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Ramakrishnan D, Farhat LC, Vattimo EFQ, Levine JLS, Johnson JA, Artukoglu BB, Landeros-Weisenberger A, Zangen A, Pelissolo A, de B Pereira CA, Rück C, Costa DLC, Mataix-Cols D, Shannahoff-Khalsa D, Tolin DF, Zarean E, Meyer E, Hawken ER, Storch EA, Andersson E, Miguel EC, Maina G, Leckman JF, Sarris J, March JS, Diniz JB, Kobak K, Mallet L, Vulink NCC, Amiaz R, Fernandes RY, Shavitt RG, Wilhelm S, Golshan S, Tezenas du Montcel S, Erzegovesi S, Baruah U, Greenberg WM, Kobayashi Y, Bloch MH. An evaluation of treatment response and remission definitions in adult obsessive-compulsive disorder: A systematic review and individual-patient data meta-analysis. J Psychiatr Res 2024; 173:387-397. [PMID: 38598877 DOI: 10.1016/j.jpsychires.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Expert consensus operationalized treatment response and remission in obsessive-compulsive disorder (OCD) as a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) reduction ≥35% and score ≤12 with ≤2 on Clinical Global Impressions Improvement (CGI-I) and Severity (CGI-S) scales, respectively. However, there has been scant empirical evidence supporting these definitions. METHODS We conducted a systematic review and an individual participant data meta-analysis of randomized-controlled trials (RCTs) in adults with OCD to determine optimal Y-BOCS thresholds for response and remission. We estimated pooled sensitivity/specificity for each percent reduction threshold (response) or posttreatment score (remission) to determine response and remission defined by a CGI-I and CGI-S ≤ 2, respectively. RESULTS Individual participant data from 25 of 94 eligible RCTs (1235 participants) were included. The optimal threshold for response was ≥30% Y-BOCS reduction and for remission was ≤15 posttreatment Y-BOCS. However, differences in sensitivity and specificity between the optimal and nearby thresholds for response and remission were small with some uncertainty demonstrated by the confidence ellipses. CONCLUSION While the empirically derived Y-BOCS thresholds in our meta-analysis differ from expert consensus, given the predominance of data from more recent trials of OCD, which involved more refractory participants and novel treatment modalities as opposed to first-line therapies, we recommend the continued use of the consensus definitions.
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Affiliation(s)
| | - Luis C Farhat
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Edoardo F Q Vattimo
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | | | - Jessica A Johnson
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Bekir B Artukoglu
- Department of Child and Adolescent Psychiatry, Baylor College of Medicine, Houston, TX, USA
| | | | - Abraham Zangen
- Department of Life Sciences and the Zelman Center for Neuroscience, Ben Gurion University, Be'er Sheva, Israel
| | - Antoine Pelissolo
- Psychiatry Department, Henri-Mondor University Hospitals, Faculty of Medicine, Créteil, France
| | - Carlos A de B Pereira
- Mathematics and Statistics Institute, Statistics Department, University of São Paulo, São Paulo, Brazil
| | - Christian Rück
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Daniel L C Costa
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - David Shannahoff-Khalsa
- The Research Group for Mind-Body Dynamics, BioCircuits Institute and Center for Integrative Medicine, University of California San Diego, CA, USA; The Khalsa Foundation for Medical Science, Del Mar, CA, USA
| | - David F Tolin
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; The Institute of Living, Hartford, CT, USA
| | - Elham Zarean
- Department of Psychiatry, School of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Elisabeth Meyer
- Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Emily R Hawken
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Eric A Storch
- Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Euripedes C Miguel
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Turin, Italy
| | - James F Leckman
- Child Study Center, Department of Pediatrics and Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Jerome Sarris
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Victoria, Australia; NICM Health Research Institute, Western Sydney University, NSW, Australia
| | - John S March
- Department of Psychiatry and Behavioral Sciences, Duke School of Medicine, Durham, NC, USA
| | - Juliana B Diniz
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | | | - Luc Mallet
- Medical-University Department of Psychiatry and Addictology, Henri Mondor - Albert Chenevier University Hospitals, Créteil, France
| | - Nienke C C Vulink
- The Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | | | - Rodrigo Yacubian Fernandes
- The National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Department of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Roseli G Shavitt
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Sabine Wilhelm
- OCD and Related Disorders Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shahrokh Golshan
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Sophie Tezenas du Montcel
- Sorbonne Universite, Institut du Cerveau Paris Brain Institute-ICM, Inserm, CNRS, AP-HP, Inria Aramis project-team, Paris, France
| | - Stefano Erzegovesi
- Department of Neurosciences, Eating Disorders Unit, IRCCS San Raffaele, Milano, Italy
| | - Upasana Baruah
- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | | | - Yuki Kobayashi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Michael H Bloch
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
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Shannahoff-Khalsa D, Fernandes RY, Pereira CADB, March JS, Leckman JF, Golshan S, Vieira MSR, Polanczyk GV, Miguel EC, Shavitt RG. Kundalini Yoga Meditation Versus the Relaxation Response Meditation for Treating Adults With Obsessive-Compulsive Disorder: A Randomized Clinical Trial. Front Psychiatry 2019; 10:793. [PMID: 31780963 PMCID: PMC6859828 DOI: 10.3389/fpsyt.2019.00793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/04/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Obsessive-compulsive disorder (OCD) is often a life-long disorder with high psychosocial impairment. Serotonin reuptake inhibitors (SRIs) are the only FDA approved drugs, and approximately 50% of patients are non-responders when using a criterion of 25% to 35% improvement with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). About 30% are non-responders to combined first-line therapies (SRIs and exposure and response prevention). Previous research (one open, one randomized clinical trial) has demonstrated that Kundalini Yoga (KY) meditation can lead to an improvement in symptoms of obsessive-compulsive severity. We expand here with a larger trial. Design: This trial compared two parallel run groups [KY vs. Relaxation Response meditation (RR)]. Patients were randomly allocated based on gender and Y-BOCS scores. They were told two different (unnamed) types of meditation would be compared, and informed if one showed greater benefits, the groups would merge for 12 months using the more effective intervention. Raters were blind in Phase One (0-4.5 months) to patient assignments, but not in Phase Two. Main Outcome Measures: Primary outcome variable, clinician-administered Y-BOCS. Secondary scales: Dimensional Yale-Brown Obsessive Compulsive Scale (clinician-administered), Profile of Mood Scales, Beck Anxiety Inventory, Beck Depression Inventory, Clinical Global Impression, Short Form 36 Health Survey. Results: Phase One: Baseline Y-BOCS scores: KY mean = 26.46 (SD 5.124; N = 24), RR mean = 26.79 (SD = 4.578; N = 24). An intent-to-treat analysis with the last observation carried forward for dropouts showed statistically greater improvement with KY compared to RR on the Y-BOCS, and statistically greater improvement on five of six secondary measures. For completers, the Y-BOCS showed 40.4% improvement for KY (N = 16), 17.9% for RR (N = 11); 31.3% in KY were judged to be in remission compared to 9.1% in RR. KY completers showed greater improvement on five of six secondary measures. At the end of Phase Two (12 months), patients, drawn from the initial groups, who elected to receive KY continued to show improvement in their Y-BOCS scores. Conclusion: KY shows promise as an add-on option for OCD patients unresponsive to first line therapies. Future studies will establish KY's relative efficacy compared to Exposure and Response Prevention and/or medications, and the most effective treatment schedule. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01833442.
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Affiliation(s)
- David Shannahoff-Khalsa
- BioCircuits Institute, University of California, San Diego, La Jolla, CA, United States.,Center for Integrative Medicine, University of California, San Diego, La Jolla, CA, United States.,The Khalsa Foundation for Medical Science, Del Mar, CA, United States
| | - Rodrigo Yacubian Fernandes
- The National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Department of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carlos A de B Pereira
- Mathematics and Statistics Institute, Statistics Department, University of São Paulo, São Paulo, Brazil
| | - John S March
- Department of Psychiatry and Behavioral Sciences, Duke School of Medicine, Durham, NC, United States
| | - James F Leckman
- Child Study Center, Department of Pediatrics and Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Shahrokh Golshan
- Center for Integrative Medicine, University of California, San Diego, La Jolla, CA, United States.,Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States
| | | | - Guilherme V Polanczyk
- The National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Department of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Euripedes C Miguel
- The National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Department of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Roseli G Shavitt
- The National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Department of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil
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Fatori D, de Bragança Pereira CA, Asbahr FR, Requena G, Alvarenga PG, de Mathis MA, Rohde LA, Leckman JF, March JS, Polanczyk GV, Miguel EC, Shavitt RG. Adaptive treatment strategies for children and adolescents with Obsessive-Compulsive Disorder: A sequential multiple assignment randomized trial. J Anxiety Disord 2018; 58:42-50. [PMID: 30025255 DOI: 10.1016/j.janxdis.2018.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/19/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE This sequential multiple assignment randomized trial (SMART) tested the effect of beginning treatment of childhood OCD with fluoxetine (FLX) or group cognitive-behavioral therapy (GCBT) accounting for treatment failures over time. METHODS A two-stage, 28-week SMART was conducted with 83 children and adolescents with OCD. Participants were randomly allocated to GCBT or FLX for 14 weeks. Responders to the initial treatment remained in the same regimen for additional 14 weeks. Non-responders, defined by less than 50% reduction in baseline Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores, were re-randomized to either switch to or add the other treatment. Assessments were performed at baseline, 7, 14, 21, and 28 weeks. RESULTS Among the 43 children randomized to FLX who completed the first stage, 15 (41.7%) responded to treatment and 21 non-responders were randomized to switch to (N = 9) or add GCBT (N = 12). Among the 40 children randomized to GCBT who completed the first stage, 18 (51.4%) responded to treatment and 17 non-responders were randomized to switch to (N = 9) or add FLX (N = 8). Primary analysis showed that significant improvement occurred in children initially treated with either FLX or GCBT. Each time point was statistically significant, showing a linear trend of symptom reduction. Effect sizes were large within (0.76-0.78) and small between (-0.05) groups. CONCLUSIONS Fluoxetine and GCBT are similarly effective initial treatments for childhood OCD considering treatment failures over time. Consequently, provision of treatment for childhood OCD could be tailored according to the availability of local resources.
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Affiliation(s)
- Daniel Fatori
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil; National Institute of Developmental Psychiatry for Children and Adolescents (INCT-CNPq), São Paulo, Brazil.
| | | | - Fernando R Asbahr
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Guaraci Requena
- Institute of Mathematics and Statistics, University of Sao Paulo, Sao Paulo, Brazil
| | - Pedro G Alvarenga
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Luis A Rohde
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil; National Institute of Developmental Psychiatry for Children and Adolescents (INCT-CNPq), São Paulo, Brazil; Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - James F Leckman
- Child Study Center, School of Medicine, Yale University, New Haven, CT, USA
| | - John S March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Guilherme V Polanczyk
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil; National Institute of Developmental Psychiatry for Children and Adolescents (INCT-CNPq), São Paulo, Brazil
| | - Eurípedes C Miguel
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil; National Institute of Developmental Psychiatry for Children and Adolescents (INCT-CNPq), São Paulo, Brazil
| | - Roseli G Shavitt
- Department of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil; National Institute of Developmental Psychiatry for Children and Adolescents (INCT-CNPq), São Paulo, Brazil
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Salvador MDC, Matos AP, Oliveira S, S. March J, Arnarson EÖ, Carey SC, Craighead WE. A Escala Multidimensional de Ansiedade para Crianças (MASC): Propriedades psicométricas e análise fatorial confirmatória numa amostra de adolescentes portugueses. REV IBEROAM DIAGN EV 2017. [DOI: 10.21865/ridep45.3.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Gordon-Hollingsworth AT, Becker EM, Ginsburg GS, Keeton C, Compton SN, Birmaher BB, Sakolsky DJ, Piacentini J, Albano AM, Kendall PC, Suveg CM, March JS. Anxiety Disorders in Caucasian and African American Children: A Comparison of Clinical Characteristics, Treatment Process Variables, and Treatment Outcomes. Child Psychiatry Hum Dev 2015; 46:643-55. [PMID: 25293650 PMCID: PMC4390415 DOI: 10.1007/s10578-014-0507-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study examined racial differences in anxious youth using data from the Child/Adolescent Anxiety Multimodal Study (CAMS) [1]. Specifically, the study aims addressed whether African American (n = 44) versus Caucasian (n = 359) children varied on (1) baseline clinical characteristics, (2) treatment process variables, and (3) treatment outcomes. Participants were ages 7-17 and met DSM-IV-TR criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder. Baseline data, as well as outcome data at 12 and 24 weeks, were obtained by independent evaluators. Weekly treatment process variables were collected by therapists. Results indicated no racial differences on baseline clinical characteristics. However, African American participants attended fewer psychotherapy and pharmacotherapy sessions, and were rated by therapists as less involved and compliant, in addition to showing lower mastery of CBT. Once these and other demographic factors were accounted for, race was not a significant predictor of response, remission, or relapse. Implications of these findings suggest African American and Caucasian youth are more similar than different with respect to the manifestations of anxiety and differences in outcomes are likely due to treatment barriers to session attendance and therapist engagement.
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Affiliation(s)
- Arlene T. Gordon-Hollingsworth
- Department of Pediatrics, Psychology Section, Baylor College of Medicine, 6701 Fannin Street, CC1630, Houston, TX 77030, USA
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, 550 N. Broadway, Baltimore, MD 21205, USA
| | - Emily M. Becker
- Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124-0751, USA
| | - Golda S. Ginsburg
- Department of Psychiatry, University of Connecticut Health Center, 65 Kane Street, Room 1005, West Hartford, CT 06119, USA
| | - Courtney Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, 550 N. Broadway, Baltimore, MD 21205, USA
| | - Scott N. Compton
- Department of Psychiatry, Duke University Medical Center, Suite 3527, Durham, NC 27710, USA
| | - Boris B. Birmaher
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburg, PA 15213, USA
- Western Psychiatric Institute & Clinic, University of Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburg, PA, USA
| | - Dara J. Sakolsky
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburg, PA 15213, USA
- Western Psychiatric Institute & Clinic, University of Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburg, PA, USA
| | - John Piacentini
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, Los Angeles, CA 90024, USA
| | - Anne M. Albano
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA
| | - Philip C. Kendall
- Department of Psychology, Temple University, 1701 North 13th Street, Philadelphia, PA 19122, USA
| | - Cynthia M. Suveg
- Department of Psychology, University of Georgia, 125 Baldwin Street, Athens, GA 30602, USA
| | - John S. March
- Division of Neurosciences Medicine, Duke Research Institute, 2400 Pratt Street, Durham, NC 27710, USA
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Emslie GJ, Wells TG, Prakash A, Zhang Q, Pangallo BA, Bangs ME, March JS. Acute and longer-term safety results from a pooled analysis of duloxetine studies for the treatment of children and adolescents with major depressive disorder. J Child Adolesc Psychopharmacol 2015; 25:293-305. [PMID: 25978741 DOI: 10.1089/cap.2014.0076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess acute and longer-term safety of duloxetine in the treatment of children and adolescents with major depressive disorder (MDD), a pooled analysis of data from two completed randomized, double-blind, multicenter, phase 3, placebo- and active-controlled trials was undertaken. In these studies, neither duloxetine (investigational drug) nor fluoxetine (active control) demonstrated a statistically significant improvement compared with placebo on the primary efficacy measure. METHODS Patients ages 7-17 years with MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) received duloxetine (n=341), fluoxetine (n=234), or placebo (n=225) for 10 week acute and 26 week extended (duloxetine or fluoxetine only) treatments. Safety measures included treatment-emergent adverse events (TEAEs), the Columbia-Suicide Severity Rating Scale, vital signs, electrocardiograms, laboratory samples, and growth (height and weight) assessments. RESULTS Significantly more patients discontinued because of adverse events during duloxetine (8.2%) treatment than during placebo (3.1%) treatment (p≤0.05). TEAEs in >10% of duloxetine-treated patients were headache and nausea. No completed suicides or deaths occurred. During acute treatment, 6.6% of duloxetine-, 8.0% of fluoxetine-, and 8.2% of placebo-treated patients had worsening suicidal ideation from baseline. Among patients initially randomized to duloxetine or fluoxetine who had suicidal ideation at study baseline, 81% of duloxetine- and 77% of fluoxetine-treated patients had improvements in suicidal ideation at end-point in the 36-week studies. Suicidal behavior occurred in two fluoxetine-treated patients and one placebo-treated patient during acute treatment, and in seven duloxetine-treated patients and one fluoxetine-treated patient during extended treatment. Duloxetine-treated patients had a mean pulse increase of ∼3 beats per minute, and mean blood pressure (both systolic and diastolic) increases of <2.0 mm Hg at week 36. Weight decrease (≥3.5%) during acute treatment occurred with statistically (p≤0.05) greater frequency for both the duloxetine (11.4%) and fluoxetine (11.5%) groups versus the placebo (5.5%) group; however, mean weight increase occurred for both duloxetine and fluoxetine groups during extended treatment. CONCLUSION Results from this pooled analysis of two studies were consistent with the known safety and tolerability profile of duloxetine. Clinical Trial Registry Numbers: NCT00849901 and NCT00849693.
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Affiliation(s)
- Graham J Emslie
- 1 Department of Psychiatry, University of Texas Southwestern and Children's Medical Center , Dallas, Texas
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Rynn MA, Walkup JT, Compton SN, Sakolsky DJ, Sherrill JT, Shen S, Kendall PC, McCracken J, Albano AM, Piacentini J, Riddle MA, Keeton C, Waslick B, Chrisman A, Iyengar S, March JS, Birmaher B. Child/Adolescent anxiety multimodal study: evaluating safety. J Am Acad Child Adolesc Psychiatry 2015; 54:180-90. [PMID: 25721183 PMCID: PMC4362776 DOI: 10.1016/j.jaac.2014.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/08/2014] [Accepted: 12/29/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of adverse events (AEs) across 4 treatment conditions in the Child/Adolescent Anxiety Multimodal Study (CAMS), and to compare the frequency of AEs between children and adolescents. METHOD Participants ages 7 to 17 years (mean = 10.7 years) meeting the DSM-IV criteria for 1 or more of the following disorders: separation anxiety disorder, generalized anxiety disorder, or social phobia were randomized (2:2:2:1) to cognitive-behavioral therapy (CBT, n = 139), sertraline (SRT, n = 133), a combination of both (COMB, n = 140), or pill placebo (PBO, n = 76). Data on AEs were collected via a standardized inquiry method plus a self-report Physical Symptom Checklist (PSC). RESULTS There were no differences between the double-blinded conditions (SRT versus PBO) for total physical and psychiatric AEs or any individual physical or psychiatric AEs. The rates of total physical AEs were greater in the SRT-alone treatment condition when compared to CBT (p < .01) and COMB (p < .01). Moreover, those who received SRT alone reported higher rates of several physical AEs when compared to COMB and CBT. The rate of total psychiatric AEs was higher in children (≤12 years) across all arms (31.7% versus 23.1%, p < .05). Total PSC scores decreased over time, with no significant differences between treatment groups. CONCLUSION The results support the tolerability/safety of selective serotonin reuptake inhibitor (SSRI) treatment for anxiety disorders even after adjusting for the number of reporting opportunities, leading to no differences in overall rates of AEs. Few differences occurred on specific items. Additional monitoring of psychiatric AEs is recommended in children (≤12 years). Clinical trial registration information-Child and Adolescent Anxiety Disorders (CAMS); http://clinicaltrials.gov; NCT00052078.
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Affiliation(s)
- Moira A Rynn
- Columbia University Medical Center (CUMC)/New York State Psychiatric Institute, New York.
| | - John T Walkup
- Weill Cornell Medical College and New York Presbyterian Hospital, New York
| | | | - Dara J Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
| | - Joel T Sherrill
- Division of Services and Intervention Research at the National Institute of Mental Health (NIMH), Bethesda, MD
| | - Sa Shen
- University of Illinois at Urbana-Champaign
| | | | - James McCracken
- University of California, Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior
| | - Anne Marie Albano
- Columbia University Medical Center (CUMC)/New York State Psychiatric Institute, New York
| | - John Piacentini
- University of California, Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior
| | - Mark A Riddle
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Satish Iyengar
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
| | | | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
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Emslie GJ, Prakash A, Zhang Q, Pangallo BA, Bangs ME, March JS. A double-blind efficacy and safety study of duloxetine fixed doses in children and adolescents with major depressive disorder. J Child Adolesc Psychopharmacol 2014; 24:170-9. [PMID: 24815533 PMCID: PMC4026396 DOI: 10.1089/cap.2013.0096] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of duloxetine fixed dose in the treatment of children (7-11 years) and adolescents (12-17 years) with major depressive disorder (MDD). METHODS Patients (n=463) in this 36 week study (10 week acute and 26 week extension treatment) received duloxetine 60 mg QD (n=108), duloxetine 30 mg QD (n=116), fluoxetine 20 mg QD (n=117, active control), or placebo (n=122). Measures included: Children's Depression Rating Scale-Revised (CDRS-R), treatment-emergent adverse events (TEAEs), and Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS Neither active drug (duloxetine or fluoxetine) separated significantly (p<0.05) from placebo on mean change from baseline to end-point (10 weeks) on the CDRS-R total score. Total TEAEs and discontinuation for AEs were significantly (p<0.05) higher only for the duloxetine 60 mg group versus the placebo group during acute treatment. No clinically significant electrocardiogram (ECG) or laboratory abnormalities were observed, and no completed suicides or deaths occurred during the study. A total of 7 (6.7%) duloxetine 60 mg, 6 (5.2%) duloxetine 30 mg, 9 (8.0%) fluoxetine, and 11 (9.4%) placebo patients had worsening of suicidal ideation from baseline during acute treatment. Of the patients with suicidal ideation at baseline, 13/16 (81%) duloxetine 60 mg, 16/17 (94%) duloxetine 30 mg, 11/16 (69%) fluoxetine, and 13/15 (87%) placebo had improvement in suicidal ideation at end-point during acute treatment. One fluoxetine, one placebo, and six duloxetine patients had treatment-emergent suicidal behavior during the 36 week study. CONCLUSIONS Trial results were inconclusive, as neither the investigational drug (duloxetine) nor the active control (fluoxetine) separated from placebo on the CDRS-R at 10 weeks. No new duloxetine safety signals were identified relative to those seen in adults. Clinical Trial Registry Number ( www.ClinicalTrials.gov ): NCT00849693.
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Affiliation(s)
- Graham J. Emslie
- Child and Adolescent Psychiatry Division, University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - Apurva Prakash
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Qi Zhang
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Beth A. Pangallo
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Mark E. Bangs
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - John S. March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Atkinson SD, Prakash A, Zhang Q, Pangallo BA, Bangs ME, Emslie GJ, March JS. A double-blind efficacy and safety study of duloxetine flexible dosing in children and adolescents with major depressive disorder. J Child Adolesc Psychopharmacol 2014; 24:180-9. [PMID: 24813026 DOI: 10.1089/cap.2013.0146] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of duloxetine flexible dose in children (7-11 years) and adolescents (12-17 years) with major depressive disorder (MDD). METHODS Patients (n=337) in this 36 week study (10 week acute and 26 week extension treatment) received duloxetine (60-120 mg once daily [QD], n=117), fluoxetine (20-40 mg QD, n=117), or placebo (n=103). Measures included: Children's Depression Rating Scale-Revised (CDRS-R), treatment-emergent adverse events (TEAEs), and Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS Neither active drug (duloxetine or fluoxetine) separated significantly (p<0.05) from placebo on mean change from baseline to end-point (10 weeks) on the CDRS-R total score. There were no significant differences between the duloxetine or fluoxetine groups compared with placebo on serious AEs (SAEs), total TEAEs, or discontinuation for AE during acute treatment. There were no completed suicides or deaths, and no clinically significant electrocardiogram (ECG) abnormalities observed during the study. One fluoxetine and one duloxetine patient experienced alanine aminotransferase (ALT) three or more times the upper limit of normal, which resolved during the study. A total of 8 (7.1%) duloxetine patients, 7 (6.8%) placebo patients, and 9 (8.0%) fluoxetine patients had worsening of suicidal ideation from baseline during acute treatment. Of the patients with suicidal ideation at baseline, 15/19 (79%) duloxetine, 19/19 (100%) placebo, and 16/19 (84%) fluoxetine had improvement in suicidal ideation at end-point during acute treatment. One duloxetine and two fluoxetine patients had treatment-emergent suicidal behavior during the 36 week study. CONCLUSION Trial results were inconclusive, as neither the investigational drug (duloxetine) nor the active control (fluoxetine) separated from placebo on the CDRS-R at 10 weeks. No new duloxetine safety signals were identified relative to those seen in adults. Clinical Trial Registry Number: NCT00849901.
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Compton SN, Peris TS, Almirall D, Birmaher B, Sherrill J, Kendall PC, March JS, Gosch EA, Ginsburg GS, Rynn MA, Piacentini JC, McCracken JT, Keeton CP, Suveg CM, Aschenbrand SG, Sakolsky D, Iyengar S, Walkup JT, Albano AM. Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial. J Consult Clin Psychol 2014; 82:212-24. [PMID: 24417601 DOI: 10.1037/a0035458] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS). METHOD Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures. RESULTS Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I). DISCUSSION Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.
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Affiliation(s)
- Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Tara S Peris
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Daniel Almirall
- Survey Research Center, Institute for Social Research, University of Michigan
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - Joel Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health
| | | | - John S March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Elizabeth A Gosch
- Department of Psychology, Philadelphia College of Osteopathic Medicine
| | - Golda S Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital
| | - Moira A Rynn
- Department of Child Psychiatry, Columbia University Medical Center
| | - John C Piacentini
- John C. Piacentini and James T. McCracken, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - James T McCracken
- John C. Piacentini and James T. McCracken, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Courtney P Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital
| | | | | | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - Satish Iyengar
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - John T Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College
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Keeton CP, Ginsburg GS, Drake KL, Sakolsky D, Kendall PC, Birmaher B, Albano AM, March JS, Rynn M, Piacentini J, Walkup JT. Benefits of child-focused anxiety treatments for parents and family functioning. Depress Anxiety 2013; 30:865-72. [PMID: 23390005 PMCID: PMC4144828 DOI: 10.1002/da.22055] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 12/12/2012] [Accepted: 12/16/2012] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND To examine (1) changes in parent (global psychological distress, trait anxiety) and family (dysfunction, burden) functioning following 12 weeks of child-focused anxiety treatment, and (2) whether changes in these parent and family factors were associated with child's treatment condition and response. METHODS Participants were 488 youth ages 7-17 years (50% female; mean age 10.7 years) who met DSM-IV-TR criteria for social phobia, separation anxiety, and/or generalized anxiety disorder, and their parents. Youth were randomly assigned to 12 weeks of "Coping Cat" individual cognitive-behavioral therapy (CBT), medication management with sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) within the multisite Child/Adolescent Anxiety Multimodal Study (CAMS). At pre- and posttreatment, parents completed measures of trait anxiety, psychological distress, family functioning, and burden of child illness; children completed a measure of family functioning. Blinded independent evaluators rated child's response to treatment using the Clinical Global Impression-Improvement Scale at posttreatment. RESULTS Analyses of covariance revealed that parental psychological distress and trait anxiety, and parent-reported family dysfunction improved only for parents of children who were rated as treatment responders, and these changes were unrelated to treatment condition. Family burden and child-reported family dysfunction improved significantly from pre- to posttreatment regardless of treatment condition or response. CONCLUSIONS Findings suggest that child-focused anxiety treatments, regardless of intervention condition, can result in improvements in nontargeted parent symptoms and family functioning particularly when children respond successfully to the treatment.
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Affiliation(s)
- Courtney P. Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland,Correspondence to: Courtney P. Keeton, Division of Child & Adolescent Psychiatry, The Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 201A, Baltimore, MD 21205.
| | - Golda S. Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly L. Drake
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Philip C. Kendall
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anne Marie Albano
- Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - John S. March
- Department of Psychiatry and Behavioral Services, Duke University Medical Center, Durham, North Carolina
| | - Moira Rynn
- Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, California
| | - John T. Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, New York
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Podell JL, Kendall PC, Gosch EA, Compton SN, March JS, Albano AM, Rynn MA, Walkup JT, Sherrill JT, Ginsburg GS, Keeton CP, Birmaher B, Piacentini JC. Therapist Factors and Outcomes in CBT for Anxiety in Youth. ACTA ACUST UNITED AC 2013; 44:89-98. [PMID: 25419042 DOI: 10.1037/a0031700] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive-behavioral therapy (CBT) as part of the Child-Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7-17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive-behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist "coach" style was a significant predictor of child-reported outcome, with the collaborative "coach" style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.
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Cole DA, Cho SJ, Martin NC, Youngstrom EA, March JS, Findling RL, Compas BE, Goodyer IM, Rohde P, Weissman M, Essex MJ, Hyde JS, Curry JF, Forehand R, Slattery MJ, Felton JW, Maxwell MA. Are increased weight and appetite useful indicators of depression in children and adolescents? J Abnorm Psychol 2012; 121:838-51. [PMID: 22686866 PMCID: PMC3547528 DOI: 10.1037/a0028175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
During childhood and adolescence, physiological, psychological, and behavioral processes strongly promote weight gain and increased appetite while also inhibiting weight loss and decreased appetite. The Diagnostic and Statistical Manual-IV (DSM-IV) treats both weight-gain/increased-appetite and weight-loss/decreased-appetite as symptoms of major depression during these developmental periods, despite the fact that one complements typical development and the other opposes it. To disentangle the developmental versus pathological correlates of weight and appetite disturbance in younger age groups, the current study examined symptoms of depression in an aggregated sample of 2307 children and adolescents, 47.25% of whom met criteria for major depressive disorder. A multigroup, multidimensional item response theory model generated three key results. First, weight loss and decreased appetite loaded strongly onto a general depression dimension; in contrast, weight gain and increased appetite did not. Instead, weight gain and increased appetite loaded onto a separate dimension that did not correlate strongly with general depression. Second, inclusion or exclusion of weight gain and increased appetite affected neither the nature of the general depression dimension nor the fidelity of major depressive disorder diagnosis. Third, the general depression dimension and the weight-gain/increased-appetite dimension showed different patterns across age and gender. In child and adolescent populations, these results call into question the utility of weight gain and increased appetite as indicators of depression. This has serious implications for the diagnostic criteria of depression in children and adolescents. These findings inform a revision of the DSM, with implications for the diagnosis of depression in this age group and for research on depression.
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Affiliation(s)
- David A Cole
- Department of Psychology and Human Development, Vanderbilt University, 230 Appleton Place, Nashville, TN 37203, USA.
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Przeworski A, Zoellner LA, Franklin ME, Garcia A, Freeman J, March JS, Foa EB. Maternal and child expressed emotion as predictors of treatment response in pediatric obsessive-compulsive disorder. Child Psychiatry Hum Dev 2012; 43:337-53. [PMID: 22090186 PMCID: PMC3337147 DOI: 10.1007/s10578-011-0268-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Expressed emotion (EE) is associated with symptoms and treatment outcome in various disorders. Few studies have examined EE in pediatric OCD and none of these has assessed the child's perspective. This study examined the relationship among maternal and child EE, child OCD severity, and OCD-related functioning pre- and post-treatment. At pre-treatment, mothers completed speech samples about the child with OCD and an unaffected sibling. Children with OCD completed speech samples about parents. There were low rates of high maternal EE (child with OCD: 16.1%; sibling: 2.6%) and high child EE about parents (mothers: 11.9%; fathers: 10.2%). High EE was primarily characterized by high criticism, not high overinvolvement. High maternal EE and child EE regarding fathers were associated with pre-treatment child OCD severity but not post-treatment severity. High child and maternal EE were predictive of post-treatment OCD-related functioning. EE may be an important child and maternal trait associated with pre-treatment OCD severity and generalization of treatment gains.
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Affiliation(s)
- Amy Przeworski
- Department of Psychological Sciences, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7123, USA.
| | | | | | - Abbe Garcia
- Brown University Medical School, Providence, RI, USA
| | | | | | - Edna B. Foa
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Villabø M, Gere M, Torgersen S, March JS, Kendall PC. Diagnostic efficiency of the child and parent versions of the Multidimensional Anxiety Scale for Children. J Clin Child Adolesc Psychol 2012; 41:75-85. [PMID: 22233247 DOI: 10.1080/15374416.2012.632350] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The objective of this study is to evaluate the psychometrics and clinical efficiency of the Multidimensional Anxiety Scale for Children (MASC), which measures physical symptoms, harm avoidance, social anxiety, and separation/panic. Using a sample of 190 treatment-seeking Norwegian youth (aged 7-13 years, M (age) = 10.3 years, 62.1% male), the internal stability and ability to predict to disorder were examined for child, mother, and father reports on the MASC. Moderate to strong internal reliability was exhibited across all MASC subscales. Parent-child agreement was low, but mother-father agreement was high. MASC scores successfully distinguished between children with and without anxiety disorders and identified youth with separation anxiety disorder and social phobia, but less accurately generalized anxiety disorders. The MASC has favorable psychometric properties and is a useful screening instrument for identifying youth with anxiety disorders.
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March JS, Fegert JM. Drug development in pediatric psychiatry: current status, future trends. Child Adolesc Psychiatry Ment Health 2012; 6:7. [PMID: 22313578 PMCID: PMC3296572 DOI: 10.1186/1753-2000-6-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 02/07/2012] [Indexed: 12/12/2022] Open
Affiliation(s)
- John S March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.
| | - Joerg M Fegert
- University Hospital Ulm, Department of Child and Adolescent Psychiatry/Psychotherapy, Steinhövelstr 5, 89075 Ulm, Germany
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Prakash A, Lobo E, Kratochvil CJ, Tamura RN, Pangallo BA, Bullok KE, Quinlan T, Emslie GJ, March JS. An open-label safety and pharmacokinetics study of duloxetine in pediatric patients with major depression. J Child Adolesc Psychopharmacol 2012; 22:48-55. [PMID: 22251023 DOI: 10.1089/cap.2011.0072] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This preliminary, 32-week study assessed the safety, tolerability, and pharmacokinetics of duloxetine in pediatric patients (aged 7-17 years) with major depressive disorder. METHODS Patients received flexible duloxetine doses of 20-120 mg once daily, with dose changes made based on clinical improvement and tolerability. Pharmacokinetic samples were collected across all duloxetine doses, and data were analyzed using population modeling. Primary outcome measures included treatment-emergent adverse events (TEAEs), vital signs, and Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS Of the 72 enrolled patients, 48 (66.7%) completed acute treatment (18 weeks) and 42 (58.3%) completed extended treatment. Most patients (55/72; 76%) required doses ≥ 60 mg once daily to optimize efficacy based on investigator judgment and Clinical Global Impressions-Severity score. Body weight and age did not significantly affect duloxetine pharmacokinetic parameters. Typical duloxetine clearance in pediatric patients was ≈ 42%-60% higher than that in adults. Four patients (5.6%) discontinued due to TEAEs. Many (36/72, 50%) patients experienced potentially clinically significant (PCS) elevations in blood pressure, with most cases (21/36, 58%) being transient. As assessed via C-SSRS, one nonfatal suicidal attempt occurred, two patients (2.8%) experienced worsening of suicidal ideation, and among the 19 patients reporting suicidal ideation at baseline, 17 (90%) reported improvement in suicidal ideation. CONCLUSION Results suggested that pediatric patients generally tolerated duloxetine doses of 30 to 120 mg once daily, although transient PCS elevations in blood pressure were observed in many patients. Pharmacokinetic results suggested that adjustment of total daily dose based on body weight or age is not warranted for pediatric patients and different total daily doses may not be warranted for pediatric patients relative to adults.
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Affiliation(s)
- Apurva Prakash
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana 46285, USA.
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Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D, Moore P, Choate-Summers M, Garcia A, Edson AL, Foa EB, March JS. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA 2011; 306:1224-32. [PMID: 21934055 PMCID: PMC3495326 DOI: 10.1001/jama.2011.1344] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
CONTEXT The extant literature on the treatment of pediatric obsessive-compulsive disorder (OCD) indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit. OBJECTIVE To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management. DESIGN, SETTING, AND PARTICIPANTS A 12-week randomized controlled trial conducted at 3 academic medical centers between 2004 and 2009, involving 124 pediatric outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis and a Children's Yale-Brown Obsessive Compulsive Scale score of 16 or higher despite an adequate SRI trial. INTERVENTIONS Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions. MAIN OUTCOME MEASURES Whether patients responded positively to treatment by improving their baseline obsessive-compulsive scale score by 30% or more and demonstrating a change in their continuous scores over 12 weeks. RESULTS The medication management plus CBT strategy was superior to the other 2 strategies on all outcome measures. In the primary intention-to-treat analysis, 68.6% (95% CI, 53.9%-83.3%) in the plus CBT group were considered responders, which was significantly better than the 34.0% (95% CI, 18.0%-50.0%) in the plus instructions in CBT group, and 30.0% (95% CI, 14.9%-45.1%) in the medication management only group. The results were similar in pairwise comparisons with the plus CBT strategy being superior to the other 2 strategies (P < .01 for both). The plus instructions in CBT strategy was not statistically superior to medication management only (P = .72). The number needed-to-treat analysis with the plus CBT vs medication management only in order to see 1 additional patient at week 12, on average, was estimated as 3; for the plus CBT vs the plus instructions in CBT strategy, the number needed to treat was also estimated as 3; for the plus instructions in CBT vs medication management only the number needed to treat was estimated as 25. CONCLUSIONS Among patients aged 7 to 17 years with OCD and partial response to SRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00074815.
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Affiliation(s)
- Martin E Franklin
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Miller LD, Laye-Gindhu A, Bennett JL, Liu Y, Gold S, March JS, Olson BF, Waechtler VE. An Effectiveness Study of a Culturally Enriched School-Based CBT Anxiety Prevention Program. Journal of Clinical Child & Adolescent Psychology 2011; 40:618-29. [DOI: 10.1080/15374416.2011.581619] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Flessner CA, Freeman JB, Sapyta J, Garcia A, Franklin ME, March JS, Foa E. Predictors of parental accommodation in pediatric obsessive-compulsive disorder: findings from the Pediatric Obsessive-Compulsive Disorder Treatment Study (POTS) trial. J Am Acad Child Adolesc Psychiatry 2011; 50:716-25. [PMID: 21703499 PMCID: PMC3128390 DOI: 10.1016/j.jaac.2011.03.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 03/24/2011] [Accepted: 03/29/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Few studies have examined predictors of parental accommodation (assessed with the Family Accommodation Scale-Parent Report) among families of children with obsessive-compulsive disorder (OCD). No studies have examined this phenomenon using empirically derived subscales of the Family Accommodation Scale-Parent Report (i.e., Caregiver Involvement, Avoidance of Triggers). METHOD Ninety-six youths (and their families) were included in the present study. Parents were asked to complete the Family Accommodation Scale-Parent Report. Families also completed several additional measurements assessing child- and parent-level variables of interest. Regression analyses were used to examine potential predictors of accommodation. RESULTS Results support prior research suggesting that accommodation is ubiquitous among the families of children with OCD. Analyses revealed that several child-level (i.e., compulsion severity, oppositional behavior, and frequency of washing symptoms) and one parent-level (i.e., symptoms of anxiety) predictors work jointly to provide significant predictive models of parental accommodation. CONCLUSIONS Clinicians and researchers should be aware of the impact of specific child- and parent-level variables on family accommodation in pediatric OCD and in turn their implications for treatment compliance, adherence, and, by extension, outcome. Study limitations warrant replication and extension of these findings; in particular, researchers may seek to obtain a better understanding of how the various facets of parental accommodation may differentially affect treatment.
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Affiliation(s)
- Christopher A Flessner
- Bradley/Hasbro Children's Research Center and Alpert School of Medicine at Brown University, 1 Hoppin Street, Providence, RI 02903, USA.
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Correll CU, Kratochvil CJ, March JS. Developments in pediatric psychopharmacology: focus on stimulants, antidepressants, and antipsychotics. J Clin Psychiatry 2011; 72:655-70. [PMID: 21658348 DOI: 10.4088/jcp.11r07064] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 04/14/2011] [Indexed: 10/18/2022]
Abstract
Most major psychiatric disorders have an onset in childhood or adolescence in a sizeable proportion of patients, and earlier onset disorders often have a severe and chronic course that can seriously disrupt sensitive developmental periods, with lifelong adverse consequences. Accordingly, psychopharmacologic treatments have been increasingly utilized in severely ill youth. However, the increased use of psychopharmacologic treatments in pediatric patients has also raised concerns regarding a potential overdiagnosis and overtreatment of youth, without adequate data regarding the pediatric efficacy and safety of psychotropic agents. Over the past decade, a remarkable number of pediatric randomized controlled trials have been completed, especially with psychostimulants, antidepressants, and antipsychotics. For these frequently used agents, effect sizes against placebo have typically been at least moderate, with most numbers-needed-to-treat well below 10 for response, indicating clinical significance as well. Nevertheless, data also point to a greater and/or different profile of susceptibility to adverse effects in pediatric compared to adult patients, as well as to a role for nonpharmacologic treatments, given alone or combined with pharmacotherapy, for many of the youth. Taken together, these results highlight the need for a careful assessment of the risk-benefit relationship of psychopharmacologic treatments in patients who cannot be managed sufficiently with nonpharmacologic interventions and for routine, proactive adverse effect monitoring and management. Although considerable progress has been made, there is still enormous need for additional data and funding of pediatric psychopharmacology trials. It is hoped that the field will acquire the necessary resources to propel pediatric clinical psychopharmacology to new levels of insight by linking it with, but not replacing it by, pharmacoepidemiologic and biomarker approaches and advances.
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Affiliation(s)
- Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, NY 11004, USA,
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Miller LD, Laye-Gindhu A, Liu Y, March JS, Thordarson DS, Garland EJ. Evaluation of a preventive intervention for child anxiety in two randomized attention-control school trials. Behav Res Ther 2011; 49:315-23. [DOI: 10.1016/j.brat.2011.02.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 01/17/2011] [Accepted: 02/16/2011] [Indexed: 10/18/2022]
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Kratochvil CJ, Vaughan BS, Stoner JA, Daughton JM, Lubberstedt BD, Murray DW, Chrisman AK, Faircloth MA, Itchon-Ramos NB, Kollins SH, Maayan LA, Greenhill LL, Kotler LA, Fried J, March JS. A double-blind, placebo-controlled study of atomoxetine in young children with ADHD. Pediatrics 2011; 127:e862-8. [PMID: 21422081 PMCID: PMC3387889 DOI: 10.1542/peds.2010-0825] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and tolerability of atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in 5- and 6-year-old children. METHODS This was an 8-week, double-blind, placebo-controlled randomized clinical trial of atomoxetine in 101 children with ADHD. Atomoxetine or placebo was flexibly titrated to a maximum dose of 1.8 mg/kg per day. The pharmacotherapist reviewed psychoeducational material on ADHD and behavioral-management strategies with parents during each study visit. RESULTS Significant mean decreases in parent (P = .009) and teacher (P = .02) ADHD-IV Rating Scale scores were demonstrated with atomoxetine compared with placebo. A total of 40% of children treated with atomoxetine met response criteria (Clinical Global Impression-Improvement Scale indicating much or very much improved) compared with 22% of children on placebo, which was not significant (P = .1). Decreased appetite, gastrointestinal upset, and sedation were significantly more common with atomoxetine than placebo. Although some children demonstrated a robust response to atomoxetine, for others the response was more attenuated. Sixty-two percent of subjects who received atomoxetine were moderately, markedly, or severely ill according to the Clinical Global Impression-Severity Scale at study completion. CONCLUSIONS To our knowledge, this is the first randomized controlled trial of atomoxetine in children as young as 5 years. Atomoxetine generally was well tolerated and reduced core ADHD symptoms in the children on the basis of parent and teacher reports. Reductions in the ADHD-IV Rating Scale scores, however, did not necessarily translate to overall clinical and functional improvement, as demonstrated on the Clinical Global Impression-Severity Scale and the Clinical Global Impression-Improvement Scale. Despite benefits, the children in the atomoxetine group remained, on average, significantly impaired at the end of the study.
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Affiliation(s)
| | - Brigette S. Vaughan
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska
| | - Julie A. Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joan M. Daughton
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska
| | - Brian D. Lubberstedt
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska
| | - Desiree W. Murray
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
| | - Allan K. Chrisman
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
| | - Melissa A. Faircloth
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
| | | | - Scott H. Kollins
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
| | - Lawrence A. Maayan
- Department of Child Psychiatry, New York University Child Study Center, New York, New York; ,Department of Child Psychiatry, Nathan Kline Institute for Psychiatric Research, New York, New York; and
| | - Laurence L. Greenhill
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University, New York, New York
| | - Lisa A. Kotler
- Department of Child Psychiatry, New York University Child Study Center, New York, New York
| | - Jane Fried
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University, New York, New York
| | - John S. March
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
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Abstract
OBJECTIVE The rapid emergence of translational developmental neuroscience as the key driver in understanding the onset of mental illness, the restructuring of academic health science centers on the NIH Roadmap, and dramatic shifts in drug, biological, device, and psychosocial intervention development all have important consequences for pediatric anxiety disorders as a field. METHOD This article, which tracks the final presentation at a day-long symposium on pediatric anxiety disorders at the 2010 annual meeting of the Anxiety Disorders Association of America (ADAA), will try to outline where the field will head over the next decade as these forces combine to shape research and practice. RESULTS After 20 years of large comparative treatment trials that have defined the place of current generation treatments, the field is shifting toward interventions that will emerge from the revolution in translational developmental neuroscience and that herald the dawn of stratified and ultimately personalized medicine. With a much more efficient discovery to translational continuum, intervention development and dissemination will benefit from the concurrent transformation of the clinical and clinical research enterprise. CONCLUSION Dramatic advances in science and changes in the structure of medicine will condition the future of clinical research across every therapeutic area in medicine. For the field of pediatric anxiety disorders to thrive it will be important to embrace and actively participate in this revolution so that anxious youth are viewed as a key target population and, consequently, preemptive, preventive, and curative interventions will be developed for children by first intent.
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Affiliation(s)
- John S March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA.
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Affiliation(s)
- John S March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27705, USA.
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Jacobs RH, Becker-Weidman EG, Reinecke MA, Jordan N, Silva SG, Rohde P, March JS. Treating depression and oppositional behavior in adolescents. J Clin Child Adolesc Psychol 2010; 39:559-67. [PMID: 20589566 DOI: 10.1080/15374416.2010.486318] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Adolescents with depression and high levels of oppositionality often are particularly difficult to treat. Few studies, however, have examined treatment outcomes among youth with both externalizing and internalizing problems. This study examines the effect of fluoxetine, cognitive behavior therapy (CBT), the combination of fluoxetine and CBT, and placebo on co-occurring oppositionality within a sample of depressed adolescents. All treatments resulted in decreased oppositionality at 12 weeks. Adolescents receiving fluoxetine, either alone or in combination with CBT, experienced greater reductions in oppositionality than adolescents not receiving antidepressant medication. These results suggest that treatments designed to alleviate depression can reduce oppositionality among youth with a primary diagnosis of depression.
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Affiliation(s)
- Rachel H Jacobs
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Jacobs RH, Reinecke MA, Gollan JK, Jordan N, Silva SG, March JS. Extreme thinking in clinically depressed adolescents: Results from the Treatment for Adolescents with Depression Study (TADS). Behav Res Ther 2010; 48:1155-9. [PMID: 20843506 DOI: 10.1016/j.brat.2010.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 08/02/2010] [Accepted: 08/04/2010] [Indexed: 11/30/2022]
Abstract
The purpose of this report is to examine relations between extreme thinking, as measured by the Dysfunctional Attitudes Scale, and the maintenance of gains among adolescents who participated in the Treatment for Adolescents with Depression Study (TADS). We examine extreme thinking among 327 adolescents (mean age=14.56, 57% female, 75% White) who received cognitive behavior therapy (CBT), fluoxetine (FLX), or a combination of CBT and FLX (COMB). Among those who met remission status on the Children's Depression Rating Scale - Revised (CDRS-R≤28; 56 at week 12, 79 at week 18) extreme thinking did not predict failure to maintain remission. This is in contrast to findings with depressed adults. Treatment influenced level of extreme thinking, and this appeared to be driven by greater endorsement of positively valenced beliefs as opposed to a decrease in negatively valenced beliefs. Developmental or investigation characteristics may account for the discrepancy in findings.
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Affiliation(s)
- Rachel H Jacobs
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Ginsburg GS, Silva SG, Jacobs RH, Tonev S, Hoyle RH, Kingery JN, Reinecke MA, Curry JF, March JS. Cognitive measures of adolescent depression: unique or unitary constructs? J Clin Child Adolesc Psychol 2010; 38:790-802. [PMID: 20183663 DOI: 10.1080/15374410903259015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The factor structure of several self-report questionnaires assessing depression-relevant cognitions frequently employed in clinical research was examined in a sample of 390 adolescents (M age = 14.54; 216 girls; 74% Caucasian) with current major depressive disorder enrolled in the Treatment of Adolescents with Depression Study. A four-factor solution resulted, accounting for 65% of the total variance. The factors were labeled (a) Cognitive Distortions and Maladaptive Beliefs, (b) Cognitive Avoidance, (c) Positive Outlook, and (d) Solution-Focused Thinking. Internal consistencies for the factor-based composite scores were .83, .85, .84, and .82, respectively. Girls endorsed more negative cognitions than boys on three of the four factors. Maladaptive cognitions were positively related to severity of depression and predicted treatment response. Taken together, findings indicated that there are four distinct domains of cognitions that are present among adolescents with depression that are tapped by several widely used self-report measures of cognitions.
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Affiliation(s)
- Golda S Ginsburg
- Johns Hopkins University School of Medicine, Baltimore, MD 21287-3325, USA.
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Rogers GM, Park JH, Essex MJ, Klein MH, Silva SG, Hoyle RH, Curry JF, Feeny NC, Kennard B, Kratochvil CJ, Pathak S, Reinecke MA, Rosenberg DR, Weller EB, March JS. The dysfunctional attitudes scale: psychometric properties in depressed adolescents. J Clin Child Adolesc Psychol 2010; 38:781-9. [PMID: 20183662 DOI: 10.1080/15374410903259007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The psychometric properties and factor structure of the Dysfunctional Attitudes Scale were examined in a sample of 422 male and female adolescents (ages 12-17) with current major depressive disorder. The scale demonstrated high internal consistency (alpha = .93) and correlated significantly with self-report and interview-based measures of depression. Confirmatory factor analysis indicated that a correlated 2-factor model, with scales corresponding to perfectionism and need for social approval, provided a satisfactory fit to the data. The goodness-of-fit was equivalent across sexes and age groups. The findings support the use of the Dysfunctional Attitudes Scale and its subscales in the assessment of clinically depressed adolescents.
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Affiliation(s)
- Gregory M Rogers
- Department of Psychiatry and Behavioral Sciences, University of Wisconsin, Madison, Madison, WI 53719-1176, USA.
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Jacobs RH, Silva SG, Reinecke MA, Curry JF, Ginsburg GS, Kratochvil CJ, March JS. Dysfunctional attitudes scale perfectionism: a predictor and partial mediator of acute treatment outcome among clinically depressed adolescents. J Clin Child Adolesc Psychol 2010; 38:803-13. [PMID: 20183664 DOI: 10.1080/15374410903259031] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The effect of perfectionism on acute treatment outcomes was explored in a randomized controlled trial of 439 clinically depressed adolescents (12-17 years of age) enrolled in the Treatment for Adolescents with Depression Study (TADS) who received cognitive behavior therapy (CBT), fluoxetine, a combination of CBT and FLX, or pill placebo. Measures included the Children's Depression Rating Scale-Revised, the Suicidal Ideation Questionnaire-Grades 7-9, and the perfectionism subscale from the Dysfunctional Attitudes Scale (DAS). Predictor results indicate that adolescents with higher versus lower DAS perfectionism scores at baseline, regardless of treatment, continued to demonstrate elevated depression scores across the acute treatment period. In the case of suicidality, DAS perfectionism impeded improvement. Treatment outcomes were partially mediated by the change in DAS perfectionism across the 12-week period.
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Affiliation(s)
- Rachel H Jacobs
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, USA.
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Domino ME, Burns BJ, Mario J, Reinecke MA, Vitiello B, Weller EB, Kratochvil CJ, May DE, Feeny NC, Robins M, Hallin MJ, Silva SG, March JS. Service use and costs of care for depressed adolescents: who uses and who pays? J Clin Child Adolesc Psychol 2010; 38:826-36. [PMID: 20183666 DOI: 10.1080/15374410903259023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Major depressive disorder is common in adolescence and is associated with significant morbidity and family burden. Little is known about service use by depressed adolescents. The purpose of this article is to report the patterns of services use and costs for participants in the Treatment for Adolescents with Depression Study sample during the 3 months before randomization. Costs were assigned across three categories of payors: families, private insurance, and the public sector. We examined whether costs from payors varied by baseline covariates, such as age, gender, insurance status, and family income. The majority (71%) of depressed youth sought services during the 3-month period. Slightly more than one-fifth had contact with a behavioral health specialist. The average participant had just under $300 (SD = $437.67, range = $0-$3,747.71) in treatment-related costs, with most of these costs borne by families and private insurers.
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Affiliation(s)
- Marisa Elena Domino
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411, USA.
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Compton SN, Walkup JT, Albano AM, Piacentini JC, Birmaher B, Sherrill JT, Ginsburg GS, Rynn MA, McCracken JT, Waslick BD, Iyengar S, Kendall PC, March JS. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health 2010; 4:1. [PMID: 20051130 PMCID: PMC2818613 DOI: 10.1186/1753-2000-4-1] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 01/05/2010] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. TRIAL REGISTRATION ClinicalTrials.gov NCT00052078.
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Affiliation(s)
- Scott N Compton
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, DUMC Box 3527, Durham, NC 27710, USA
| | - John T Walkup
- The Johns Hopkins Hospital, Division of Child and Adolescent Psychiatry, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Anne Marie Albano
- New York State Psychiatric Institute-Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA
| | - John C Piacentini
- University of California at Los Angeles, Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 68-251B, Los Angeles, CA 90095, USA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Joel T Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health, 6001 Executive Boulevard, MSC 9633, Bethesda, MD 20892, USA
| | - Golda S Ginsburg
- The Johns Hopkins Hospital, Division of Child and Adolescent Psychiatry, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Moira A Rynn
- New York State Psychiatric Institute-Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA
| | - James T McCracken
- University of California at Los Angeles, Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 68-251B, Los Angeles, CA 90095, USA
| | - Bruce D Waslick
- Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Satish Iyengar
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Phillip C Kendall
- Temple University, Department of Psychology, Weiss Hall 1701 North 13th Street, Philadelphia, PA 19122, USA
| | - John S March
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, DUMC Box 3527, Durham, NC 27710, USA
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Reinecke MA, Curry JF, March JS. Findings From the Treatment for Adolescents with Depression Study (TADS): What Have We Learned? What Do We Need to Know? Journal of Clinical Child & Adolescent Psychology 2009; 38:761-7. [DOI: 10.1080/15374410903258991] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kingery JN, Kepley HO, Ginsburg GS, Walkup JT, Silva SG, Hoyle RH, Reinecke MA, March JS. Factor Structure and Psychometric Properties of the Children's Negative Cognitive Error Questionnaire with a Clinically Depressed Adolescent Sample. Journal of Clinical Child & Adolescent Psychology 2009; 38:768-80. [DOI: 10.1080/15374410903297130] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Feeny NC, Silva SG, Reinecke MA, McNulty S, Findling RL, Rohde P, Curry JF, Ginsburg GS, Kratochvil CJ, Pathak SM, May DE, Kennard BD, Simons AD, Wells KC, Robins M, Rosenberg D, March JS. An exploratory analysis of the impact of family functioning on treatment for depression in adolescents. J Clin Child Adolesc Psychol 2009; 38:814-25. [PMID: 20183665 PMCID: PMC3609662 DOI: 10.1080/15374410903297148] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article explores aspects of family environment and parent-child conflict that may predict or moderate response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive behavioral therapy, their combination, or placebo. Outcomes were Week 12 scores on measures of depression and global impairment. Of 20 candidate variables, one predictor emerged: Across treatments, adolescents with mothers who reported less parent-child conflict were more likely to benefit than their counterparts. When family functioning moderated outcome, adolescents who endorsed more negative environments were more likely to benefit from fluoxetine. Similarly, when moderating effects were seen on cognitive behavioral therapy conditions, they were in the direction of being less effective among teens reporting poorer family environments.
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Affiliation(s)
- Norah C Feeny
- Department of Psychology, Case Western Reserve University, Cleveland, OH 44106, USA.
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Affiliation(s)
- J S March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.
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Abstract
OBJECTIVE The purpose of this report was to summarize the key clinical messages from the Treatment for Adolescents with Depression Study (TADS). METHODS TADS is a National Institute of Mental Health (NIMH)-funded randomized controlled trial designed to evaluate the relative effectiveness of fluoxetine, cognitive-behavioral therapy (CBT), and the combination of fluoxetine plus CBT across acute treatment, maintenance treatment, and naturalistic follow-up periods among adolescents with major depressive disorder. RESULTS Findings revealed that 6 to 9 months of combined fluoxetine plus CBT should be the modal treatment from a public health perspective as well as to maximize benefits and minimize harms for individual patients. CONCLUSION The combination of fluoxetine and CBT appears to be superior to both CBT monotherapy and fluoxetine monotherapy as a treatment for moderate to severe major depressive disorder in adolescents.
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Affiliation(s)
- John S March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
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Kratochvil CJ, May DE, Silva SG, Madaan V, Puumala SE, Curry JF, Walkup J, Kepley H, Vitiello B, March JS. Treatment response in depressed adolescents with and without co-morbid attention-deficit/hyperactivity disorder in the Treatment for Adolescents with Depression Study. J Child Adolesc Psychopharmacol 2009; 19:519-27. [PMID: 19877976 PMCID: PMC2830214 DOI: 10.1089/cap.2008.0143] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE In the Treatment for Adolescents with Depression Study (TADS), fluoxetine (FLX) and the combination of fluoxetine with cognitive-behavioral therapy (COMB) had superior improvement trajectories compared to pill placebo (PBO), whereas cognitive-behavioral therapy (CBT) was not significantly different from PBO. Because attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) frequently co-exist, we examined whether ADHD moderated these outcomes in TADS. METHOD A total of 439 adolescents with MDD, 12-17 years old, were randomized to FLX, CBT, COMB, or PBO. Random coefficients regression models examined depression improvement in 377 depressed youths without ADHD and 62 with ADHD, including 20 who were treated with a psychostimulant. RESULTS Within the ADHD group, the improvement trajectories of the three active treatments were similar, all with rates of improvement greater than PBO. For those without ADHD, only COMB had a rate of improvement that was superior to PBO. CONCLUSIONS Co-morbid ADHD moderated treatment of MDD. CBT alone or FLX alone may offer benefits similar to COMB in the treatment of MDD in youths with co-morbid MDD and ADHD, whereas monotherapy may not match the benefits of COMB for those without ADHD. The ADHD subgroup analysis presented in this paper is exploratory in nature because of the small number of youths with ADHD in the sample. CLINICAL TRIAL REGISTRY www.clinicaltrials.gov Identifier: NCT00006286. The TADS protocol and all of the TADS manuals are available on the Internet at https://trialweb.dcri.duke.edu/tads/index.html .
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Affiliation(s)
| | - Diane E. May
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Vishal Madaan
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska
| | - Susan E. Puumala
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska
| | - John F. Curry
- Duke University Medical Center, Durham, North Carolina
| | - John Walkup
- Johns Hopkins University, Baltimore, Maryland
| | - Hayden Kepley
- University of North Carolina at Wilmington, Wilmington, North Carolina
| | | | - John S. March
- Duke University Medical Center, Durham, North Carolina
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Becker-Weidman EG, Jacobs RH, Reinecke MA, Silva SG, March JS. Social problem-solving among adolescents treated for depression. Behav Res Ther 2009; 48:11-8. [PMID: 19775677 DOI: 10.1016/j.brat.2009.08.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 08/20/2009] [Accepted: 08/27/2009] [Indexed: 10/20/2022]
Abstract
Studies suggest that deficits in social problem-solving may be associated with increased risk of depression and suicidality in children and adolescents. It is unclear, however, which specific dimensions of social problem-solving are related to depression and suicidality among youth. Moreover, rational problem-solving strategies and problem-solving motivation may moderate or predict change in depression and suicidality among children and adolescents receiving treatment. The effect of social problem-solving on acute treatment outcomes were explored in a randomized controlled trial of 439 clinically depressed adolescents enrolled in the Treatment for Adolescents with Depression Study (TADS). Measures included the Children's Depression Rating Scale-Revised (CDRS-R), the Suicidal Ideation Questionnaire--Grades 7-9 (SIQ-Jr), and the Social Problem-Solving Inventory-Revised (SPSI-R). A random coefficients regression model was conducted to examine main and interaction effects of treatment and SPSI-R subscale scores on outcomes during the 12-week acute treatment stage. Negative problem orientation, positive problem orientation, and avoidant problem-solving style were non-specific predictors of depression severity. In terms of suicidality, avoidant problem-solving style and impulsiveness/carelessness style were predictors, whereas negative problem orientation and positive problem orientation were moderators of treatment outcome. Implications of these findings, limitations, and directions for future research are discussed.
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Affiliation(s)
- Emily G Becker-Weidman
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Abbott Hall, 710N. Lake Shore Drive, Chicago, IL 60611, USA.
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Lewis CC, Simons AD, Silva SG, Rohde P, Small DM, Murakami JL, High RR, March JS. The role of readiness to change in response to treatment of adolescent depression. J Consult Clin Psychol 2009; 77:422-8. [PMID: 19485584 DOI: 10.1037/a0014154] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The effect of readiness to change on treatment outcome was examined among 332 adolescents (46% male, 74% Caucasian), ages 12 through 17 years (M = 14.6, SD = 1.5), with major depressive disorder who were participating in the Treatment for Adolescents With Depression Study (TADS). TADS is a randomized clinical trial comparing the effectiveness of fluoxetine (an antidepressant medication), cognitive-behavioral therapy, their combination, and a pill placebo. An abbreviated Stages of Change Questionnaire was used to obtain 4 readiness to change scores: precontemplation, contemplation, action, and maintenance. The association between each readiness score and depression severity across 12 weeks of acute treatment for depression, as measured by the Children's Depression Rating Scale--Revised, was examined. Although treatment response was not moderated by any of the readiness scores, baseline action scores predicted outcome: Higher action scores were associated with better outcome regardless of treatment modality. Furthermore, treatment effects were mediated by change in action scores during the first 6 weeks of treatment, with increases in action scores related to greater improvement in depression. Assessing readiness to change may have implications for tailoring treatments for depressed adolescents.
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Affiliation(s)
- Cara C Lewis
- Department of Psychology, University of Oregon, Eugene, OR 97403, USA.
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Lewin AB, Piacentini J, Flessner CA, Woods DW, Franklin ME, Keuthen NJ, Moore P, Khanna M, March JS, Stein DJ. Depression, anxiety, and functional impairment in children with trichotillomania. Depress Anxiety 2009; 26:521-7. [PMID: 19016486 DOI: 10.1002/da.20537] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Trichotillomania (TTM) remains understudied in children. Adult research suggests that TTM is accompanied by significant depression, anxiety, and functional impairment. The purpose of this study is to examine the occurrence of depression and anxiety in a relatively large sample of youth with TTM and the extent to which these symptoms mediate the relationship between TTM severity and associated impairment. METHODS The study utilized data from the Child and Adolescent Trichotillomania Impact Project (CA-TIP), an internet-based sample of 133 youth aged 10-17 (inclusive) with TTM. RESULTS Over 45% of children with TTM endorsed depressive symptoms and 40% endorsed anxiety symptoms in excess of one standard deviation (SD) above published community norms. More remarkably, 25% of our sample reported depressive and 20% reported anxiety symptoms in excess of 2 SD above these norms. Older participants reported more symptoms of depression and anxiety than younger ones; age of onset (children with later onset), but not duration of illness, was predictive of higher reports of both depressive and anxiety symptoms. Neither depressive nor anxiety symptoms were related to pulling site. Depressive symptoms partially mediated the relationship between TTM severity and functional impairment. CONCLUSIONS Based on an internet sample recruited from the homepage of the Trichotillomania Learning Center, data from this study suggests that symptoms of depression and anxiety may be pervasive among youth with TTM and likely impact functional impairment. Longitudinal studies using directly assessed samples are needed to replicate and extend these findings.
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Affiliation(s)
- Adam B Lewin
- UCLA Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, Los Angeles, CA 90024-1759, USA.
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Vitiello B, Silva S, Rohde P, Kratochvil C, Kennard B, Reinecke M, Mayes T, Posner K, May DE, March JS. Suicidal events in the Treatment for Adolescents With Depression Study (TADS). J Clin Psychiatry 2009; 70:741-7. [PMID: 19552869 PMCID: PMC2702701 DOI: 10.4088/jcp.08m04607] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 11/24/2008] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The Treatment for Adolescents with Depression Study (TADS) database was analyzed to determine whether suicidal events (attempts and ideation) occurred early in treatment, could be predicted by severity of depression or other clinical characteristics, and were preceded by clinical deterioration or symptoms of increased irritability, akathisia, sleep disruption, or mania. METHOD TADS was a 36-week randomized, controlled clinical trial of pharmacologic and psychotherapeutic treatments involving 439 youths with major depressive disorder (DSM-IV criteria). Suicidal events were defined according to the Columbia Classification Algorithm of Suicidal Assessment. Patients were randomly assigned into the study between spring 2000 and summer 2003. RESULTS Forty-four patients (10.0%) had at least 1 suicidal event (no suicide occurred). Events occurred 0.4 to 31.1 weeks (mean +/- SD = 11.9 +/- 8.2) after starting TADS treatment, with no difference in event timing for patients receiving medication versus those not receiving medication. Severity of self-rated pretreatment suicidal ideation (Suicidal Ideation Questionnaire adapted for adolescents score > or = 31) and depressive symptoms (Reynolds Adolescent Depression Scale score > or = 91) predicted occurrence of suicidal events during treatment (P < .05). Patients with suicidal events were on average still moderately ill prior to the event (mean +/- SD Clinical Global Impressions-Severity of Illness scale score = 4.0 +/- 1.3) and only minimally improved (mean +/- SD Clinical Global Impressions-Improvement scale score = 3.2 +/- 1.1). Events were not preceded by increased irritability, akathisia, sleep disturbance, or manic signs. Specific interpersonal stressors were identified in 73% of cases (N = 44). Of the events, 55% (N = 24) resulted in overnight hospitalization. CONCLUSIONS Most suicidal events occurred in the context of persistent depression and insufficient improvement without evidence of medication-induced behavioral activation as a precursor. Severity of self-rated suicidal ideation and depressive symptoms predicted emergence of suicidality during treatment. Risk for suicidal events did not decrease after the first month of treatment, suggesting the need for careful clinical monitoring for several months after starting treatment.
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Affiliation(s)
| | - Susan Silva
- Duke Clinical Research Institute and Duke University Medical Center
| | | | | | | | | | - Taryn Mayes
- University of Texas Southwestern Medical Center
| | | | | | - John S. March
- Duke Clinical Research Institute and Duke University Medical Center
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Shapiro M, Silva SG, Compton S, Chrisman A, DeVeaugh-Geiss J, Breland-Noble A, Kondo D, Kirchner J, March JS. The child and adolescent psychiatry trials network (CAPTN): infrastructure development and lessons learned. Child Adolesc Psychiatry Ment Health 2009; 3:12. [PMID: 19320979 PMCID: PMC2673205 DOI: 10.1186/1753-2000-3-12] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 03/25/2009] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In 2003, the National Institute of Mental Health funded the Child and Adolescent Psychiatry Trials Network (CAPTN) under the Advanced Center for Services and Intervention Research (ACSIR) mechanism. At the time, CAPTN was believed to be both a highly innovative undertaking and a highly speculative one. One reviewer even suggested that CAPTN was "unlikely to succeed, but would be a valuable learning experience for the field." OBJECTIVE To describe valuable lessons learned in building a clinical research network in pediatric psychiatry, including innovations intended to decrease barriers to research participation. METHODS The CAPTN Team has completed construction of the CAPTN network infrastructure, conducted a large, multi-center psychometric study of a novel adverse event reporting tool, and initiated a large antidepressant safety registry and linked pharmacogenomic study focused on severe adverse events. Specific challenges overcome included establishing structures for network organization and governance; recruiting over 150 active CAPTN participants and 15 child psychiatry training programs; developing and implementing procedures for site contracts, regulatory compliance, indemnification and malpractice coverage, human subjects protection training and IRB approval; and constructing an innovative electronic casa report form (eCRF) running on a web-based electronic data capture system; and, finally, establishing procedures for audit trail oversight requirements put forward by, among others, the Food and Drug Administration (FDA). CONCLUSION Given stable funding for network construction and maintenance, our experience demonstrates that judicious use of web-based technologies for profiling investigators, investigator training, and capturing clinical trials data, when coupled to innovative approaches to network governance, data management and site management, can reduce the costs and burden and improve the feasibility of incorporating clinical research into routine clinical practice. Having successfully achieved its initial aim of constructing a network infrastructure, CAPTN is now a capable platform for large safety registries, pharmacogenetic studies, and randomized practical clinical trials in pediatric psychiatry.
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Affiliation(s)
- Mark Shapiro
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.
| | - Susan G Silva
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Allan Chrisman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph DeVeaugh-Geiss
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Alfiee Breland-Noble
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Douglas Kondo
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Jerry Kirchner
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - John S March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Kennard BD, Silva SG, Mayes TL, Rohde P, Hughes JL, Vitiello B, Kratochvil CJ, Curry JF, Emslie GJ, Reinecke MA, March JS. Assessment of safety and long-term outcomes of initial treatment with placebo in TADS. Am J Psychiatry 2009; 166:337-44. [PMID: 19147693 PMCID: PMC2823118 DOI: 10.1176/appi.ajp.2008.08040487] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined whether initial assignment to receive placebo for 12 weeks followed by open active treatment as clinically indicated was associated with different levels of benefit and risk of harm across 36 weeks as compared with initial assignment to receive active treatments. METHOD Adolescents with major depressive disorder (N=439) were randomly assigned to receive an initial 12 weeks of treatment with fluoxetine, cognitive-behavioral therapy (CBT), combination treatment with fluoxetine and CBT, or clinical management with placebo; those assigned to placebo received open active treatment as clinically indicated after 12 weeks of placebo. Assessments were conducted every 6 weeks for 36 weeks. The primary outcome measures were response and remission based on scores on the Children's Depression Rating Scale-Revised and the Clinical Global Impression improvement subscale. RESULTS At week 36, the response rate was 82% in the placebo/open group and 83% in the active treatment groups. The remission rate was 48% in the placebo/open group and 59% in the active treatment groups, a difference that approached statistical significance. Patients who responded to placebo generally retained their response. Those who did not respond to placebo subsequently responded to active treatment at the same rate as those initially assigned to active treatments. There were no differences between groups in rates of suicidal events, study retention, or symptom worsening. CONCLUSIONS Remission rates at 9 months were lower in patients treated initially with placebo, but 3 months of placebo treatment was not associated with any harm or diminished response to subsequent treatment.
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Freeman JB, Choate-Summers ML, Garcia AM, Moore PS, Sapyta JJ, Khanna MS, March JS, Foa EB, Franklin ME. The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods. Child Adolesc Psychiatry Ment Health 2009; 3:4. [PMID: 19183470 PMCID: PMC2646688 DOI: 10.1186/1753-2000-3-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Accepted: 01/30/2009] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7-17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits. TRIAL REGISTRATION NCT00074815.
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Affiliation(s)
- Jennifer B Freeman
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI USA
| | - Molly L Choate-Summers
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI USA
| | - Abbe M Garcia
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI USA
| | - Phoebe S Moore
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Jeffrey J Sapyta
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Muniya S Khanna
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC USA
| | - John S March
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Edna B Foa
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC USA
| | - Martin E Franklin
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC USA
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Abstract
OBJECTIVE Given striking advances in translational developmental neuroscience and its convergence with developmental psychopathology and developmental epidemiology, it is now clear that mental illnesses are best thought of as neurodevelopmental disorders. This simple fact has enormous implications for the nature and organization of psychotherapy for mentally ill children, adolescents and adults. METHOD This article reviews the 'trajectory' of psychosocial interventions in pediatric psychiatry, and makes some general predictions about where this field is heading over the next several decades. RESULTS Driven largely by scientific advances in molecular, cellular and systems neuroscience, psychotherapy in the future will focus less on personal narratives and more on the developing brain. In place of disorders as intervention targets, modularized psychosocial treatment components derived from current cognitive-behavior therapies will target corresponding central nervous system (CNS) information processes and their functional behavioral consequences. Either preventive or rehabilitative, the goal of psychotherapy will be to promote development along typical developmental trajectories. In place of guilds, psychotherapy will be organized professionally much as physical therapy is organized today. As with other forms of increasingly personalized health care, internet-based delivery of psychotherapy will become commonplace. CONCLUSION Informed by the new field of translational developmental neuroscience, psychotherapy in the future will take aim at the developing brain in a service delivery model that closely resembles the place and role of psychosocial interventions in the rest of medicine. Getting there will be, as they say, interesting.
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Affiliation(s)
- John S March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27705, USA.
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Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S, March JS, Kendall PC. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008; 359:2753-66. [PMID: 18974308 PMCID: PMC2702984 DOI: 10.1056/nejmoa0804633] [Citation(s) in RCA: 813] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. METHODS In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. RESULTS The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. CONCLUSIONS Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)
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Affiliation(s)
- John T Walkup
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21287, USA
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Jacobs RH, Klein JB, Reinecke MA, Silva SG, Tonev S, Breland-Noble A, Martinovich Z, Kratochvil CJ, Rezac AJ, Jones J, March JS. Ethnic Differences in Attributions and Treatment Expectancies for Adolescent Depression. Int J Cogn Ther 2008; 1:163-178. [PMID: 19169367 PMCID: PMC2629601 DOI: 10.1680/ijct.2008.1.2.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Studies suggest that ethnicity and socioeconomic factors may relate to differences in treatment expectancies and the attributions made for emotional or behavioral problems. We examined ethnic differences in (1) parents' attributions about the causes of adolescent behavioral and emotional problems and (2) treatment expectancies among 236 adolescent participants who enrolled in a 36-week randomized controlled trial for depression. Controlling for education and income, European American parents were more likely to endorse beliefs reflecting physical causes of depression than African American parents. There were no ethnic differences for beliefs reflecting external, familial, or community factors. Ethnic differences were observed in the treatment expectancies reported by parents, but not adolescents, with African American parents more likely than European Americans and Other minorities to endorse positive expectations for CBT. These findings may have implications for understanding discrepancies in mental health service use.
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Jacobs RH, Klein JB, Reinecke MA, Silva SG, Tonev S, Breland–Noble A, Martinovich Z, Kratochvil CJ, Rezac AJ, Jones J, March JS. Ethnic Differences in Attributions and Treatment Expectancies for Adolescent Depression. Int J Cogn Ther 2008. [DOI: 10.1521/ijct.2008.1.2.163] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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