February 2009

Combination Approach to Childhood Anxiety
In a study of children with anxiety disorders, the combination of cognitive behavioral therapy and an antidepressant was superior to either treatment alone.

Antipsychotic-Induced Weight Gain: Management Without Meds
Several behavioral interventions effectively promote weight loss in patients taking antipsychotics.

Allopurinol: Novel Treatment for Mania?
Allopurinol (Lopurin and others) as an adjunct to lithium may help improve manic symptoms in patients with bipolar disorder.

In Brief
Behavioral Risk Factors Mediate Hospitalization and Mortality; International Internet Day of Action Results in Drug Seizures

Adjunctive Estrogen for Schizophrenia?
Exogenously administered estradiol added to antipsychotic therapy might benefit women with schizophrenia.

Injection Site Reactions with Naltrexone
Injections of extended-release naltrexone (Vivitrol) can cause serious skin reactions.

Combination Approach to Childhood Anxiety

February 2009

Anxiety disorders afflict an estimated 10% to 20% of children and adolescents, causing substantial impairment in school, family relationships, and social functioning, as well as predicting adult anxiety disorders and depression. Walkup and colleagues report on a National Institutes of Health-funded treatment trial of children with separation anxiety disorder, generalized anxiety disorder, or social phobia.1

Four hundred eighty-eight children, aged 7 to 17 years, were assigned at random to receive 14 sessions of cognitive behavioral therapy (CBT); the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft and others), up to 200 mg/day; sertraline plus CBT; or pill placebo for 12 weeks.

Results favored the combination treatment. The percentages of children categorized as much or very much improved (on the Clinical Global Impression-Improvement scale at 12 weeks) were 80.7% for combination treatment, 59.7% for CBT, 54.9% for sertraline, and 23.7% for placebo. All treatments were statistically superior to placebo (P < .001), and the combination was statistically superior to both monotherapies (P < .001). The average decrease in symptoms on the Pediatric Anxiety Rating Scale showed a similar magnitude and pattern of response.

There were no suicide attempts, and suicidal and homicidal thinking was no more frequent in patients assigned to sertraline than in those who took placebo. Insomnia, fatigue, sedation, and restlessness were more common with sertraline than with CBT. Patients treated with CBT were significantly (P = .03) less likely to withdraw prematurely from treatment than those who received sertraline.

The results of this large and well-executed trial are straightforward. CBT and the SSRI are comparable in efficacy against these pediatric anxiety disorders. The combination was superior to either treatment alone. For an individual patient, the best treatment is one that is available and will be adhered to. Clinicians treating children and adolescents with anxiety disorders can present options to the family and, with all practical considerations taken into account, arrive at an optimal strategy—whether beginning with a single treatment or combining psychotherapy and medication from the start.

1Walkup 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;359:2753-2766.