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CBT for Childhood Anxiety and Depression

Effective Treatments for Youth Anxiety Disorders

anxietyVice Chair of the Department of Psychiatry and Behavioral Sciences and Director of Child and Adolescent Psychiatry at the University of Texas Medical Branch at Galveston, Karen Wagner, M.D. examines the increasing evidence stating the efficacy of cognitive-behavioral therapy (CBT) for children and adolescents with anxiety and depressive disorders in her article “Cognitive-Behavioral Therapy for Childhood Anxiety and Depression.”[1]

Currently, it is well-known that both SSRI antidepressants and CBT are independently effective treatments for youth anxiety disorders; however, the combined use of the treatments has consistently shown even better results.1 A large study conducted by Walkup and colleagues examined the combined efficacy of the SSRI sertraline and CBT in 488 youths, aged seven to 17, who suffered from any of the following anxiety disorders: separation anxiety disorder, social phobia, or generalized anxiety disorder.[2] Compared to either sertraline or CBT alone, the combination of the two showed significantly superior results. The response rates for the combination were 81 percent, compared to sertraline alone at 55 percent, CBT alone at 60 percent, and placebo at 24 percent.2 Therefore, Walkup and colleagues stated that children and adolescents treated with a combination of an SSRI and CBT could expect to see a significant reduction in anxiety.2

Family-Based CBT and Anxiety

As anxiety studies often target children eight-years-old and up, the question of the efficacy of CBT in children younger than eight was investigated.1 Freeman and colleagues conducted a study that compared the effectiveness of family-based CBT with family-based relaxation treatment in children ages five to eight who suffered from obsessive-compulsive disorder (OCD).[3] Results showed that half of the children who received CBT achieved clinical remission, compared with 20 percent who received relaxation treatment.3 Therefore, family-based CBT may be a strong treatment for young children suffering from early-onset OCD.3

Regarding depression, the Treatment for Adolescents with Depression Study stated that the response rates following 12 weeks of treatment were the highest with the SSRI fluoxetine plus CBT at 71 percent, compared with fluoxetine alone at 61 percent and CBT alone at 43 percent.[4]  Also, rates of remission were also highest for individuals who received fluoxetine plus CBT at 37 percent, compared with fluoxetine alone at 23 percent and CBT alone at 16 percent.[5] Adolescents who did not show a successful response at 12 weeks of treatment, response rates increased at week 36, with rates for combination therapy being 80 percent, fluoxetine alone being 62 percent, and CBT alone being 77 percent.[6] Therefore, adolescents suffering from depression who did not show a response to acute treatment may respond to continued and maintenance treatments.1

Preventing Anxiety and Depression Relapse

Recently, CBT was proven to prevent relapse in youths aged 11 to 18 years.1 In a study conducted by Kennard and colleagues, 46 youths who had shown a positive response to 12 weeks of fluoxetine treatment were then randomized to either continue fluoxetine or fluoxetine plus CBT for a period of six months.[7] They found that patients receiving just fluoxetine had an eight-time greater risk of relapse than patients receiving fluoxetine plus CBT. Results showed that at 36 weeks, the probability of relapse was 37 percent for those receiving just fluoxetine and only 15 percent for those receiving both fluoxetine and CBT.7 Therefore, Kennard and colleagues believe that starting with an antidepressant to achieve a clinical response and then adding CBT is an effective method of treatment for preventing relapse in youths with major depression.7

Not Only Anxiety But Depression Too

CBT has also shown to increase response rates in adolescents with treatment-resistant major depression.1 Three-hundred and thirty-four adolescents with major depression who had not shown improvement with SSRI treatment after a period of two months were randomized to receive alternative antidepressant treatment either with or without CBT.[8] Brent and colleagues found that the response rates for those receiving both an antidepressant plus CBT (55 percent) were higher than the rates for those receiving just an antidepressant alone (41 percent).8 Therefore, Brent and colleagues stated that adolescents with moderate to severe treatment-resistant depression may respond to a switch in antidepressant medicine combined with CBT.8

Wagner states that there is increasing evidence that CBT is an important part of treatment for children and adolescents who are suffering from anxiety and depressive disorders.1 Unfortunately, availability of CBT is limited as there are not many clinicians trained in providing the treatment; therefore, Wagner believes it is important for residency training programs in child and adolescent psychiatry to include a CBT component, as they should be equally trained in pharmacotherapy and CBT.1



[1] Wagner, K. (2009, Dec. 28). Cognitive-Behavioral Therapy for Childhood Anxiety and Depression. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/anxiety/content/article/10168/1504951

[2] Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359:2753-2766.

[3] Freeman JB, Garcia AM, Coyne L, et al. Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach. J Am Acad Child Adolesc Psychiatry. 2008;47:593-602.

[4] March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.

[5] Kennard B, Silva S, Vitiello B, et al; TADS Team. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45:1404-1411.

[6] Rohde P, Silva SG, Tonev ST, et al. Achievement and maintenance of sustained response during the Treatment for Adolescents With Depression Study continuation and maintenance therapy. Arch Gen Psychiatry. 2008;65:447-455.

[7] Kennard BD, Emslie GJ, Mayes TL, et al. Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. J Am Acad Child Adolesc Psychiatry. 2008;47:1395-1404.

[8] Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299:901-913. Anxiety.

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