Initiation of Pharmacotherapy Following CBT in Anxious Youth: Results From the Child/Adolescent Anxiety Multimodal Study (CAMS)

Objective: To describe youth with anxiety disorders who initiate pharmacotherapy following cognitive-behavioral therapy (CBT) in a prospective, randomized trial and to identify predictors of the decision to use pharmacotherapy. Methods: Data from CBT-treated youth (aged 7-17 years, N = 139) in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multisite, randomized controlled trial that examined the efficacy of CBT, sertraline, their combination, and placebo for pediatric anxiety disorders (DSM-IV criteria), were evaluated. Initiation of pharmacotherapy following acute CBT treatment was examined over a 24-week period; the study was conducted from December 2002 through May 2007. Logistic regression models identified features associated with initiating pharmacotherapy, including symptom severity (scores on the Pediatric Anxiety Rating Scale [PARS] and the Screen for Child/Adolescent Anxiety Related Disorders [SCARED]), parent and child treatment expectations, Clinical Global Impressions-Improvement/Severity of Illness (CGI-I/S) scores, and clinical and demographic characteristics. Results: CBT non-remitters (CGI-S score > 2) who began pharmacotherapy (n = 10) and those who did not (n = 80) were similar in age (P =.445), sex (P =.324), race (P =.242), and symptom severity based on CGI-S (P =.753), PARS (P =.845), or SCARED (P =.678) scores. Mean +/- SD improvement (CGI-I score) at week 12 did not differ between patients who initiated pharmacotherapy (3.00 +/- 0.82) and those who did not (2.69 +/- 0.89, P =.798). However, in the logistic regression, age (P =.003), race (P =.021), and parents' treatment expectation (P =.037) were significantly associated with the likelihood of initiating pharmacotherapy. Beginning pharmacotherapy in CBT non-remitters was associated with a significant improvement in CGI-S score (mean +/- SD decline: -0.99 +/- 0.46; 95% credible interval [CrI], -0.088 to -1.89; P =.035) from week 12 to week 36 compared to patients who did not begin pharmacotherapy. Discussion: Very few CBT non-remitters initiated pharmacotherapy, although beginning medication produced significant improvement. Younger and racial and ethnic minoritized patients as well as those with lower expectations for CBT were less likely to begin medication.