New Findings in Youth Anxiety Disorders

January 1, 2008

A recent longitudinal study examined the potential relationship between social anxiety disorder during adolescence and young adulthood and the subsequent development of depression.1

A total of 3021 individuals aged 14 to 24 years from a community sample in Munich, participated in the baseline evaluations. The patients had 3 follow-up diagnostic assessments over a 10-year period. It was found that the cumulative incidence of social anxiety disorder was 11%, with the greatest incidence in those aged 10 to 19 years. The cumulative incidence of depression was 27%. There was a strong association between social anxiety disorder and depression (odds ratio, 3.2). The risk of depression was independent of the age at onset of social anxiety disorder. In most cases, social anxiety disorder preceded the development of a depressive disorder.

Risk factors for subsequent depression in patients with social anxiety disorder were having a parent with an anxiety disorder or episodes of major depression, female sex, behavioral inhibition in childhood, and having at least 3 preceding anxiety disorders. This study demonstrated that during the first 3 decades of life, social anxiety disorder is associated with a substantial increase in risk of depression. This calls attention to the morbidity associated with social anxiety disorder and the importance of early treatment of the disorder.

Venlafaxine extended-release (Effexor XR) was recently shown to be effective in the treatment of children and adolescents with social anxiety disorder.2 A total of 293 outpatients aged 8 to 17 years participated in a randomized, double-blind, placebo-controlled trial. The starting venlafaxine dosage was 37.5 mg/d, which could be increased to a maximum dosage of 225 mg/d over the course of the 16-week trial. The mean daily dose of venlafaxine was 142 mg.

There was statistically significant superiority of venlafaxine over placebo in reduction of symptoms of social anxiety disorder. Response rates (defined as much or very much improved) were 56% in the venlafaxine-treated subjects and 37% in the placebo group. Treatment-emergent ad- verse events that occurred in at least 2% of participants and were at least twice the rate seen in the placebo group with a statistically significant difference between venlafaxine and placebo were asthenia (20%), anorexia (22%), nausea (23%), weight loss (11%), abnormal behavior (4%), pharyngitis (19%), and mydriasis (4%).

There were no suicides or suicide attempts during the trial. There were 3 cases of suicidal ideation in the venlafaxine group and none in the placebo group. The investigators concluded that venlafaxine is an effective and reasonably well-tolerated treatment for children and adolescents with social anxiety disorder.

Posttraumatic stress

Two recent studies have addressed the timely issue of treatment for posttraumatic stress disorder (PTSD) in children and adolescents. In one, the efficacy of individual trauma-focused cognitive-behavioral therapy (CBT) for PTSD in children and adolescents was evaluated.3 All participants with PTSD were to complete 4 weeks of symptom monitoring, with minimal telephone contact by the therapist, before being randomized to a treatment group. Participants met criteria for PTSD and had experienced a single-incident traumatic event (eg, witnessing violence or experiencinginterpersonal violence or a motor vehicle accident). The initial sample consisted of 38 participants. At the end of the 4-week monitoring period, 24% of the participants no longer met criteria for PTSD.

Twenty-four youths were then randomized to either CBT or a waiting list control. The CBT was manual-based and administered individually to participants in 10 weekly sessions. Some of the treatment components included psychoeducation, imaginal reliving, activities for scheduling and reclaiming life, cognitive restructuring, revisiting the site of the trauma, stimulus discrimination regarding traumatic reminders, work with nightmares, and work with parents.

It was found that the youths who received CBT had significantly greater improvement than the waiting list group in symptoms of PTSD, depression, and anxiety. Following CBT, 92% of the youths no longer met criteria for PTSD, compared with 42% of the youths in the waiting list group. At 6-month follow-up, treatment gains made during CBT were maintained. The authors reported that the effect of CBT was to change maladaptive appraisals about the trauma and its sequelae. It is noteworthy that although this CBT treatment is trauma-focused and discusses very traumatic events, no patients had worsening of PTSD symptoms.

In the second study, Cohen and associates4 assessed the potential benefits and risks of adding an SSRI, sertraline (Zoloft), to trauma-focused CBT for treating PTSD in children who had experienced sexual abuse. In this pilot study, 24 girls aged 10 to 17 years and their primary caregivers were randomly assigned to trauma-focused CBT and sertraline or trauma-focused CBT and placebo for a 12-week trial. Both groups showed improvement in PTSD symptoms following treatment, and there were no clinically meaningful differences between the 2 groups on measures of depression, anxiety, or behavioral problems. The only statistically significant difference in outcome between the groups was more improvement in Clinical Global Assessment Scale scores in the sertraline group. There were no suicide attempts in either group.

The investigators concluded that there is not a substantial advantage to adding medication to trauma-focused CBT. It is their recommendation that initial treatment for a child with PTSD be trauma-focused CBT or another trauma-focused psychotherapy. Medication could be added later if it is clinically indicated.

Anxiety-related sleep problems

A study by Alfano and colleagues5 called attention to the importance of assessing sleep-related problems for children and adolescents with anxiety disorders. Sleep-related problems were evaluated in 128 children aged 6 to 17 years who participated in a double-blind, randomized, controlled trial of fluvoxamine (Luvox) for treatment of an anxiety disorder.

The anxiety disorders included generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. Eighty-eight percent of the youths experienced at least 1 sleep-related problem, and more than half (55%) experienced 3 or more sleep-related problems. The most common sleep-related problems were insomnia (67%), nightmares (55%), and reluctance or refusal to sleep alone (48%).

The presence of sleep-related problems was associated with a higher degree of anxiety and greater impairment in functioning. The children who were treated with fluvoxamine showed greater reduction in sleep-related problems than the group who received placebo. The investigators recommend that information related to sleep problems be obtained whenever evaluating children with anxiety disorders.

References:

1.

Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life.

Arch Gen Psychiatry.

2007;64:903-912.

2.

March JS, Entusah AR, Rynn M, et al. A randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder.

Biol Psychiatry.

2007 Jun 4; Epub ahead of print.

3.

Smith P, Yule W, Perrin S, et al. Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial.

J Am Acad Child Adolesc Psychiatry.

2007;46:1051-1061.

4.

Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms.

J Am Acad Child Adolesc Psychiatry.

2007;46: 811-819.

5.

Alfano CA, Ginsburg GS, Kingery JN. Sleep-related problems among children and adolescents with anxiety disorders.

J Am Acad Child Adolesc Psychiatry.

2007;46:224-232. *