Stability of childhood anxiety disorder diagnoses: a follow-up naturalistic study in psychiatric care

Few studies have examined the stability of major psychiatric disorders in pediatric psychiatric clinical populations. The objective of this study was to examine the long-term stability of anxiety diagnoses starting with pre-school age children through adolescence evaluated at multiple time points. Prospective cohort study was conducted of all children and adolescents receiving psychiatric care at all pediatric psychiatric clinics belonging to two catchment areas in Madrid, Spain, between 1 January, 1992 and 30 April, 2006. Patients were selected from among 24,163 children and adolescents who received psychiatric care. Patients had to have a diagnosis of an ICD-10 anxiety disorder during at least one of the consultations and had to have received psychiatric care for the anxiety disorder. We grouped anxiety disorder diagnoses according to the following categories: phobic disorders, social anxiety disorders, obsessive–compulsive disorder (OCD), stress-related disorders, and "other" anxiety disorders which, among others, included generalized anxiety disorder, and panic disorder. Complementary indices of diagnostic stability were calculated. As much as 1,869 subjects were included and had 27,945 psychiatric/ psychological consultations. The stability of all ICD-10 anxiety disorder categories studied was high regardless of the measure of diagnostic stability used. Phobic and social anxiety disorders showed the highest diagnostic stability, whereas OCD and "other" anxiety disorders showed the lowest diagnostic stability. No significant sex differences were observed on the diagnostic stability of the anxiety disorder categories studied. Diagnostic stability measures for phobic, social anxiety, and "other" anxiety disorder diagnoses varied depending on the age at first evaluation. In this clinical pediatric outpatient sample it appears that phobic, social anxiety, and stress-related disorder diagnoses in children and adolescents treated in community outpatient services may have high diagnostic stability

SMARTer Discontinuation Trial Designs for Developing an Adaptive Treatment Strategy

Abstract Objective: Developing evidenced-based practices for the management of childhood psychiatric disorders requires research studies that address how to treat children during both the acute phase of the disorder and beyond. Given the selection of a medication for acute treatment, discontinuation trials are used to evaluate the effects of treatment duration (e.g., time on medication) and/or maintenance strategies following successful acute-phase treatment. Recently, sequential multiple assignment randomized trials (SMART) have been proposed for use in informing sequences of critical clinical decisions such as those mentioned. The objective of this article is to illustrate how a SMART study is related to the standard discontinuation trial design, while addressing additional clinically important questions with similar trial resources. Method: The recently completed Child/Adolescent Anxiety Multimodal Study (CAMS), a randomized trial that examined the relative efficacy of three acute-phase treatments for pediatric anxiety disorders, along with a next logical step, a standard discontinuation trial design, is used to clarify the ideas. This example is used to compare the discontinuation trial design relative to the SMART design. Results: We find that the standard discontinuation trial can be modified slightly using a SMART design to yield high-quality data that can be used to address a wider variety of questions in addition to the impact of treatment duration. We discuss how this innovative trial design is ultimately more efficient and less costly than the standard discontinuation trial, and may result in more representative comparisons between treatments. Conclusions: Mental health researchers who are interested in addressing questions concerning the effects of continued treatment (for different durations) following successful acute-phase treatment should consider SMART designs in place of discontinuation trial designs in their research. SMART designs can be used to address these and other questions concerning individualized sequences of treatment, such as the choice of a rescue treatment in case of postacute phase relapse.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98496/1/cap%2E2011%2E0073.pd

Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods

<p>Abstract</p> <p>Objective</p> <p>To present the design, methods, and rationale of the Child/Adolescent Anxiety Multimodal Study (CAMS), a recently completed federally-funded, multi-site, randomized placebo-controlled trial that examined the relative efficacy of cognitive-behavior therapy (CBT), sertraline (SRT), and their combination (COMB) against pill placebo (PBO) for the treatment of separation anxiety disorder (SAD), generalized anxiety disorder (GAD) and social phobia (SoP) in children and adolescents.</p> <p>Methods</p> <p>Following a brief review of the acute outcomes of the CAMS trial, as well as the psychosocial and pharmacologic treatment literature for pediatric anxiety disorders, the design and methods of the CAMS trial are described.</p> <p>Results</p> <p>CAMS was a six-year, six-site, randomized controlled trial. Four hundred eighty-eight (N = 488) children and adolescents (ages 7-17 years) with DSM-IV-TR diagnoses of SAD, GAD, or SoP were randomly assigned to one of four treatment conditions: CBT, SRT, COMB, or PBO. Assessments of anxiety symptoms, safety, and functional outcomes, as well as putative mediators and moderators of treatment response were completed in a multi-measure, multi-informant fashion. Manual-based therapies, trained clinicians and independent evaluators were used to ensure treatment and assessment fidelity. A multi-layered administrative structure with representation from all sites facilitated cross-site coordination of the entire trial, study protocols and quality assurance.</p> <p>Conclusions</p> <p>CAMS offers a model for clinical trials methods applicable to psychosocial and psychopharmacological comparative treatment trials by using state-of-the-art methods and rigorous cross-site quality controls. CAMS also provided a large-scale examination of the relative and combined efficacy and safety of the best evidenced-based psychosocial (CBT) and pharmacologic (SSRI) treatments to date for the most commonly occurring pediatric anxiety disorders. Primary and secondary results of CAMS will hold important implications for informing practice-relevant decisions regarding the initial treatment of youth with anxiety disorders.</p> <p>Trial registration</p> <p>ClinicalTrials.gov NCT00052078.</p