Treatment of Anxiety Disorders
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REMINDER: EVALUATIONS
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Learning Objectives
•
Review evidence-based psychotherapeutic
methods for managing anxiety disorders in
children and adolescents
•
Discuss evidence based pharmacologic
treatment approaches for anxiety disorders in
children and adolescents in a primary care
setting
•
Practice using tools which will assist in the
treatment of childhood anxiety disorders
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Treatment*
• Treatment planning should consider a multimodal
treatment approach:
– Education of the parents and child about the anxiety disorder
– Consultation with school personnel and other providers
– Refer to childhood mental health specialist and follow up in 612 weeks: request coordination and information
– Cognitive-behavioral interventions (first line)
– Pharmacotherapy
– Other anxiety psychotherapies (i.e. psychoeducation &
relaxation)
– If psychotherapy and pharmacotherapy are not enough, refer
to a specialist for reevaluation—consider a full assessment.
* Treatment slides adapted from AACAP Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry 2007.
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Treatment
• Treatment planning should consider severity and
impairment of the anxiety disorder
– Mild severity should begin with psychotherapy
– Valid reasons for combining medication and
psychotherapy:
• Need for acute symptom reduction in a moderately to
severely anxious child
• A comorbid disorder that requires concurrent treatment
• Partial response to psychotherapy
• Potential for improved outcome with combined treatment
– Monitor functional impairment as well as symptom
reduction during the treatment process
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CBT Treatment
• Psychotherapy should be considered as part of the
treatment of children and adolescents with anxiety disorders
– Exposure-based CBT has the most empirical support for the
treatment of anxiety disorders in youth
– CBT:
• Psychoeducation (educating the patient and the family about the
disorder, its course, management and treatment)
• Somatic management skills training (relaxation, diaphragmatic
breathing, self-monitoring)
• Cognitive restructuring (challenging negative expectations and
modifying negative self-talk)
• Exposure methods (imaginary and in vivo exposure with gradual
desensitization to feared stimuli)
• Relapse prevention plans (booster sessions and coordination with
parents and school)
• Coping Cat (Kendall, 1990)
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Pharmacologic Treatment
• SSRIs should be considered for the
treatment of youth with anxiety disorders
– Moderate-severe symptoms
– Impairment makes participation in psychotherapy
difficult
– Partial response to psychotherapy
– Be sure to monitor progress and side effects of
SSRIs 2-4 wk follow-up
– If effective, consider tapering after 6-12 months
– If ineffective, consider a psychiatric consult
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FDA-approved Medications
for OCD

SSRIs
– fluoxetine (Prozac) (≥7 y/o)
– fluvoxamine (Luvox) (>7 y/o)
– sertraline (Zoloft) (≥6 y/o)

TCAs
– clomipramine (Anafranil) >10 y/o for OCD
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Efficacy Data: Anxiety Disorders





RUPP Luvox study (2001) → NEJM
– fluvoxamine >> placebo in SAD (Social Anxiety
Disorder), GAD (Generalized Anxiety Disorder) and
SPh (Social Phobia)
Pittsburgh Anxiety Study - Birmaher et al. (2003) →
JAACAP
– fluoxetine > placebo in SAD/GAD/SPh
POTS (Pediatric OCD Treatment Study) (2004) →
JAMA
– Combination>CBT=sertraline>placebo
Brawman-Mintzer et al. (2006) → J Clin Psych
– sertraline > placebo (small difference) in GAD
CAMS 2008 → NEJM
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Child–Adolescent Anxiety Multimodal Study
(CAMS)
•
•
Federally funded, multi-site RCT in 488
youth (7-17 yrs) with a primary diagnosis of
non-OCD anxiety disorder (separation
anxiety disorder, generalized anxiety
disorder, or social phobia)
Randomized to 12 weeks of
–
–
–
–
CBT
Sertraline (SER)
Combination of CBT + SER (COMB)
Placebo (PBO)
Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill J, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S,
March JS, Kendall PC. Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety
disorders: acute phase efficacy and safety. New England Journal of Medicine. Dec 25, 2008.
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Child–Adolescent Anxiety Multimodal Study
(CAMS)--continued
•
Efficacy results:
• CGI-I Response Rates:
• COMB (81%) > CBT (60%) = SER
(55%) > PBO (24%)
• PARS (Pediatric Anxiety Rating Scale)
• COMB > SER = CBT > PBO
• Mean dose of SER/PBO at final visit:
• COMB: 134 mg/day
• SER: 146 mg/day
• PBO: 176mg/day
Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill J, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S,
March JS, Kendall PC. Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety
disorders: acute phase efficacy and safety. New England Journal of Medicine. Dec 25, 2008.
Copyright © The REACH Institute. All rights reserved.
Benzodiazepines
• Have not shown efficacy in controlled trials in childhood
anxiety disorders (despite established benefit in adult
trials)
• Clinically, used as an adjunctive short-term treatment with
SSRIs to address severe anxiety symptoms and facilitate
exposure phase of CBT
• Contraindications: Adolescents with substance abuse
• Possible side effects: Sedation, disinhibition, cognitive
impairment, difficulty with discontinuation
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Anxiolytics and other
medications for anxiety*
• Not first-line treatment for child anxiety disorders
– Benzodiazepines – unproven
– Beta blockers – unproven efficacy
– Irreversible monoamine oxidase inhibitors – (Phenelzine) –
risk/benefit
– Reversible monoamine oxidase inhibitors – (Moclobemide)
– social phobia
– Antipsychotic drugs
– Antihistamines
– Buspirone – unproven efficacy
Tyrer P and Baldwin D; Lancet 2006:368:2156-66
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SSRI Titration Schedule
Medication
Citalopram
Starting
Dose
Increments Effective Maximum Contraindicated
Dose
Dosage
10 mg qd
10 mg
20 mg
40 mg
MAOI’s
5mg
5mg
10mg
20mg
MAOI’s
5-10 mg qd
10-20 mg
10-20 mg
60 mg
MAOI’s
Fluvoxamine
50 mg qd
50 mg
150 mg
300 mg
MAOI’s
Paroxetine
10 mg qd
10 mg
20 mg
60 mg
MAOI’s
Sertraline
25 mg qd
12.5 –25 mg
50 mg
200 mg
MAOI’s
Escitalopram
Fluoxetine
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Group Discussion
• First, pull out your SSRI (blue) card!
• Then, decide: If YOU have a child with a
moderate-severe anxiety disorder, and/or
not responsive to CBT:
– What medication will you use? Why?
– What will be your starting dose?
– What is your target therapeutic dose?
• Discuss
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What about
psychoactive medications
for sleep?
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Sleep
• More research is needed
• Look for iatrogenic causes
• Sleep hygiene / Behavioral strategies (see following slide)
• Treat primary disorder (e.g., MDD, anxiety disorders, RLS)
• Key Articles:
• Pharmacologic Management of Insomnia in Children and Adolescents:
Consensus Statement: Pediatrics, 2006; 117: e1223-e1232.
• * Cortese S, et. al.: Assessment & Management of Sleep Problems in
Youth w/ADHD: J Am Acad Child Adol Psychiatr, 2013; 52:784-796 *
• Melatonin – 2 RCTs (see * above)
• 2-6mg immediate-release; 5-10mg extended-release
•
Clonidine (w/ADHD youth) – 2 open-label studies, e.g.:
• Prince J, et al.: J Am Acad Child Adol Psychiatr, 1996; 35:599-606
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Panel
Discussion
Q&A
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Summary
• Be on the lookout! Anxiety disorders are
common
• Co-morbid disorders, in particular ADHD and
depression, are not uncommon
• Use standardized anxiety tools (SCARED) to
aid in the assessment
• Anxiety disorders are highly treatable
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REMINDER:
Please fill out Unit E
evaluation
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RESOURCE SLIDE:
Tips for Healthy Sleep Practices
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Copyright © The REACH Institute. All rights reserved.
See WBk A 1.3
RESOURCE SLIDE:
Annotated Bibliography

AACAP Practice Parameter for the Assessment and Treatment of
Children and Adolescents with Anxiety Disorders. Journal of the
American Academy of Child and Adolescent Psychiatry, 2007;46(2):267283.
This article provides the most recent update from the American Academy of Child and
Adolescent Psychiatry. It includes information on the presentation and epidemiology of
anxiety disorders. It details clinical guidelines as well as minimal standards for treating
anxiety disorder is children and adolescents.
•
Use of Algorithms to Treat Anxiety in Primary Care. Larry Culpepper,
MD, MPH. Journal of Clinical Psychiatry, 2003:64 Supplement 2
Abstract:
The presentations of anxiety in primary care are more numerous and broader in
spectrum than the presentations of depression, and the primary care physician is often
faced with the challenge of teasing out a diagnosis from the full spectrum of anxiety
disorders. A treatment algorithm that begins with recognition and diagnosis and carries
the primary care physician and patient through long-term treatment and, finally,
withdrawal of treatment can be a useful and appropriate tool. Use of an algorithm
targeted specifically for primary care physicians treating patients with anxiety disorders
would insure that patients in the primary care setting receive the best care during
treatment of anxiety disorders, while primary care physicians become better able to
serve a broader community
See WBk E 1.2
Copyright © 2014 The REACH Institute. All rights reserved.
RESOURCE SLIDE:
Additional Resources for
Primary Care Clinicians
• www.schoolpsychiatry.org
This web site was developed by Jeff Bostic, MD., child psychiatrist at
Harvard. There are many links to both proprietary and public-domain broadbased and domain-specific mental health rating scales.
• www.parentsmedguide.org
This web site is a collaborative effort by the American Academy of child and
Adolescent Psychiatry and the American Psychiatric Association. Practical
information and advice is posted regarding pediatric depression and anxiety
for parents, patients and clinicians.
• www.dbpeds.org
This is the web address for the American Academy of Pediatrics Section on
Developmental and Behavioral Pediatrics (SODBP) site. Non-AAP
members may also access the content on this site. There is extensive
material on developmental, behavioral and emotional screening with handouts for parents, links to public domain screening tools and other websites
with mental health content. There also are the articles on proper coding for
screening services published in the SODBP newsletter.
See WBk E 1.3
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