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Brief Behavioral Therapy for Anxiety and Depression in Pediatric Primary Care: Breadth of Intervention Impact

https://doi.org/10.1016/j.jaac.2022.08.007Get rights and content

Objective

To report on broad-based outcomes of the Brief Behavioral Therapy (BBT) trial for pediatric anxiety and depression. Secondary data analyses expand on previous reports by assessing diagnostic remission and independent functioning, impact on targeted psychopathology, and spillover effects on non-targeted outcomes.

Method

Youth (N = 185; 8-16.9 years; 58% female; 78% White; 21% Hispanic) with anxiety and/or depression were eligible for this multi-site trial. Enrolled youth were randomly assigned to receive 8 to 12 sessions of BBT in primary care or assisted referral to outpatient care (ARC). Assessments were conducted 16 and 32 weeks post randomization.

Results

BBT was superior to ARC on remission of all targeted diagnoses (week 16: 56.8% vs 28.2%, p < .001; week 32: 62.5% vs 38.9%, p = .004), clinician-rated independent functioning (week 16: 75.0% vs 45.7%, p < .001; week 32: 81.2% vs 55.7%, p < .001), and on measures of anxiety, depression, suicide items, total comorbid behavioral and emotional problems, and hyperactivity (d = 0.21-0.49). Moderation analyses revealed superior outcomes for Hispanic youth in BBT vs ARC for diagnostic remission, anxiety, emotional problems, and parent−child conflict. Youth depression at baseline moderated effects on peer problems and parent−child conflict, with effects favoring BBT. Significant main and moderated effects of BBT on change in non-targeted outcomes were largely mediated by change in anxiety (24.2%-49.3% of total effects mediated).

Conclusion

BBT has positive effects on youth, mediated by the strong impact of the intervention on anxiety. Analyses continue to support positive outcomes for Hispanic youth, suggesting that BBT is a broadly effective transdiagnostic treatment option for diverse populations.

Clinical trial registration information

Brief Cognitive Behavioral Therapy (CBT) for Pediatric Anxiety and Depression in Primary Care; https://clinicaltrials.gov; NCT01147614.

Section snippets

Participants

This work represents secondary analyses of the BBT dataset.7 Participants (N = 185) aged 8.0 to 16.9 years (referred to herein as “youth”; mean = 11.3 years, SD = 2.6; 58% female; 78% White, 21% Hispanic; Table S1, available online) were referred from pediatric clinics in San Diego, CA (n = 4) and Pittsburgh, PA (n = 5). Youth were eligible if they (1) met full or probable criteria for DSM-IV18 diagnoses of generalized anxiety disorder (GAD), social phobia, separation anxiety disorder, major

Sample Characteristics

Sample characteristics at baseline are summarized in Table S1, available online. BBT and ARC arms did not significantly differ in demographic characteristics or baseline values of primary outcomes. Youth-reports of anxiety, depression symptoms, and somatization were significantly lower among youth in the BBT group at baseline (SCARED-C: mean = 28.87, SD = 12.05; MFQ-C: mean = 15.20, SD = 11.22; CSI-C: mean = 10.93, SD = 8.66) compared to ARC (SCARED-C: mean = 33.01, SD = 14.09; MFQ-C: mean =

Discussion

In the current study, youth in BBT compared to those referred to community treatment (ARC) (1) achieved higher rates of diagnostic remission, defined by the absence of all inclusion diagnoses, (2) had a larger proportion of youth maintain remission status at both post-treatment and follow-up timepoints, and (3) more often attained independent functioning. Results on dimensional measures of anxiety and depression parallel these positive findings. Parent-report of youth anxiety symptoms indicated

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    • Cited by (2)

    Funding for data collection was awarded by the National Institute of Mental Health (NIMH; Clinicaltrials.gov Identifier: NCT01147614) to the principal investigators at each site: R01 MH084935 and R01 MH084916.

    The research was performed with permission from the San Diego State University Human Research Protection Program, the University of Pittsburgh, and Kaiser Permanente Southern California Institutional Review Boards.

    Data Transparency

    The specific data reported in this manuscript have not been previously published. However, alternate data from this dataset have been published in separate manuscripts. Weersing et al.7 focuses on primary outcomes with an emphasis on clinician-rated measures of anxiety, depression, global functioning, and improvement. Brent et al.11 focuses on maintenance of effects at follow-up, and Lynch et al.12 examines cost-effectiveness.

    Written informed consent and assent were obtained from parents and youth.

    A portion of this study was presented as a talk at the Association for Behavioral and Cognitive Therapies (ABCT) 51st Annual Convention; November 16-19, 2017; San Diego, California. Another portion of findings was presented virtually as a poster at the Association for Behavioral and Cognitive Therapies (ABCT) 54th Annual Convention; November 17-22, 2020; Virtual.

    Dr. Dickerson, Ms. Porta, and Dr. Lynch served as the statistical experts for this research.

    Author Contributions

    Conceptualization: Schwartz, Kado-Walton, Dickerson, Rozenman, Brent, Lynch, Weersing

    Data curation: Schwartz, Porta, Weersing

    Formal analysis: Dickerson

    Funding acquisition: Brent, Porta, Lynch, Weersing

    Investigation: Schwartz, Rozenman, Brent, Gonzalez, Weersing

    Methodology: Schwartz, Dickerson, Brent, Weersing

    Project administration: Schwartz, Rozenman, Porta, Gonzalez, Weersing

    Resources: Weersing

    Supervision: Brent, Weersing

    Writing – original draft: Schwartz, Kado-Walton, Dickerson, Weersing

    Writing – review and editing: Schwartz, Kado-Walton, Dickerson, Rozenman, Brent, Porta, Lynch, Gonzalez, Weersing

    The authors thank the participating families and hard-working staff at each site for their efforts, which have made this project possible.

    Disclosure: Drs. Rozenman, Gonzalez, and Weersing have reported they could receive royalties from Oxford University Press as authors of the BBT manual. Dr. Brent has received research support from NIMH, the American Foundation for Suicide Prevention (ASFP), the Once Upon a Time Foundation, and the Beckwith Foundation. He has received royalties from Guilford Press, from the electronic self-rated version of the C-SSRS from eRT, Inc., and from performing duties as an UpToDate Psychiatry Section Editor. He has received consulting fees from Healthwise, honoraria from the Klingenstein Third Generation Foundation for scientific board membership and grant reviews, and is a scientific board member for AFSP. He has received funding from NIMH, which supported the development of intellectual property for BRITE, the As Safe As Possible intervention, the Computerized Adaptive Screen for Suicidal Youth (CASSY) measure, a suicide risk machine learning algorithm, and the Screening Wizard screening tool. Drs. Schwartz, Dickerson, and Lynch and Mss. Kado-Walton and Porta have reported no biomedical financial interests or potential conflicts of interest.

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