The results of a meta-analysis published in JAMA Psychiatry suggest that group cognitive behavioral therapy (CBT) may be the most effective form of psychotherapy for children and adolescents with anxiety disorders.
Investigators performed a comprehensive literature search for randomized clinical trials across several databases, including PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, international trial registers, and US Food and Drug Administration reports. Eligible studies included any structured psychotherapy for the acute treatment of youths (≤18 years) with a primary diagnosis of anxiety disorders according to standardized diagnostic criteria. Researchers screened eligible trials independently, a panel of other investigators on the review team resolved any discrepancies through arbitration. As primary outcome measures, investigators assessed mean change scores in anxiety symptoms from baseline to treatment conclusion and from baseline to the end of follow-up (≤12 months).
Various measures were used to capture anxiety symptoms across studies, including the Revised Children’s Manifest Anxiety Scale and Spence Children’s Anxiety Scale. For studies that used the same scale with different informants, the meta-analysis prioritized self-rated scales, followed by parent report, teacher report, and healthcare professional’s report. Investigators also assessed quality of life (QoL) and functional improvement during treatment course (functioning), as well as treatment acceptability, defined as proportion of patients who discontinued treatment. Across the selected studies, 11 different psychotherapy techniques were used, including group and/or individual behavioral therapy, group and/or individual CBT, and therapies with parental involvement. These therapies were compared with the 4 control conditions: wait list treatment, psychological placebo, no treatment, and treatment as usual.
In total, 101 unique randomized clinical trials with 6625 enrollees were included in the meta-analysis. Participants were mean age 10.8±3.0 years, and half (50.6%) were girls. Regarding study quality, 72 (71.3%) trials were rated as at moderate risk for bias, 21 (20.8%) were rated at high risk for bias, and 8 (7.9%) were rated at low risk for bias. According to network meta-analysis, all psychotherapy modes were more beneficial than the wait list control condition at posttreatment (standardized mean difference [SMD], −1.43 to −0.61) and at the conclusion of follow-up (SMD, −1.84 to −1.64); however, only group CBT was significantly more effective than all neutral control conditions (SMD, −1.43 to −0.76) and most other psychotherapies (SMD, −0.82 to −0.43). According to pairwise meta-analysis, group CBT, individual CBT, and parental involvement CBT were significantly more efficacious than the wait list condition both at posttreatment and at follow-up. Regarding acceptability, bibliotherapy CBT had the highest rate of all-cause discontinuation compared with other forms of CBT and the control conditions. For QoL/functioning, group CBT with parental involvement, individual CBT, individual and group behavioral therapy, internet-assisted CBT, and parent-only CBT were significantly more effective than the wait list condition or psychological placebo (SMDs, 0.73 to 1.99).
According to these data, group CBT appears to be the most effective treatment mode for reducing anxiety symptoms and improving QoL/functioning in young patients. Acceptability for group CBT was also high compared with other forms of psychotherapy. Given the low certainty of evidence and moderate risk for bias among the assessed trials, further research is necessary to confirm these findings. Additionally, research exploring different moderators of treatment effects may be useful in parsing out the precise therapy mode most effective for each patient.
Zhou X, Zhang Y, Furukawa TA, et al. Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: a network meta-analysis [published online October 31, 2018]. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2018.3070