Copyright © The REACH Institute. All rights reserved. Treatment of Anxiety Disorders.

Copyright © The REACH Institute. All rights reserved.

Treatment of Anxiety Disorders

http://www.thereachinstitute.org/


REMINDER: EVALUATIONS


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


Treatment*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 6-12 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.


• 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

TreatmentTreatment


CBT TreatmentCBT 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)


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


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


Efficacy Data: Anxiety DisordersEfficacy 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


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.


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.


BenzodiazepinesBenzodiazepines• 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


Anxiolytics and othermedications for anxiety*

Anxiolytics and othermedications 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


Medication Starting Dose

Increments Effective Dose

Maximum Dosage

Contraindicated

Citalopram 10 mg qd 10 mg 20 mg 40 mg MAOI’s

Escitalopram 5mg 5mg 10mg 20mg MAOI’s

Fluoxetine 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

SSRI Titration Schedule


Group DiscussionGroup 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


What aboutpsychoactive medications

for sleep?


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


Panel Discussion

Panel Discussion

Q&AQ&A


SummarySummary

• 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


REMINDER: Please fill out Unit E

evaluation


RESOURCE SLIDE:Tips for Healthy Sleep Practices

Copyright © 2014 The REACH Institute. All rights reserved.

1. Promote Sleep Regulation 3. Reduce Arousal & Promote Relaxation

- Maintain organized/consistent sleep schedule - Keep electronics out of BR, limit use before bed

- Set/enforce consistent bedtime weekdays & weekends

- Reduce stimulating play before bedtime

- Keep regular schedule of activities (including meals)

- Avoid heavy meals or vigorous exercise before bedtime

- Avoid bright light in bedroom at bedtime and during night

- Reduce cognitive &/or emotional stimulation before bedtime

- Increase light exposure in morning - Eliminate caffeine

- Establish appropriate napping schedule - Do relaxing/calming activities in bedtime routine

2. Promote Sleep Conditioning 4. Promote Adequate Sleep Quantity & Quality

- Limit activities that promote wakefulness (TV, cell) - Set age-appropriate bedtime & wake time

- Use bed for sleep only – no “time-out” on bed - Maintain safe & comfortable sleep environment

- Avoid staying up late for rewards or early bed for punishment

- Ensure low noise & light levels, cool temperatures

- Avoid sleeping in other places (e.g., couch, car) - Ensure adequate, comfortable bedding and sleep surface

See WBk A 1.3Copyright © The REACH Institute. All rights reserved.

RESOURCE SLIDE:Annotated Bibliography

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):267-283.

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

Copyright © 2014 The REACH Institute. All rights reserved. See WBk E 1.2


RESOURCE SLIDE:Additional Resources forPrimary Care Clinicians

RESOURCE SLIDE:Additional Resources forPrimary Care Clinicians

• www.schoolpsychiatry.orgThis web site was developed by Jeff Bostic, MD., child psychiatrist at Harvard. There are many links to both proprietary and public-domain broad-based and domain-specific mental health rating scales.

• www.parentsmedguide.orgThis 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.orgThis 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 hand-outs 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

Copyright © The REACH Institute. All rights reserved. Treatment of Anxiety Disorders.

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