From the Editor
“Anxiety and depression in youth are widely prevalent, highly impairing, and woefully undertreated.”
So writes San Diego State University’s V. Robin Weersing and her co-authors in a new JAMA Psychiatry paper. In this study, they compare a pediatric clinic-based brief behavioural treatment to referral to outpatient services for depression and anxiety. It’s a novel approach – and one with significant advantages (housing treatment in a primary care setting, to name just one).
So does this work? Spoiler alert: the brief behavioural treatment (BBT) comes out on top.
Anxiety treatment in the peds office: would Norman Rockwell approve?
As an accompanying Editorial notes: “The efficacy of BBT is particularly telling given the low response rate to treatment as usual in the control condition (57% vs 28%), especially for Hispanic populations (76% vs 7%).”
Please note: there will be no Reading next week because of the APA Annual Meeting. (I hope to see you in California.)
Kids and Therapy
“Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care: A Randomized Clinical Trial”
Robin Weersing, David A. Brent, Michelle S. Rozenman, Araceli Gonzalez, Megan Jeffreys, John F. Dickerson, Frances L. Lynch, Giovanna Porta, Satish Iyengar
JAMA Psychiatry, 19 April 2017 Online First
Anxiety and mood disorders in youth are prevalent and impairing, with a high degree of current and lifetime comorbidity in part because of shared etiologic factors. These patients also are markedly undertreated, with only 1 in 5 anxious youths and 2 in 5 depressed youths reporting any lifetime mental health service use for these disorders, the lowest treatment rates for any pediatric mental health disorder. Furthermore, there are notable ethnic disparities in care, with Hispanic youths significantly less likely to receive mental health services than similarly affected non-Hispanic white youths, despite experiencing similar or higher rates of anxiety and depression.
To improve access to and quality of care, the current trial tested the effectiveness of a brief behavioral therapy (BBT) developed to efficiently target anxiety and depression as a unified problem area. There is increasing support for the efficacy of transdiagnostic cognitive behavioral interventions for emotional disorders in adults and preliminary support for such interventions in youths. The BBT trial built on this work by testing a streamlined behavioral intervention without the cognitive restructuring elements present in other programs to aid in the dissemination of BBT to active service settings. The intervention was sited in pediatric primary care, a major focus of public health efforts to improve access to mental health services and a setting with low cultural stigma.
Here’s what they did:
- Participants were randomized to a brief behavioural therapy (BBT) intervention or an assisted referral to outpatient mental health care (ARC) intervention.
- Participants were recruited from 9 pediatric clinics in San Diego and Pittsburgh between 6 October 2010 and 5 December 2014.
- Youth had anxiety disorders (e.g., generalized anxiety disorder) or depressive disorders (e.g., major depression and minor depression). They also had a Clinical Global Impression-Severity score of 3 or greater. Exclusion criteria included alternative treatment, intellectual delay, substance dependence.
- BBT consisted on 8 to 12 weekly 45-minute sessions of behavioural therapy delivered in pediatric clinics by masters-level clinicians. BBT: “exposure and behavioral activation were combined in the current protocol 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.”
- ARC included feedback about symptoms, referrals to services, and problem-solving barriers to treatment, with a masters-level coordinator.
- Measures included the Clinical Global Impressions scale.
- Several statistical analyses were done, including logical regression methods.
Here’s what they found:
- 185 patients were enrolled in the study.
- Demographically: the median age was 11.3 years; participants tended to be female (57.8%) and white (77.8%). Most had anxiety (61.6%).
- “50 (56.8%) of the 88 BBT youth were rated as responders on our primary outcome measure (CGI-I score ≤2) at week 16 compared with only 20 (28.2%) of 71 youths in the ARC group…” That works out to a Number Needed to Treat of 4.
- BBT participants had a faster rate of functional improvement, and a higher functioning level at week 16.
- The study authors were interested in the possible effect of BBT for minorities (in particular, Hispanics). “Ethnicity significantly moderated response… with Hispanic youths having heightened response to BBT and little response to ARC (13 [76.5%] of 17 vs 1 [7.1%] of 14)…”
- The authors note that BBT was administered with high adherence with “a mean of 96% manual content delivered…” In terms of the patient experience: “The BBT youth attended a mean of 11.2 sessions, and 85 youths (90.4%) received at least a minimum protocol dose of at least 8 sessions.”
Response (Clinical Global Impression–Improvement Score ≤2) at Week 16 to Brief Behavioral Therapy (BBT) and Assisted Referral to Care (ARC) for Total Sample and by Hispanic Ethnicity
The ARC response rate was half that of the BBT, with a corresponding smaller improvement in functioning. These effects were especially stark for Hispanic youths, who had heightened response to BBT (76.5% response rate) and worse outcomes in ARC (7.1%) than did non-Hispanic white youths. Even for non-Hispanic white youths, the response rate for outpatient care in the ARC resembled that of clinical trial control conditions (eg, 24%; Child-Adolescent Anxiety Multimodal Study), adding to a troubling body of evidence suggesting that typical, eclectic community outpatient services for youths may be of modest effectiveness and reliably less efficacious than evidence-based psychosocial treatment protocols.
The paper runs with a short and highly readable editorial by Weill Cornell Medical College’s John T. Walkup et al.
You can find the editorial here:
The Editorial opens simply: “There is much to like about the randomized clinical trial reported by Weersing et al…”
Walkup et al. praise BBT:
Traditionally, psychotherapy developers focused on interventions for specific diagnoses to be implemented by mental health professionals in mental health settings. Once established as evidenced based, these therapies often failed to be disseminated into mental health centers, let alone pediatric primary care clinics. In contrast, BBT is a single transdiagnostic intervention that targets the most common internalizing conditions that affect children and adolescents: anxiety and depression.
They also praise different aspects of the intervention:
- The short duration of the intervention – just 8 sessions.
- The more focused nature of BBT – meaning, among other things, it’s easier to train and supervise therapists.
- The use of master’s level-prepared therapist who are “in greater supply and less expensive” that Ph.D-level therapists.
A few thoughts:
- This is a good study.
- The Discussion section opens (as this Reading opened) with the following observation: “Anxiety and depression in youth are widely prevalent, highly impairing, and woefully undertreated.” This paper points a way forward, looking at a practical intervention in a primary care setting. Nice.
- The paper raises a larger question: how can therapies be better used in the primary care setting?
- Let’s note how novel the approach is – transdiagnostic (meaning mood and/or anxiety problems), the use of masters-level clinicians, with a therapy that is focused.
- Though there is much to like in this study, the paper itself is not without problems. It should be noted that the recruitment period was unusually long, stretching for years yet the total number of patient was low. (Thanks to Dr. Benoit Mulsant for this observation, and the suggestion of this paper.) Was it difficult to recruit people? We can wonder if part of the problem may be that the “brief” therapy wasn’t so brief – requiring 8 sessions of 45 minutes.
- There are other attempts at bringing psychotherapy to the primary care setting for the child and adolescent population. For example, Asarnow et al. wrote a classic paper looking at CBT in the primary care setting over the usual care, finding fewer depressive symptoms and greater patient satisfaction. (Thanks to Dr. Amy Cheung for this tip.)
- The Weersing et al. study is American. I note that there is innovation north of the 49th parallel attempting to help youth with mental health problems, including anxiety disorders, moving beyond the traditional bricks and mortar/mental health centre approach. Strongest Families Institute works directly with parents and children, with videos, relaxation audio clips, and weekly telephone support.And congratulations to Patricia Lingley-Pottie and her group on winning the Governor General’s Innovation Award. Here’s the press release from earlier this month: https://www.gg.ca/document.aspx?id=16805&lan=eng
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.