Brief Therapy Bests Specialty Care for Kids' Anxiety, Depression

Batya Swift Yasgur, MA, LSW

June 14, 2017

A streamlined brief behavioral intervention for pediatric anxiety and depression delivered by pediatricians is superior to outpatient mental health care with follow-up, new research shows.

A randomized trial comparing the two approaches found that 56.8% of youth who received brief behavioral therapy (BBT) experienced improvement in anxiety and depression scores compared to 28.2% of those who were referred to mental health care with follow-up calls, an approach described as assisted referral to care (ARC).

In particular, Hispanic youth had markedly stronger responses to BBT than non-Hispanic patients, suggesting that the protocol "may be a useful tool in addressing ethnic disparities in care," the investigators, led by V. Robin Weersing, PhD, associate professor at the Department of Psychology, San Diego State University, and director of the Child and Adolescent Anxiety and Mood Program, write.

"In order to reach the very large number of youth suffering from emotional problems, we need to explore treatment delivery settings, like pediatrics, with a wide reach and low stigma. This has great promise for improving access to care, particularly for Latino youth," Dr Weersing said in a release.

The study was published online June 1 in JAMA Psychiatry.

Care Disparities

Youth with anxiety and depression are currently undertreated: only 1 in 5 youths with anxiety and 2 in 5 youths with depression receive any lifetime mental health services, the authors note.

Moreover, they add, "there are notable ethnic disparities of care, with Hispanic youths significantly less likely to receive mental health services than similarly affected non-Hispanic youths."

Transdiagnostic cognitive-behavioral interventions have been found to be effective in adults, and preliminary data suggest such approaches are efficacious in youth as well. Building on this prior research, the researchers tested "a streamlined behavioral intervention without the cognitive restructuring elements present in other programs."

BBT integrates "the core behavioral elements of evidence-based treatments" for anxiety, depression, and their comorbid presentation, the authors explain. It combines exposure and behavioral activation as "graded engagement in avoided activities, supplemented by relaxation to manage somatic symptoms common among internalizing youth in primary care and by problem-solving skills to aid in stress management."

The intervention consisted of eight to 12 weekly 45-minute sessions that were completed within 16 weeks and were delivered by Masters-level study therapists.

The researchers chose to study the intervention in pediatric primary care settings, which are "a major focus of public health efforts to improve access to mental health services" and have "low cultural stigma."

They recruited youths aged 8 to 16.9 years from nine pediatric clinics in the San Diego, California, and the Pittsburgh, Pennsylvania, metropolitan areas during a 4-year period. Participants had to meet criteria at baseline for full or probable diagnoses of separation anxiety disorder (Clinical Global Impression–Severity score [CGI-S] >3), generalized anxiety disorder (GAD), social phobia, major depression, dysthymic disorder, or minor depression. Probable depression was determined on the basis of the Children's Depression Rating Scaled–Revised.

ARC was "modeled on evidence-based practices for reducing no-show rates in community mental health care" and included feedback about the youth's symptoms and benefits of the services, referrals and education about how to obtain these services, and problem-solving regarding barriers to treatment.

Greater, More Rapid Response

Of the study participants (mean [SD] age, 11.3 [2.6] years), 58.5% were female, 77.8% were white, and 28% were Hispanic. Participants did not significantly differ by group on demographic or clinical characteristics at baseline. Retention rates did not differ by site but were higher in the BBT group than in the ARC group (92.6% vs 78.9%; χ 2 1 = 7.23; P = 0.01).

At week 16, among the youth in the BBT group, 56.5% were rated as "responders" on the primary outcome measure (CGI-I score ≤2), compared with only 28.2% of youth in the ARC group (χ 2 1 = 13.09; P < .001; number needed to treat [NNT], 4; 95% confidence interval [CI], 2.3 - 7.2). Youths in the BBT group also experienced significantly faster functional improvement (χ 2 1 = 0.44; SE, 0.10; z = 4.45; P < .001; Cohen d = 0.50), and their level of functioning was higher than that of the youths in the ARC group at week 16 (mean [SD], 95% CI, 68.5] vs 61.9; t156 = 3.64; P<0.001; Cohen d = 0.58; 95% CI, 0.26 - 0.90).

Anxiety and depression scores improved significantly more rapidly from baseline to week 16 (F2146 = 54.03; P < .001; Cohen f = 0.86). The treatment x time interaction likewise demonstrated that youths in the BBT group had a faster rate of improvement than youths randomly assigned to the ARC group (F2146 = 5.72; P = .004; Cohen f = 0.28). "These effects appear to be largely driven by the superior effect of BBT on anxiety," the authors suggest.

Ethnicity had a significant bearing on response (OR, 19.94; SE, 24.74; z = 2.41; P = .02), with Hispanic youths experiencing superior response to BBT and little response to ARC (76.5% vs 7.1%; χ 2 1 = 14.90; P < .001; NNT, 2; 95% CI, 1.1 - 2.2). Moreover, improvement in functioning was far greater for Hispanic youths in the BBT group (mean of 15.5 points on the CGAS, representing a shift of two qualitative functioning categories). The mean CGAS score change for Hispanic youths in the ARC group was <1 point.

Among non-Hispanic white youths, response was significantly higher in the BBT group compared to the ARC group, an effect that the authors describe as "clinically meaningful."

The authors write that youths assigned to BBT "readily accepted the behavioral treatment (92.6% retained), demonstrated excellent sessions attendance (mean of 11.2 sessions), and achieved high clinical response rates (56.8%) and substantial functional improvement."

They note that these positive effects in the streamlined BBT intervention suggest that it "may be possible to simplify interventions for some psychiatric conditions to aid in the dissemination of evidence-based treatment without a decrease in efficacy."

"In these interventions, kids learn to slowly withdraw from what's upsetting them," said Dr Weersing, who developed the intervention.

"Slowly they learn to approach and actively problem solve. Step by step, they reengage with tasks that they need to do or want to do — school, social, family-related — but previously struggled to do because negative emotions were in the way," she added.

The Next Step

Commenting on the study for Medscape Medical News, John T. Walkup, MD, professor of psychiatry and vice chair for child and adolescent psychiatry, Weill Cornell Medical College, New York City, called the researchers "an outstanding group of psychosocial intervention innovators."

Dr Walkup, who is also director, Division of Child and Adolescent Psychiatry, New York–Presbyterian Hospital, and is the coauthor of an accompanying editorial, commended the intervention as being the "next step" from "branded, proprietary therapy" to a shortened intervention conducted in a primary care setting.

"They identified what we think of as the generic components of a psychotherapeutic intervention, namely, activation for depression and exposure tasks for anxiety," he said.

"They dismantled and created a treatment that really takes the best of what we believe works for these conditions, condensed them into shorter form, and placed them in primary care, which is absolutely terrific," said Dr Walkup, who was not involved in the study.

He cautioned that one problem with the study is implementing it "in a full-scale way, since not all clinics have space or budget for a new intervention."

Moreover, BBT was conducted in pediatric clinics associated with academic institutions, whereas ARC took place in community-based mental health clinics, suggesting that the ARC group "might have been undertreated," potentially accounting for their lower response rate, he noted.

He emphasized that one of the most important take-home messages of the study concern not only the high percentage of youth who responded to the intervention but also the low percentage who responded to ARC.

"The trial not only demonstrated that treatment oriented toward anxiety and low mood can be effective but also that if you do not administer an intervention with effective elements, these children will simply not respond," he said.

The higher response rates of Hispanic youth to BBT vs ARC might be attributable to the emphasis on behavioral rather than cognitive elements, Dr Walkup suggested.

"Doing something you are afraid of and getting involved with physical activities may translate better in communities that are historically undertreated, because these interventions are not necessarily focused on language, which may have an inadvertent cultural overlay associated with it," he said.

The authors conclude that planned future research will "probe cost-effectiveness of the co-located BBT arm, as compared with ARC referral to community outpatient care" and would benefit from consideration of such factors as workforce development, staff training, and practice and healthcare system characteristics.

The study was funded by grants from the National Institute of Mental Health. Dr Weersing has disclosed no relevant financial relationships. Dr Walkup has received research support from the Tourette's Association of America and the Hartwell Foundation. He also receives royalties from Guilford and Oxford Presses. He is on advisory boards for the Anxiety and Depression Association of America, the American Foundation of Suicide Prevention, and the TLC Foundation for Body-Focused Repetitive Behaviors.

JAMA Psychiatry. Published online June 2, 2017. Abstract, Editorial

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