Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders : a sytematic review and meta-analysis

IMPORTANCE

Childhood anxiety is common. Multiple treatment options are available, but existing guidelines provide inconsistent advice on which treatment to use.

OBJECTIVES

To evaluate the comparative effectiveness and adverse events of cognitive behavioral therapy (CBT) and pharmacotherapy for childhood anxiety disorders.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus from database inception through February 1, 2017.

STUDY SELECTION

Randomized and nonrandomized comparative studies that enrolled children and adolescents with confirmed diagnoses of panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety and who received CBT, pharmacotherapy, or the combination.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers selected studies and extracted data. Random-effects meta-analysis was used to pool data.

MAIN OUTCOMES AND MEASURES

Primary anxiety symptoms (measured by child, parent, or clinician), remission, response, and adverse events.

RESULTS

A total of 7719 patientswere included from 115 studies. Of these, 4290 (55.6%) were female, and the mean (range) agewas 9.2 (5.4-16.1) years. Compared with pill placebo, selective serotonin reuptake inhibitors (SSRIs) significantly reduced primary anxiety symptoms and increased remission (relative risk, 2.04; 95%CI, 1.37-3.04) and response (relative risk, 1.96; 95%CI, 1.60-2.40). Serotonin-norepinephrine reuptake inhibitors (SNRIs) significantly reduced clinician-reported primary anxiety symptoms. Benzodiazepines and tricyclicswere not found to significantly reduce anxiety symptoms. When CBTwas compared withwait-listing/no treatment, CBT significantly improved primary anxiety symptoms, remission, and response.  ognitive behavioral therapy reduced primary anxiety symptoms more than fluoxetine and improved remission more than sertraline. The combination of sertraline and CBT significantly reduced clinician-reported primary anxiety symptoms and response more than either treatment alone. Head-to-head comparisonswere sparse, and network meta-analysis estimates were imprecise. Adverse eventswere common with medications but not with CBT andwere not severe. Studieswere too small or too short to assess suicidality with SSRIs or SNRIs. One trial showed a statistically nonsignificant increase in suicidal ideation with venlafaxine. Cognitive behavioral therapywas associated with fewer dropouts than pill placebo or medications.

CONCLUSIONS AND RELEVANCE

Evidence supports the effectiveness of CBT and SSRIs for reducing childhood anxiety symptoms. Serotonin-norepinephrine reuptake inhibitors also appear to be effective based on less consistent evidence. Head-to-head comparisons between various medications and comparisons with CBT represent a need for research in the field.