Journal Article Reviews.

Anxiety: Psychopharmacology Strawn JR, Mills JA, Sauley BA, Welge JA. The impact of antidepressant dose and class on treatment response in pediatric anxiety disorders: a meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry. 2018;57(4):235–244. Anxiety disorders are common in childhood and confer an increased risk of depressive disorder, other anxiety disorders, and suicidality. Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line psychopharmacologic interventions for treatment of children with anxiety disorders, and improvement seems to be dose related with selective serotoninnorepinephrine reuptake inhibitors (SNRIs) also used in treatment of anxiety. Understanding the effectiveness of various treatments is necessary to provide the most appropriate interventions and may affect clinical practice. Strawn et al. performed a meta-analysis with data from 9 prospective, randomized, placebo-controlled trials evaluating 7 medications in 1673 children with social, generalized, and/or separation anxiety disorder. Overall, 923 patients were randomly assigned to antidepressant and 882 to placebo treatment groups. Of the sample, 53% were male, and the median duration of treatment was 10 weeks across trials. The samples included children aged 5 to 17 years, and 44% to 67% were male, depending on the study. Four SSRIs (fluoxetine, fluvoxamine, paroxetine, and sertraline) and 3 SNRIs (atomoxetine, venlafaxine, and duloxetine) were evaluated. For both SSRIs and SNRIs, statistically significant improvement occurred at week 2 (dSSRI 5 20.054, CI 5 20.096 to 20.077 vs dSNRI 5 20.07, CI 5 20.113–0; p 5 0.02) and remained statistically significant over the subsequent 10 weeks. Overall, both treatments resulted in significant improvements (dSSRI 5 20.294, CI 5 20.304 to 20.284; p 5 0.001; dSNRI 5 20.136, CI 5 20.179 to 20.092; p 5 0.001), and SSRIs overall provided greater treatment response than that of SNRIs (p 5 0.003). Statistically significant symptom improvement occurred earlier with high-dose treatment; however, over the course of treatment, no significant difference was noted between high versus low-dose treatment (d 5 0.010; p 5 0.638). Overall, this study highlights the effectiveness of pharmacologic treatment for anxiety disorders. Benefits were noted soon after treatment was initiated, and SSRIs were associated with earlier and greater symptom improvement in anxiety disorders. O.V.B. Anxiety Disorders: Psychotherapy Hainsworth CJ, Dixon AL, Koo S, Munro K. Acceptance and Commitment Therapy versus Cognitive Behavior Therapy for children with anxiety: outcomes of a randomized controlled trial. Journal of Clinical Child & Adolescent Psychology. 2018;47(2):296–311. Cognitive and behavioral therapy (CBT) is an evidencebased gold standard in the treatment of anxiety. Acceptance and commitment therapy (ACT) incorporates psychoeducation, exposure, skills training (e.g., problemsolving and social skills), use of metaphors, and experiential approaches, which may be suited for children. For children and adolescents (mean 5 11 years, SD 5 2.76; 78% white, 58% female) with comorbid (e.g., more than 1) anxiety disorders (n 5 181, 94%), this randomized controlled trial evaluated the effectiveness of 10 sessions (1.5 hr) of group-based ACT (n 5 54) and CBT (n 5 57) and a waitlist control. Clinician severity ratings (CSR) from the Anxiety Disorders Interview Schedule, Fourth Edition, as well as selfand parent-report measures of anxiety and health-related quality of life were obtained at pretreatment, post-treatment, and 3 months after treatment. Compared with waiting list control (WLC), both ACT (p, 0.001; d 5 3.30) and CBT (p , 0.001; d 5 3.31) led to significant reductions in CSR (p , 0.001; D 5 1.32 for ACT vs WLC, D 5 1.60 for CBT vs WLC) and improvements in psychosocial quality of life (p , 0.001; d 5 0.71 for ACT and 0.56 for CBT); both were maintained at 3-month follow-up (p , 0.001; d 5 1.03 and 1.43). The average number of anxiety diagnoses was reduced in both treatment groups from 3 to 1, which was maintained at 3-month follow-up (p , 0.001; d 5 1.43 for ACT 0.93 for CBT; D 5 0.64 for ACT vs WLC, D 5 0.94 for CBT vs WLC; d 5 0.32 and 0.36 for ACT vs CBT at post and 3 mo). Although results suggest that both approaches were effective in achieving a clinical change, the specific mechanisms or processes of change are unknown; however, ACT may be an alternative treatment option for CBT nonresponders in anxious youth. R.M.