September 01, 2017
2 min read

Cognitive behavioral therapy, SSRIs, SNRIs effective for anxiety in children

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Cognitive behavioral therapy, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors were effective for pediatric anxiety disorders; however, behavioral therapy appeared most effective.

“Treatment guidelines recommend cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) as first-line interventions and also discuss the potential benefits of other interventions, such as serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepine and tricyclic antidepressant,” Zhen Wang, PhD, of Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota, and colleagues wrote. “However, to our knowledge, comparative effectiveness or, in some cases, the absolute effectiveness of these treatments has not been established.”

To compare efficacy and adverse events of CBT and pharmacotherapy for childhood anxiety disorders, researchers conducted a systematic review and meta-analysis of 115 studies among 7,719 individuals. Analysis included randomized and nonrandomized comparative studies among children and adolescents with panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder or separation anxiety who received CBT, pharmacotherapy, or a combination. Mean age was 9.2 years.

SSRIs significantly reduced primary anxiety symptoms and increased remission (RR = 2.04; 95% CI, 1.37-3.04) and response (RR = 1.96; 95% CI, 1.6-2.4), compared with placebo.

SNRIs significantly reduced primary anxiety symptoms reported by clinicians.

Benzodiazepines and tricyclics did not significantly reduce anxiety symptoms.

Compared with wait-listing or no treatment, CBT significantly improved primary anxiety symptoms, remission and response.

CBT was more effective for primary anxiety symptoms than fluoxetine and more effective for remission vs. sertraline.

Combination sertraline and CBT was most effective for clinician-reported anxiety symptoms and response, compared with any other treatment alone.

Adverse events were common among medications but not CBT.


Associations between suicidality and SSRIs or SNRIs were not assessed due to small study size or study duration. One trial indicated a statistically nonsignificant increase in suicidal ideation after receiving venlafaxine.

CBT was associated with fewer dropouts than placebo or medications.

“The important meta-analysis by Wang et al demonstrates that there are acute treatments that work. Still, roughly 40% to 50% of anxious children who receive gold standard CBT or SSRI remain symptomatic following acute treatment. While this is comparable with effects for treatments of pediatric medical conditions, such as asthma, this means that full remission is not expected for many children, even with our best treatments,” Joan Rosenbaum Asarnow, PhD, ABBP, of University of California, Los Angeles, and colleagues wrote in an accompanying editorial. “Additional research and practice advances are needed to clarify how best to address this prevalent and impairing illness.” – by Amanda Oldt

Disclosures: Asarnow reports receiving funding from the NIMH, the American Foundation for Suicide Prevention, the Substance Abuse and Mental Health Services Administration, the American Psychological Association (APA) Committee on Division/APA Relations, and the Society of Clinical Child and Adolescent Psychology (Division 53 of the APA); and serving as a consultant on quality improvement interventions for depression and suicidal/self-harm behavior. Please see the study for a full list of relevant financial disclosures.