Monday, November 3, 2008

A Look at the New England Journal of Medicine Article on Childhood Anxiety

In the movie Ordinary People, Timothy Hutton plays a deeply anxious and depressed young man named Conrad Jarrett who ultimately finds redemption thanks to the intense counseling provided by a therapist played by Judd Hirsch. The Disease Management Care Blog agrees Robert Redford deserved the Oscar for this wonderful movie, which not only portrays the malignant impact of mental illness on an seemingly ‘ordinary’ family but has a pretty good score of Pachbelbel’s Canon in D.

The message is that it’s hard to underestimate the burden of mental illness on the individual and people and community around them. It wasn’t just Conrad who taught that to the DMCB, but many years of clinical practice. This was tough, very tough to manage.

So when the New England Journal of Medicine publishes an “on-line first” randomized clinical trial consisting of 488 Conrad Jarretts, it pays close attention so that you don't have to. Briefly, 488 persons aged 7-17 years (average age about 11 years) with anxiety or phobia were randomly assigned to either 1) a series of 14 sixty-minute counseling sessions or, 2) the SSRI sertraline ('Zoloft') with 8 sessions to assess response to therapy or 3) placebo with 8 sessions to assess response to therapy or 4) both the 14 counseling sessions plus the SSRI. Psychological scales were used to assess progress in all four groups over 12 weeks. The persons performing the psychological assessments were unaware of the treatment. While the children on just drug or placebo (groups 2 and 3 above) weren’t sure what they were getting, the children getting the therapy plus drug (group 4 above) were aware that they weren’t getting a placebo.

The bottom line? At 12 weeks, 81% in the combination therapy group were significantly improved vs. 60% and 55% in the active drug and counseling groups, respectively, vs. 24% in the placebo group. Adverse events were assiduously tracked and no particularly significant pattern stood out.

What are the DMCB take aways? They fall in three categories:

Confirmation of what is known: Previous studies over the past decade have shown that psychotherapy and drug therapy in depression share the same success rates and that both have a higher success rate than either alone. In addition, a top success rate 80% is consistent with some previous studies on the topic. So this particular NEJM piece is not that newsworthy other than the confirmation of the same findings for anxiety. It does remind us, however, that there is a ‘hard core’ 20% minority of persons who don’t get better. Think the character Karen in Ordinary People. She didn’t do well.

Criticism of the study method: Persons in the combination therapy group knew they were getting active drug. It is possible that this knowledge contributed to their improvement – not because the anxiety was any better but because they thought they were going to get better. In addition, the study was not powered to detect any meaningful difference in adverse effects between the groups, so the fact that nothing showed up doesn't mean nothing is there. At any rate, in this age of SSRIs, the DMCB wonders if Ordinary People would have a chance of being made into a movie today. Not much of a plot when Conrad is taking his daily medicine and doing fine.

The impact on day-to-day clinical practice: The DMCB doesn’t think it will be a lot. Many readers assume that young people with anxiety are probably getting offered drugs more often that psychotherapy. That’s because that course of therapy is cheaper (one month of sertraline is relatively inexpensive under most insurance benefit plans) and it doesn’t use up to 14 hours of valuable time otherwise spent in school or at home, not mention 14 individual co-pays. While an 80% chance of improvement with combination therapy ‘beats’ the 60% with drugs alone, the DMCB thinks most parents and physicians will continue to opt for the drug therapy first and then add counseling if it drugs don’t work.

Finally, there is far more to the modern treatment of depression and anxiety disorders than just drugs or psychotherapy. This excellent article in JAMA reminds us about the role of collaborative care strategies, quality improvement activities, case management, pharmacist-provided follow-up, and decision support. And oh yes, the same principles of disease management that has conclusively been shown to work for depression may also help in the area of anxiety disorders.

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