brain networks suggest that more diffuse alterations in brain connectivity may underlie its pathophysiology. Few studies have assessed functional connectivity within or between networks across the whole brain in pediatric OCD or how patterns of connectivity associate with treatment response. Resting-state functional magnetic resonance imaging scans were acquired from 25 unmedicated, treatment-naive children and adolescents with OCD (12.8 ± 2.9 years) and 23 matched healthy control (HC) participants (11.0 ± 3.3 years) before participants with OCD completed a course of cognitive-behavioral therapy (CBT). Participants were re-scanned after 12-16 weeks. Whole-brain connectomic analyses were conducted to assess baseline group differences and group-by-time interactions, corrected for multiple comparisons. Relationships between functional connectivity and OCD symptoms pre- and post-CBT were examined using longitudinal cross-lagged panel modeling. Reduced connectivity in OCD relative to HC participants was detected between default mode and task-positive network regions. Greater (less altered) connectivity between left angular gyrus and left frontal pole predicted better response to CBT in the OCD group. Altered connectivity between task-positive and task-negative networks in pediatric OCD may contribute to the impaired control over intrusive thoughts early in the illness. This is the first study to show that altered connectivity between large-scale network regions may predict response to CBT in pediatric OCD, highlighting the clinical relevance of these networks as potential circuit-based targets for the development of novel treatments.
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Affiliation(s)
- Marilyn Cyr
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA. .,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | - David Pagliaccio
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Paula Yanes-Lukin
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Martine Fontaine
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Moira A. Rynn
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Rachel Marsh
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
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Sanchez AL, Comer JS, Coxe S, Albano AM, Piacentini J, Compton SN, Ginsburg GS, Rynn MA, Walkup JT, Sakolsky DJ, Birmaher B, Kendall PC. The Effects of Youth Anxiety Treatment on School Impairment: Differential Outcomes Across CBT, Sertraline, and their Combination. Child Psychiatry Hum Dev 2019; 50:940-949. [PMID: 31087216 DOI: 10.1007/s10578-019-00896-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Youth anxiety disorders are highly prevalent and are associated with considerable school impairment. Despite the identification of well-supported strategies for treating youth anxiety, research has yet to evaluate the differential effects of these treatments on anxiety-related school impairment. The present study leveraged data from the Child/Adolescent Anxiety Multimodal Study to examine differential treatment effects of CBT, sertraline, and their combination (COMB), relative to placebo (PBO), on anxiety-related school impairment among youth (N = 488). Latent growth modeling revealed that all three active treatments demonstrated superiority over PBO in reducing anxiety-related school impairment over time, with COMB showing the most robust effects. According to parent report, medication strategies may have stronger effects on anxiety-related school impairment among males than among females. Results were discrepant across parents and youth. Findings are discussed in terms of clinical implications for anxious youth and the need for continued research to examine treatment effects on anxiety-related school impairment.
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Affiliation(s)
- Amanda L Sanchez
- Center for Children and Families and Department of Psychology, Florida International University, Miami, FL, USA.
| | - Jonathan S Comer
- Center for Children and Families and Department of Psychology, Florida International University, Miami, FL, USA
| | - Stefany Coxe
- Center for Children and Families and Department of Psychology, Florida International University, Miami, FL, USA
| | - Anne Marie Albano
- Division of Child & Adolescent Psychiatry, Department of Psychiatry, Columbia University Medical Center, New York State Psychiatric Institute, New York, NY, USA
| | - John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | - Scott N Compton
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, NC, USA
| | - Golda S Ginsburg
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Moira A Rynn
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, NC, USA
| | - John T Walkup
- Anne and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Dara J Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, USA
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Bushnell GA, Compton SN, Dusetzina SB, Gaynes BN, Brookhart MA, Walkup JT, Rynn MA, Stürmer T. Treating Pediatric Anxiety: Initial Use of SSRIs and Other Antianxiety Prescription Medications. J Clin Psychiatry 2018; 79:16m11415. [PMID: 29099547 PMCID: PMC6468981 DOI: 10.4088/jcp.16m11415] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/15/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Multiple pharmacotherapies for treating anxiety disorders exist, including selective serotonin reuptake inhibitors (SSRIs), the recommended first-line pharmacotherapy for pediatric anxiety. We sought to describe initial antianxiety medication use in children and estimate how long antianxiety medications were continued. METHODS In a large commercial claims database, we identified children (3-17 years) initiating prescription antianxiety medication from 2004 to 2014 with a recent anxiety diagnosis (ICD-9-CM = 293.84, 300.0x, 300.2x, 300.3x, 309.21, 309.81, 313.23). We estimated the proportion of children initiating each medication class across the study period and used multivariable regression to evaluate factors associated with initiation with an SSRI. We evaluated treatment length for each initial medication class. RESULTS Of 84,500 children initiating antianxiety medication, 70% initiated with an SSRI (63% [95% CI, 62%-63%] SSRI alone, 7% [95% CI, 7%-7%] SSRI + another antianxiety medication). Non-SSRI medications initiated included benzodiazepines (8%), non-SSRI antidepressants (7%), hydroxyzine (4%), and atypical antipsychotics (3%). Anxiety disorder, age, provider type, and comorbid diagnoses were associated with initial medication class. The proportion of children refilling their initial medication ranged from 19% (95% CI, 18%-20%) of hydroxyzine initiators and 25% (95% CI, 24%-26%) of benzodiazepine initiators to 81% (95% CI, 80%-81%) of SSRI initiators. Over half (55%, 95% CI, 55%-56%) of SSRI initiators continued SSRI treatment for 6 months. CONCLUSIONS SSRIs are the most commonly used first-line medication for pediatric anxiety disorders, with about half of SSRI initiators continuing treatment for 6 months. Still, a third began therapy on a non-SSRI medication, for which there is limited evidence of effectiveness for pediatric anxiety, and a notable proportion of children initiated with 2 antianxiety medication classes.
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Affiliation(s)
- Greta A. Bushnell
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Scott N. Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Stacie B. Dusetzina
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy and the Department of Health Policy and Management, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - M. Alan Brookhart
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - John T. Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, New York
| | - Moira A. Rynn
- Division of Child and Adolescent Psychiatry, Department of Psychiatry at Columbia University/New York State Psychiatric Institute, New York, New York
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina
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Albano AM, Comer JS, Compton SN, Piacentini J, Kendall PC, Birmaher B, Walkup JT, Ginsburg GS, Rynn MA, McCracken J, Keeton C, Sakolsky DJ, Sherrill JT. Secondary Outcomes From the Child/Adolescent Anxiety Multimodal Study: Implications for Clinical Practice. ACTA ACUST UNITED AC 2017; 3:30-41. [PMID: 30906874 DOI: 10.1080/23794925.2017.1399485] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background Controlled evaluations comparing medication, cognitive-behavioral therapy (CBT), and their combination in the treatment of youth anxiety have predominantly focused on global ratings by independent evaluators. Such ratings are resource-intensive, may be of limited generalizability, and do not directly inform our understanding of treatment responses from the perspective of treated families. We examined outcomes from the perspective of treated youth and parents in the Child/Adolescent Anxiety Multimodal Study (CAMS). Methods Participants (N=488; ages 7-17 years) who had a primary diagnosis of separation, social, and/or generalized anxiety disorder were randomly assigned to a treatment condition in the CAMS trial. Linear mixed-effects and ANCOVA models examined parent- and youth-reported anxiety symptoms, impact of anxiety, broader internalizing and externalizing psychopathology, depressive symptoms, and family burden throughout the 12-week acute treatment phase and 6-month follow-up. Results At week 12, combination treatment showed superiority over placebo, sertraline, and CBT with regard to parent-reported youth anxiety symptoms, and sertraline and CBT as monotherapies showed superiority over placebo with regard to parent-reported youth anxiety. Combination therapy and sertraline also showed week 12 superiority over placebo with regard to parent-reported internalizing psychopathology, and superiority over placebo and CBT with regard to parent-reported impact of anxiety, family burden, and youth depressive symptoms. By week 36, parent reports of many youth outcomes were comparable across active conditions. Youth measures tracked parent measures on many outcomes. Conclusions Findings were drawn on brief, readily available questionnaires that in conjunction with clinician measures can inform patient-centered care and collaborative decision-making.Trial Registry Name: Child and Adolescent Anxiety Disorders (CAMS)Registry identification number: NCT00052078Registry URL: https://www.clinicaltrials.gov/ct2/show/NCT00052078.
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Affiliation(s)
- Anne Marie Albano
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, Columbia University Medical Center, New York, NY
| | - Jonathan S Comer
- Departments of Psychology and Psychiatry, Center for Children and Families, Florida International University, Miami, FL
| | - Scott N Compton
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, North Carolina
| | - John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
| | | | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John T Walkup
- Department of Psychiatry, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY
| | - Golda S Ginsburg
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT
| | - Moira A Rynn
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, North Carolina
| | - James McCracken
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
| | - Courtney Keeton
- Department of Psychiatry, Johns Hopkins Medical Institutions
| | - Dara J Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joel T Sherrill
- Division of Services and Interventions Research, National Institute of Mental Health, Bethesda, MD
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Strawn JR, Dobson ET, Mills JA, Cornwall GJ, Sakolsky D, Birmaher B, Compton SN, Piacentini J, McCracken JT, Ginsburg GS, Kendall PC, Walkup JT, Albano AM, Rynn MA. Placebo Response in Pediatric Anxiety Disorders: Results from the Child/Adolescent Anxiety Multimodal Study. J Child Adolesc Psychopharmacol 2017; 27:501-508. [PMID: 28384010 PMCID: PMC5568015 DOI: 10.1089/cap.2016.0198] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study is to identify predictors of pill placebo response and to characterize the temporal course of pill placebo response in anxious youth. METHODS Data from placebo-treated patients (N = 76) in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multisite, randomized controlled trial that examined the efficacy of cognitive-behavioral therapy, sertraline, their combination, and placebo for the treatment of separation, generalized, and social anxiety disorders, were evaluated. Multiple linear regression models identified features associated with placebo response and models were confirmed with leave-one-out cross-validation. The likelihood of improvement in patients receiving pill placebo-over time-relative to improvement associated with active treatment was determined using probabilistic Bayesian analyses. RESULTS Based on a categorical definition of response (Clinical Global Impressions-Improvement Scale score ≤2), nonresponders (n = 48), and pill placebo responders (n = 18) did not differ in age (p = 0.217), sex (p = 0.980), race (p = 0.743), or primary diagnosis (all ps > 0.659). In terms of change in anxiety symptoms, separation anxiety disorder and treatment expectation were associated with the degree of pill placebo response. Greater probability of placebo-related anxiety symptom improvement was observed early in the course of treatment (baseline to week 4, p < 0.0001). No significant change in the probability of placebo-related improvement was observed after week 4 (weeks 4-8, p = 0.07; weeks 8-12, p = 0.85), whereas the probability of improvement, in general, significantly increased week over week with active treatment. CONCLUSIONS Pill placebo-related improvement occurs early in the course of treatment and both clinical factors and expectation predict this improvement. Additionally, probabilistic approaches may refine our understanding and prediction of pill placebo response.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eric T. Dobson
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey A. Mills
- Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio
| | - Gary J. Cornwall
- Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA), Los Angeles, California
| | - James T. McCracken
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA), Los Angeles, California
| | | | | | - John T. Walkup
- Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Anne Marie Albano
- Columbia University Medical Center (CUMC)/New York State Psychiatric Institute, New York, New York
| | - Moira A. Rynn
- Columbia University Medical Center (CUMC)/New York State Psychiatric Institute, New York, New York
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Strawn JR, Compton SN, Robertson B, Albano AM, Hamdani M, Rynn MA. Extended Release Guanfacine in Pediatric Anxiety Disorders: A Pilot, Randomized, Placebo-Controlled Trial. J Child Adolesc Psychopharmacol 2017; 27:29-37. [PMID: 28165762 PMCID: PMC5695796 DOI: 10.1089/cap.2016.0132] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE This is a feasibility study evaluating the safety, tolerability, and potential anxiolytic efficacy of the α2 agonist guanfacine extended-release (GXR) in children and adolescents with generalized anxiety disorder (GAD), separation anxiety disorder (SAD), or social phobia/social anxiety disorder. METHODS Youth aged 6-17 years with a primary diagnosis of GAD, SAD, and/or social anxiety disorder were treated with flexibly dosed GXR (1-6 mg daily, n = 62) or placebo (n = 21) for 12 weeks. The primary aim of this study was to determine the safety and tolerability of GXR in youth with anxiety disorders, which involved the analysis of treatment-emergent adverse events (TEAEs), the emergence of suicidal ideation and behaviors, vital signs, and electrocardiographic/laboratory parameters. Exploratory efficacy measures included dimensional anxiety scales (Pediatric Anxiety Rating Scale [PARS] and Screen for Child Anxiety Related Emotional Disorders [SCARED]), as well as the Clinical Global Impression-Improvement (CGI-I) scale. As this was an exploratory study, no inferential statistical analyses were performed. RESULTS GXR was safe and well tolerated. Treatment-related mean ± standard deviation changes in heart rate (GXR: 1.8 ± 12 beats per minute [bpm] decrease; placebo: 0.5 ± 11 bpm decrease), systolic blood pressure (GXR: 2.3 ± 11 mm Hg decrease; placebo: 1.7 ± 11 mm Hg decrease), or diastolic blood pressure (GXR: 1.3 ± 9 mm Hg decrease; placebo: 0.9 ± 7 mm Hg increase) were similar between treatment groups. TEAEs, including headache, somnolence/fatigue, abdominal pain, and dizziness, were consistent with the known safety profile of GXR. No differences were observed between treatment groups for PARS and SCARED scores, although at endpoint, a higher proportion of subjects receiving GXR versus placebo demonstrated CGI-I scores ≤2 (54.2% vs. 31.6%), as rated by the clinician investigator. CONCLUSIONS GXR was well tolerated in pediatric subjects with GAD, SAD, and/or social anxiety disorder. ClinicalTrials.gov Identifier: NCT01470469.
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Affiliation(s)
- Jeffrey R. Strawn
- Anxiety Disorders Research Program, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Scott N. Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Anne Marie Albano
- New York State Psychiatric Institute, Columbia University, New York, New York
| | | | - Moira A. Rynn
- New York Presbyterian Morgan Stanley Children's Hospital, Columbia University/New York State Psychiatric Institute, New York, New York
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Rynn MA, Walkup JT, Compton SN, Sakolsky DJ, Sherrill JT, Shen S, Kendall PC, McCracken J, Albano AM, Piacentini J, Riddle MA, Keeton C, Waslick B, Chrisman A, Iyengar S, March JS, Birmaher B. Child/Adolescent anxiety multimodal study: evaluating safety. J Am Acad Child Adolesc Psychiatry 2015; 54:180-90. [PMID: 25721183 PMCID: PMC4362776 DOI: 10.1016/j.jaac.2014.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/08/2014] [Accepted: 12/29/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of adverse events (AEs) across 4 treatment conditions in the Child/Adolescent Anxiety Multimodal Study (CAMS), and to compare the frequency of AEs between children and adolescents. METHOD Participants ages 7 to 17 years (mean = 10.7 years) meeting the DSM-IV criteria for 1 or more of the following disorders: separation anxiety disorder, generalized anxiety disorder, or social phobia were randomized (2:2:2:1) to cognitive-behavioral therapy (CBT, n = 139), sertraline (SRT, n = 133), a combination of both (COMB, n = 140), or pill placebo (PBO, n = 76). Data on AEs were collected via a standardized inquiry method plus a self-report Physical Symptom Checklist (PSC). RESULTS There were no differences between the double-blinded conditions (SRT versus PBO) for total physical and psychiatric AEs or any individual physical or psychiatric AEs. The rates of total physical AEs were greater in the SRT-alone treatment condition when compared to CBT (p < .01) and COMB (p < .01). Moreover, those who received SRT alone reported higher rates of several physical AEs when compared to COMB and CBT. The rate of total psychiatric AEs was higher in children (≤12 years) across all arms (31.7% versus 23.1%, p < .05). Total PSC scores decreased over time, with no significant differences between treatment groups. CONCLUSION The results support the tolerability/safety of selective serotonin reuptake inhibitor (SSRI) treatment for anxiety disorders even after adjusting for the number of reporting opportunities, leading to no differences in overall rates of AEs. Few differences occurred on specific items. Additional monitoring of psychiatric AEs is recommended in children (≤12 years). Clinical trial registration information-Child and Adolescent Anxiety Disorders (CAMS); http://clinicaltrials.gov; NCT00052078.
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Affiliation(s)
- Moira A Rynn
- Columbia University Medical Center (CUMC)/New York State Psychiatric Institute, New York.
| | - John T Walkup
- Weill Cornell Medical College and New York Presbyterian Hospital, New York
| | | | - Dara J Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
| | - Joel T Sherrill
- Division of Services and Intervention Research at the National Institute of Mental Health (NIMH), Bethesda, MD
| | - Sa Shen
- University of Illinois at Urbana-Champaign
| | | | - James McCracken
- University of California, Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior
| | - Anne Marie Albano
- Columbia University Medical Center (CUMC)/New York State Psychiatric Institute, New York
| | - John Piacentini
- University of California, Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior
| | - Mark A Riddle
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Satish Iyengar
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
| | | | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
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Strawn JR, Welge JA, Wehry AM, Keeshin BR, Rynn MA. Efficacy and tolerability of antidepressants in pediatric anxiety disorders: a systematic review and meta-analysis. Depress Anxiety 2015; 32:149-57. [PMID: 25449861 PMCID: PMC4514767 DOI: 10.1002/da.22329] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/28/2014] [Accepted: 09/27/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Randomized controlled trials have demonstrated that antidepressants are efficacious in the treatment of anxiety disorders in youth. However, there are no recent, systematic analyses of the efficacy, safety, or tolerability of these medications in pediatric anxiety disorders. METHODS A systematic review and meta-analysis of prospective, randomized, parallel-group, controlled trials of selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) in pediatric patients with non-obsessive compulsive disorder (OCD) anxiety disorders was undertaken using a search of PubMed/Medline (1966-2014). The meta-analysis utilized random-effects models to evaluate change in the Pediatric Anxiety Rating Scale or similar anxiety scale, suicidality, and adverse events. Additionally, pharmacologic variables were explored with regard to effect size, although no correction for multiple comparisons was made with regard to these relationships. RESULTS Nine trials involving 1,673 patients and six medications were included. All SSRI/SSNRIs evaluated demonstrated efficacy, and the meta-analytic estimate of effect was of moderate magnitude (Cohen's d = 0.62, confidence interval [CI]: 0.34-0.89, P = .009) and there was evidence of modest heterogeneity (I(2) = 0.29, P = .103). Activation trended toward being more likely with antidepressant treatment (OR: 1.86, CI: 0.98-3.53, P = .054), but no increased risk was observed for nausea/abdominal symptoms (P = .262), discontinuation as a result of an adverse event (P = .132), or suicidality (OR: 1.3, CI: 0.53-3.2, P = .514). Finally, the effect size correlated with the serotonergic specificity of the agent (R = .79, P = .021). CONCLUSIONS Data for nine SSRI/SSNRIs suggest superiority of antidepressants relative to placebo for the treatment of pediatric anxiety disorders with a moderate effect size.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH 45219
- Cincinnati Children's Hospital Medical Center, Department of Psychiatry, Cincinnati, Ohio, 45267
| | - Jeffrey A. Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH 45219
| | - Anna M. Wehry
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH 45219
| | | | - Moira A. Rynn
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute (NYSPI), New York, New York
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Rickels K, Etemad B, Rynn MA, Lohoff FW, Mandos LA, Gallop R. Remission of generalized anxiety disorder after 6 months of open-label treatment with venlafaxine XR. Psychother Psychosom 2014; 82:363-71. [PMID: 24061331 DOI: 10.1159/000351410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 04/16/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Remission has become one of the leading outcome criteria in clinical trials. Data collected by this research group assessed the rate of remission after 6 months of treatment of generalized anxiety disorder (GAD) with venlafaxine XR, to search for predictors of remission and to define how early on in treatment later remission can be predicted. METHOD Two hundred sixty-eight patients with a GAD diagnosis enrolled into an open-label 6-month-treatment trial with venlafaxine XR (75-225 mg/day). Remission was defined by a Hamilton anxiety scale total score ≤7. Logistic regression approaches were used to find out how early on in treatment later remission could be predicted, as well as to determine predictors of remission. In addition, adverse events were also followed over time. RESULTS While the total enrolled patient sample (n = 268) had a remission rate of 53%, 6-month completers (n = 159) had a remission rate of 79%. The only statistically significant predictor of remission, independent of baseline anxiety and depression levels, was a low Eysenck neuroticism score. The remission status outcome could best be predicted after 8 weeks of treatment when a CGI-I score of 1 or 2 predicted later remission with 78% accuracy and later nonremission with 91% accuracy. The incidence of adverse events decreased over the 6-month period, with sexual adverse events decreasing the least. CONCLUSION The only significant predictor of remission was a low score on the Eysenck neuroticism scale. The earliest reliable prediction of later remission, based on improvement, could be made after 8 weeks of treatment with 91% accuracy.
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Affiliation(s)
- Karl Rickels
- Mood and Anxiety Disorders Section, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pa., USA
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15
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Compton SN, Peris TS, Almirall D, Birmaher B, Sherrill J, Kendall PC, March JS, Gosch EA, Ginsburg GS, Rynn MA, Piacentini JC, McCracken JT, Keeton CP, Suveg CM, Aschenbrand SG, Sakolsky D, Iyengar S, Walkup JT, Albano AM. Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial. J Consult Clin Psychol 2014; 82:212-24. [PMID: 24417601 DOI: 10.1037/a0035458] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS). METHOD Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures. RESULTS Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I). DISCUSSION Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.
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Affiliation(s)
- Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Tara S Peris
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Daniel Almirall
- Survey Research Center, Institute for Social Research, University of Michigan
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - Joel Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health
| | | | - John S March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Elizabeth A Gosch
- Department of Psychology, Philadelphia College of Osteopathic Medicine
| | - Golda S Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital
| | - Moira A Rynn
- Department of Child Psychiatry, Columbia University Medical Center
| | - John C Piacentini
- John C. Piacentini and James T. McCracken, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - James T McCracken
- John C. Piacentini and James T. McCracken, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Courtney P Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital
| | | | | | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - Satish Iyengar
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - John T Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College
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Podell JL, Kendall PC, Gosch EA, Compton SN, March JS, Albano AM, Rynn MA, Walkup JT, Sherrill JT, Ginsburg GS, Keeton CP, Birmaher B, Piacentini JC. Therapist Factors and Outcomes in CBT for Anxiety in Youth. ACTA ACUST UNITED AC 2013; 44:89-98. [PMID: 25419042 DOI: 10.1037/a0031700] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive-behavioral therapy (CBT) as part of the Child-Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7-17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive-behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist "coach" style was a significant predictor of child-reported outcome, with the collaborative "coach" style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.
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Abstract
OBJECTIVE Developing evidenced-based practices for the management of childhood psychiatric disorders requires research studies that address how to treat children during both the acute phase of the disorder and beyond. Given the selection of a medication for acute treatment, discontinuation trials are used to evaluate the effects of treatment duration (e.g., time on medication) and/or maintenance strategies following successful acute-phase treatment. Recently, sequential multiple assignment randomized trials (SMART) have been proposed for use in informing sequences of critical clinical decisions such as those mentioned. The objective of this article is to illustrate how a SMART study is related to the standard discontinuation trial design, while addressing additional clinically important questions with similar trial resources. METHOD The recently completed Child/Adolescent Anxiety Multimodal Study (CAMS), a randomized trial that examined the relative efficacy of three acute-phase treatments for pediatric anxiety disorders, along with a next logical step, a standard discontinuation trial design, is used to clarify the ideas. This example is used to compare the discontinuation trial design relative to the SMART design. RESULTS We find that the standard discontinuation trial can be modified slightly using a SMART design to yield high-quality data that can be used to address a wider variety of questions in addition to the impact of treatment duration. We discuss how this innovative trial design is ultimately more efficient and less costly than the standard discontinuation trial, and may result in more representative comparisons between treatments. CONCLUSIONS Mental health researchers who are interested in addressing questions concerning the effects of continued treatment (for different durations) following successful acute-phase treatment should consider SMART designs in place of discontinuation trial designs in their research. SMART designs can be used to address these and other questions concerning individualized sequences of treatment, such as the choice of a rescue treatment in case of postacute phase relapse.
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Affiliation(s)
- Daniel Almirall
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Scott N. Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Moira A. Rynn
- New York State Psychiatric Institute–Columbia University Medical Center, New York, New York
| | - John T. Walkup
- Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Susan A. Murphy
- Department of Statistics and Institute for Social Research, University of Michigan, Ann Arbor, Michigan
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Abstract
Over the last decade, psychopharmacologic treatments for pediatric anxiety disorders have been developed and increasingly subjected to randomized, controlled trials. The authors summarize the data concerning the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), atypical anxiolytics, and benzodiazepines. The extant data suggest that SSRIs--both as monotherapy and when combined with psychotherapy--are effective in the treatment of pediatric anxiety disorders. In addition, some TCAs and SNRIs are effective. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the atypical anxiolytic, buspirone, for children and adolescents with anxiety disorders.
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Affiliation(s)
- Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH 45219, USA.
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Ginsburg GS, Kendall PC, Sakolsky D, Compton SN, Piacentini J, Albano AM, Walkup JT, Sherrill J, Coffey KA, Rynn MA, Keeton CP, McCracken JT, Bergman L, Iyengar S, Birmaher B, March J. Remission after acute treatment in children and adolescents with anxiety disorders: findings from the CAMS. J Consult Clin Psychol 2012; 79:806-13. [PMID: 22122292 DOI: 10.1037/a0025933] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report on remission rates in anxious youth who participated in the Child/Adolescent Anxiety Multimodal Study (CAMS). The CAMS, a multisite clinical trial, randomized 488 children and adolescents (ages 7-17 years; 79% Caucasian; 50% female) with separation, social, and/or generalized anxiety disorder to a 12-week treatment of sertraline (SRT), cognitive behavioral therapy (CBT), their combination (COMB), or clinical management with pill placebo (PBO). METHOD The primary definition of remission was loss of all study-entry anxiety disorder diagnoses; additional definitions of remission were used. All outcomes were rated by independent evaluators blind to treatment assignment. Predictors of remission were also examined. RESULTS Remission rates after 12 weeks of treatment ranged from 46% to 68% for COMB, 34% to 46% for SRT, 20% to 46% for CBT, and 15% to 27% for PBO. Rates of remission (i.e., achieving a nearly symptom-free state) were significantly lower than rates of response (i.e., achieving a clinically meaningful improvement relative to baseline) for the entire sample. Youth who received COMB had significantly higher rates of remission compared to all other treatment groups. Both monotherapies had higher remission rates compared to PBO, but rates were not different from each other. Predictors of remission were younger age, nonminority status, lower baseline anxiety severity, absence of other internalizing disorders (e.g., anxiety, depression), and absence of social phobia. CONCLUSIONS For the majority of children, some symptoms of anxiety persisted, even among those showing improvement after 12 weeks of treatment, suggesting a need to augment or extend current treatments for some children.
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Affiliation(s)
- Golda S Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Strawn JR, Wehry AM, DelBello MP, Rynn MA, Strakowski S. Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder. Depress Anxiety 2012; 29:328-39. [PMID: 22511364 DOI: 10.1002/da.21913] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Generalized anxiety disorder (GAD) is associated with significant morbidity in children and adolescents, yet only recently have the neuropharmacology and neurophysiology of this condition been studied in youth. Accumulating data suggest structural and functional abnormalities within the brain's fear networks in youth with GAD. Additionally, seven studies examined the efficacy of medications that modulate this system and, in some cases, the direct effects of these medications on structures within these networks (e.g. amygdala, ventrolateral prefrontal cortex [VLPFC]). In this review, we summarize the extant functional, functional connectivity, and structural neuroimaging data in children and adolescents with GAD. In addition, data concerning selective serotonin reuptake inhibitors (SSRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), atypical anxiolytics, benzodiazepines, and psychotherapy are reviewed in the context of the neurophysiology of pediatric GAD. The existing data suggest abnormal activity within the amygdala, VLPFC, and anterior cingulate cortex, as well as the possibility of impaired connectivity among these brain regions. In addition to numerous cognitive behavioral therapy (CBT) trials, five randomized, controlled psychopharmacologic trials primarily in youth with GAD suggest that SSRIs and SSNRIs are effective for this condition. These findings also raise the possibility that functional activity within the amygdala and VLPFC may be altered following successful treatment.
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Affiliation(s)
- Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio 45267-0559, USA.
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Barber JP, Barrett MS, Gallop R, Rynn MA, Rickels K. Short-term dynamic psychotherapy versus pharmacotherapy for major depressive disorder: a randomized, placebo-controlled trial. J Clin Psychiatry 2012; 73:66-73. [PMID: 22152401 DOI: 10.4088/jcp.11m06831] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 03/04/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To determine whether supportive-expressive psychotherapy (SET), a form of dynamic psychotherapy, and pharmacotherapy + clinical management (MED) for major depressive disorder (MDD) are more effective than pill-placebo + clinical management (PBO). METHOD This National Institute of Mental Health (NIMH)-sponsored randomized controlled trial was conducted (from November 2001 through June 2007) at the University of Pennsylvania Medical School. The sample included 156 patients diagnosed with MDD (DSM-IV) and having a 17-item Hamilton Rating Scale for Depression (HRSD(17)) score ≥ 14 for at least 2 consecutive weeks. This was an underserved sample in which 41% were male, 52% were self-designated minorities, and 76% had an annual income under $30,000. Treatment lasted 16 weeks. Medication patients not responsive by week 8 (maximum dose 200 mg/d of sertraline) were switched to venlafaxine (maximum dose 375 mg/d). Nonresponsive placebo patients at week 8 were switched to a different placebo. RESULTS Patients' depression improved over the 16 weeks (P < .0001), with no between-group differences (P = .95), even among severely (HRSD(17) score ≥ 20) depressed patients (P = .45). Response rates did not differ between groups (P = .73). Gender and minority status moderated outcome (P = .014), with psychotherapy more efficacious for minority men than MED (P = .027, Cohen d = 1.02) and PBO (P = .019, d = 1.09). PBO was more efficacious for white men than MED (P = .03, d = 0.62) and SET (P = .003, d = 1.07). For white women, MED (P = .005, d = 0.77) and SET (P = .033, d = 0.71) were more efficacious than placebo. No differences among treatments were found for minority women. CONCLUSIONS This trial of urban MDD patients failed to confirm that either active treatment was better than placebo. Minority status and gender had significant and differential effects on outcome that warrant replication in future studies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00043550.
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Affiliation(s)
- Jacques P Barber
- Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, USA.
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Rickels K, Etemad B, Khalid-Khan S, Lohoff FW, Rynn MA, Gallop RJ. Time to Relapse After 6 and 12 Months' Treatment of Generalized Anxiety Disorder With Venlafaxine Extended Release. ACTA ACUST UNITED AC 2010; 67:1274-81. [DOI: 10.1001/archgenpsychiatry.2010.170] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Compton SN, Walkup JT, Albano AM, Piacentini JC, Birmaher B, Sherrill JT, Ginsburg GS, Rynn MA, McCracken JT, Waslick BD, Iyengar S, Kendall PC, March JS. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health 2010; 4:1. [PMID: 20051130 PMCID: PMC2818613 DOI: 10.1186/1753-2000-4-1] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 01/05/2010] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To present the design, methods, and rationale of the Child/Adolescent Anxiety Multimodal Study (CAMS), a recently completed federally-funded, multi-site, randomized placebo-controlled trial that examined the relative efficacy of cognitive-behavior therapy (CBT), sertraline (SRT), and their combination (COMB) against pill placebo (PBO) for the treatment of separation anxiety disorder (SAD), generalized anxiety disorder (GAD) and social phobia (SoP) in children and adolescents. METHODS Following a brief review of the acute outcomes of the CAMS trial, as well as the psychosocial and pharmacologic treatment literature for pediatric anxiety disorders, the design and methods of the CAMS trial are described. RESULTS CAMS was a six-year, six-site, randomized controlled trial. Four hundred eighty-eight (N = 488) children and adolescents (ages 7-17 years) with DSM-IV-TR diagnoses of SAD, GAD, or SoP were randomly assigned to one of four treatment conditions: CBT, SRT, COMB, or PBO. Assessments of anxiety symptoms, safety, and functional outcomes, as well as putative mediators and moderators of treatment response were completed in a multi-measure, multi-informant fashion. Manual-based therapies, trained clinicians and independent evaluators were used to ensure treatment and assessment fidelity. A multi-layered administrative structure with representation from all sites facilitated cross-site coordination of the entire trial, study protocols and quality assurance. CONCLUSIONS CAMS offers a model for clinical trials methods applicable to psychosocial and psychopharmacological comparative treatment trials by using state-of-the-art methods and rigorous cross-site quality controls. CAMS also provided a large-scale examination of the relative and combined efficacy and safety of the best evidenced-based psychosocial (CBT) and pharmacologic (SSRI) treatments to date for the most commonly occurring pediatric anxiety disorders. Primary and secondary results of CAMS will hold important implications for informing practice-relevant decisions regarding the initial treatment of youth with anxiety disorders. TRIAL REGISTRATION ClinicalTrials.gov NCT00052078.
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Affiliation(s)
- Scott N Compton
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, DUMC Box 3527, Durham, NC 27710, USA
| | - John T Walkup
- The Johns Hopkins Hospital, Division of Child and Adolescent Psychiatry, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Anne Marie Albano
- New York State Psychiatric Institute-Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA
| | - John C Piacentini
- University of California at Los Angeles, Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 68-251B, Los Angeles, CA 90095, USA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Joel T Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health, 6001 Executive Boulevard, MSC 9633, Bethesda, MD 20892, USA
| | - Golda S Ginsburg
- The Johns Hopkins Hospital, Division of Child and Adolescent Psychiatry, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Moira A Rynn
- New York State Psychiatric Institute-Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA
| | - James T McCracken
- University of California at Los Angeles, Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 68-251B, Los Angeles, CA 90095, USA
| | - Bruce D Waslick
- Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Satish Iyengar
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Phillip C Kendall
- Temple University, Department of Psychology, Weiss Hall 1701 North 13th Street, Philadelphia, PA 19122, USA
| | - John S March
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, DUMC Box 3527, Durham, NC 27710, USA
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Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S, March JS, Kendall PC. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008; 359:2753-66. [PMID: 18974308 PMCID: PMC2702984 DOI: 10.1056/nejmoa0804633] [Citation(s) in RCA: 813] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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.)
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Affiliation(s)
- John T Walkup
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21287, USA
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Abstract
Social anxiety disorder (SOC) is characterized by marked and persistent fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny. The person fears that she or he might act in a way that will be humiliating or embarrassing. Children and adolescents with this disorder often have great impairment in their academic performance, social skills, peer relationships, and family life. Early diagnosis is vital. Primary care providers are in a unique situation to first diagnose and treat SOC in children and adolescents. There is evidence of successful pharmacologic and psychosocial treatment in pediatric SOC. Serotonin reuptake inhibitors, which are considered first-line medications for SOC, have shown promising results in open-label and double-blind trials. Studies have demonstrated that psychosocial treatments, specifically cognitive-behavioral therapy and group therapy, are efficacious in pediatric SOC. There is some evidence that the use of combination therapy, both pharmacology and psychosocial treatment, is beneficial in the management of pediatric SOC.
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Affiliation(s)
- Sarosh Khalid-Khan
- Department of Psychiatry, Mood and Anxiety Disorders Clinic, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Rynn MA, Riddle MA, Yeung PP, Kunz NR. Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. Am J Psychiatry 2007; 164:290-300. [PMID: 17267793 DOI: 10.1176/ajp.2007.164.2.290] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors evaluated the efficacy, safety, and tolerability of extended-release venlafaxine in the treatment of pediatric generalized anxiety disorder. METHOD Two randomized, double-blind, placebo-controlled trials were conducted at 59 sites in 2000 and 2001. Participants 6 to 17 years of age who met DSM-IV criteria for generalized anxiety disorder received a flexible dosage of extended-release venlafaxine (N=157) or placebo (N=163) for 8 weeks. The primary outcome measure was the composite score for nine delineated items from the generalized anxiety disorder section of a modified version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, and the primary efficacy variable was the baseline-to-endpoint change in this composite score. Secondary outcome measures were overall score on the nine delineated items, Pediatric Anxiety Rating Scale, Hamilton Anxiety Rating Scale, Screen for Child Anxiety Related Emotional Disorders, and the severity of illness and improvement scores from the Clinical Global Impression scale (CGI). RESULTS The extended-release venlafaxine group showed statistically significant improvements in the primary and secondary outcome measures in study 1 and significant improvements in some secondary outcome measures but not the primary outcome measure in study 2. In a pooled analysis, the extended-release venlafaxine group showed a significantly greater mean decrease in the primary outcome measure compared with the placebo group (-17.4 versus -12.7). The response rate as indicated by a CGI improvement score <3 was significantly greater with extended-release venlafaxine than placebo (69% versus 48%). Common adverse events were asthenia, anorexia, pain, and somnolence. Statistically significant changes in height, weight, blood pressure, pulse, and cholesterol levels were observed in the extended-release venlafaxine group. CONCLUSIONS Extended-release venlafaxine may be an effective, well-tolerated short-term treatment for pediatric generalized anxiety disorder.
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Affiliation(s)
- Moira A Rynn
- New York State Psychiatric Institute, 1051 Riverside Drive, Unit 74, New York, NY 10032, USA.
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Rynn MA, Barber JP, Khalid-Khan S, Siqueland L, Dembiski M, McCarthy KS, Gallop R. The psychometric properties of the MASC in a pediatric psychiatric sample. J Anxiety Disord 2006; 20:139-57. [PMID: 16464701 DOI: 10.1016/j.janxdis.2005.01.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Revised: 12/14/2004] [Accepted: 01/20/2005] [Indexed: 10/25/2022]
Abstract
The goals of this study were twofold: to examine the psychometric properties of the Multidimensional Anxiety Scale for Children (MASC) in a clinical sample of 193 children and adolescents who had received a diagnosis of major depressive or anxiety disorder, and to discriminate between these two groups of patients. Participants had volunteered in randomized psychopharmacological clinical trials. The MASC four-factor structure was confirmed and its subscales were found to be reliable. The MASC correlated well with other self-report measures of anxiety, and less so with measures of depressive symptoms. The MASC subscales and two MASC items as well as age differentiated between anxious and depressed pediatric patients. If these results are replicated in an independent study, those items could be used by clinicians to discriminate between these two disorders. The MASC is a clinically useful measure to discriminate between anxious and depressed pediatric patients. Limitations due to the highly selective sample are noted.
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Affiliation(s)
- Moira A Rynn
- Department of Psychiatry, Mood and Anxiety Disorders Program, Center for Psychotherapy Research, Suite 670, University of Pennsylvania School of Medicine, 3535 Market Street, Philadelphia, PA 19104-3309, USA.
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Feiger AD, Rickels K, Rynn MA, Zimbroff DL, Robinson DS. Selegiline transdermal system for the treatment of major depressive disorder: an 8-week, double-blind, placebo-controlled, flexible-dose titration trial. J Clin Psychiatry 2006; 67:1354-61. [PMID: 17017821 DOI: 10.4088/jcp.v67n0905] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study investigated the efficacy, safety, and tolerability of the selegiline transdermal system (STS) administered in a dose range of 6 mg/24 hours to 12 mg/24 hours for treating major depressive disorder (MDD). METHOD Patients meeting DSM-IV criteria for MDD (N = 265) were randomly assigned to blinded treatment with STS or a matching placebo patch for 8 weeks. Patients failing to meet or maintain protocol-defined therapeutic response criteria at predetermined time points had their STS (or placebo) dose increased. Assessments were conducted at weeks 1, 2, 3, 5, 6, and 8. Patients were not required to follow a tyramine-restricted diet. The study ran from September 2001 through August 2002. RESULTS Selegiline transdermal system treatment resulted in significantly greater improvement (p < or = .05) compared with placebo treatment on the 3 depression rating scales: the 28-item Hamilton Rating Scale for Depression (HAM-D28) (primary outcome measure), the Montgomery-Asberg Depression Rating Scale, and the Inventory for Depressive Symptomatology-Self Rated. The treatment effect measured by the HAM-D28 was modest, primarily due to insomnia side effects. The antidepressant efficacy of STS was substantiated further by the significantly greater improvement in core depression symptoms (HAM-D Bech-6 subscale). The side effects of highest incidence were application site reactions and insomnia. There were no safety concerns based on routine clinical laboratory and electrocardiogram monitoring, and there were no occurrences of hypertensive crisis. CONCLUSION Results of this double-blind, placebo-controlled, dose titration trial provide evidence of short-term efficacy, safety, and tolerability of STS in the dose range of 6 mg/24 hours to 12 mg/24 hours for treatment of MDD. Selegiline transdermal system has an improved margin of safety compared with oral monoamine oxidase inhibitors and represents a useful addition to the existing array of antidepressants.
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Affiliation(s)
- Alan D Feiger
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, USA.
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Abstract
Paroxetine is a selective serotonin re-uptake inhibitor useful in the treatment of a wide range of psychiatric disorders. Generalised anxiety disorder (GAD) is characterised by excessive persistent anxiety and worry about a number of events and activities occurring on more days than not for at least 6 months. GAD is the most common anxiety disorder in primary care settings. Paroxetine was the second antidepressant to receive an FDA indication for the treatment of GAD. In contrast to benzodiazepines, which had been the mainstay of treatment for anxiety disorders for many years, antidepressants, such as paroxetine, are more effective for the psychic symptoms of anxiety, which include worry, tension, irritability and concentration difficulties, and carry a more tolerable and safe side effect profile.
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Affiliation(s)
- Steven H Snyderman
- Mood & Anxiety Disorders Section, Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA.
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Abstract
Clinical and epidemiological data suggest that generalized anxiety disorder (GAD) is a chronic illness causing patients to suffer for many years leading to significant distress in daily life functioning. The literature suggests the several conclusions. GAD is a disorder in need of appropriate treatment and often has a chronic course with comorbid conditions, such as major depression and other anxiety disorders. Benzodiazepines, while effective anxiolytic agents acutely, when prescribed for >4 weeks cause rebound anxiety and following prolonged therapy may lead to withdrawal symptoms. Antidepressants cause significant anxiety relief compared with placebo and for psychosocial treatment cognitive-behavioral therapy is an efficacious psychosocial treatment. Many GAD patients are in need of long-term medication management. Furthermore, there is limited data for patients diagnosed with GAD the treatment outcome with the combination of medication and psychotherapy both acutely and long-term; how to best sequence these treatments; for those patients who do not meet remission criteria what is the ideal approach for augmentation; and for patients with treatment-refractory GAD the empirical evidence is lacking on medication switching and augmentation strategies. Research is needed in the area of developing treatment strategies for patients suffering from treatment-refractory GAD. There is still an urgent need to explore treatment combinations and duration strategies in the management of patients suffering with GAD.
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Affiliation(s)
- Moira A Rynn
- Mood and Anxiety Disorders Section, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, USA.
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Ambrosini PJ, Elia J, Rynn MA. 49th Annual Meeting of the American Academy of Child & Adolescent Psychiatry. 22-27 October 2002, San Francisco, CA, USA. Expert Opin Pharmacother 2003; 4:591-4. [PMID: 12667122 DOI: 10.1517/14656566.4.4.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The diverse programme covered recent advances in developmental neurobiology, genetics, psychotherapy and pharmacotherapy. Presentations included clinical consultation breakfasts, with experts in their specialities, clinical case conferences, media theatre events, symposia, special interest groups, workshops and poster presentations. Several awards were presented to members to acknowledge their research achievements and service to the academy, and to children in need. All the presentations were focused on keeping the clinician and the researcher up-to-date on the advancements within the field of child and adolescent psychiatry. This report will focus on the new research poster presentations, which highlight the current status of paediatric pharmacotherapy. The data will be presented within the major diagnostic groups of the affective, behavioural, anxiety and developmental, autistic and psychotic syndromes. In paediatric pharmacotherapy particularly, several agents are administered as broad spectrum pharmacotherapeutics, and therefore, are used across several disorders.
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Affiliation(s)
- P J Ambrosini
- Drexel University College of Medicine, 3200 Henry Avenue, Philadelphia, PA 19129, USA.
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Abstract
Atypical antipsychotics are now commonly used in the treatment of bipolar disorder, as they have been shown to have effects on mania as well as psychosis. Shortly after the introduction of atypical antipsychotics, several cases of associated hypomania and mania were reported. Ziprasidone is an atypical antipsychotic recently approved by the Food and Drug Administration for the treatment of psychosis. Although ziprasidone has also been shown to be effective in treating mania, it may be associated with the induction of mania or hypomania. We report four cases of mania associated with initiation of ziprasidone, which, to our knowledge, are the first reported for this drug in bipolar patients. As ziprasidone has substantial serotonergic and noradrenergic action, we hypothesize, it may more likely induce mania than other atypical antipsychotics. We advocate future studies to evaluate ziprasidone's efficacy in treating bipolar disorder and caution clinicians that induction of mania or hypomania may be possible with this agent.
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Affiliation(s)
- C F Baldassano
- Hospital of the University of Pennsylvania, Philadelphis, USA.
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Abstract
OBJECTIVE The study compared the safety and efficacy of sertraline, a selective serotonin reuptake inhibitor, and placebo in the treatment of generalized anxiety disorder in children and adolescents. METHOD The study subjects were 22 children and adolescents age 5-17 years who met the DSM-IV criteria for generalized anxiety disorder according to the Anxiety Disorders Interview Schedule for Children-Revised and who had a Hamilton Anxiety Rating Scale score > or = 16. The patients underwent a 2-3-week prestudy evaluation period, followed by a 9-week double-blind treatment phase in which they were randomly assigned in blocks of four to receive either sertraline or pill placebo. The maximum dose of sertraline was 50 mg/day. Primary outcome measures were the Hamilton anxiety scale and the Clinical Global Impression scale. RESULTS The Hamilton anxiety scale total score, psychic factor, and somatic factor and the Clinical Global Impression severity and improvement scales showed significant differences with treatment in favor of sertraline over placebo beginning at week 4. Self-report measures reflected these results at the end of treatment. CONCLUSIONS The results of this double-blind, placebo-controlled trial suggest that sertraline at the daily dose of 50 mg is safe and efficacious for the treatment of generalized anxiety disorder in children and adolescents.
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Affiliation(s)
- M A Rynn
- Mood and Anxiety Disorders Section, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Rickels K, Rynn MA. What is generalized anxiety disorder? J Clin Psychiatry 2001; 62 Suppl 11:4-12; discussion 13-4. [PMID: 11414550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Generalized, persistent, and free-floating anxiety was first described by Freud in 1894, although the diagnostic term generalized anxiety disorder (GAD) was not included in classification systems until 1980 (Diagnostic and Statistical Manual for Mental Disorders, Third Edition [DSM-III]). Initially considered a residual category to be used when no other diagnosis could be made, it is now widely accepted that GAD represents a distinct diagnostic category. Since 1980, revisions to the diagnostic criteria for GAD in the DSM-III-R and DSM-IV classifications have markedly redefined this disorder, increasing the duration criterion to 6 months and increasing the emphasis on worry and psychic symptoms. This article reviews the development of the diagnostic criteria for defining GAD from Freud to DSM-IV and compares the DSM-IV criteria with the criteria set forth in the tenth revision of the International Classification of Diseases. The impact of the changes in diagnostic criteria on research into GAD, and on diagnosis, differential diagnosis, and treatment of GAD, will be discussed.
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Affiliation(s)
- K Rickels
- Department of Psychiatry, University of Pennsylvania, Philadelphia 19104, USA.
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