Pediatrics-based Brief Therapy Outdoes Referral for Youths with Anxiety and Depression

Striking benefit seen for Hispanic youths

May 31, 2017 • Science Update

A streamlined behavioral therapy delivered in a pediatrics practice offered much greater benefit to youth with anxiety and depression than a more standard referral to mental health care with follow-up in a clinical trial comparing the two approaches. The benefit of the former approach in comparison with referral was especially striking in Hispanic youth, a finding that may help inform efforts to address disparities in care.

Depression and anxiety disorders are prevalent among youth; an estimated 25.1 percent of 13 to 18-year-olds have an anxiety disorder. Surveys also suggest that less than a third of youth with anxiety and just over 40 percent with mood disorders receive treatment. These disorders can have serious consequences for affected youth; depression and anxiety can compromise education, employment, and relationships with friends and family.

V. Robin Weersing, Ph.D., at San Diego State University, and David A. Brent, M.D., at the University of Pittsburgh, led the clinical trial, which enrolled 185 youths, ages 8 to 16, from pediatric clinics in San Diego and Pittsburgh. Participants in the trial met criteria for depression or an anxiety disorder, including separation anxiety, generalized anxiety disorder, or social phobia. Each was randomly assigned to either a brief behavioral therapy (BBT) or to referral to mental health care with periodic check-in calls (“assisted referral”).

The BBT tested in this trial simultaneously addresses both depression and anxiety, rather than targeting one or the other, and it is streamlined in comparison to some standard approaches, with fewer therapeutic components. Of the 95 youths assigned to BBT in the trial, 50 (56.8 percent) improved on a scale that assesses improvement across anxiety and depression, while 20 (28.2 percent) of youths in the assisted referral group improved. Raters who evaluated the youth were unaware of which treatment each received. Youth in the BBT group also did better on a scale of overall functioning and had fewer symptoms of anxiety.

The contrast in results between the Hispanic youth receiving BBT and those receiving assisted referral was even greater: 13 of 17 (76.5 percent) responded to BBT, while 1 of 14 (7.1 percent) assigned to assisted referral did. Hispanic youths receiving BBT also did much better on measures of functioning.

One of the central elements of the BBT was behavioral activation in which a youth is encouraged to engage in activities that he or she finds desirable but difficult, such as social functions. “In these interventions, kids learn not to withdraw from what’s upsetting them,” said Dr. Weersing, lead author and developer of the intervention. “Slowly they learn to approach and actively problem solve. Step by step, they re-engage with the tasks that they need to do or want to do—school, social, family-related—but previously struggled to do, because negative emotions were in the way.”

Any differences in the number of therapeutic sessions received either with BBT or as a result of referral did not account for the differences measured in benefits to youth. The referral coordinators successfully connected 82 percent of families with specialty mental health care, and the youth in that group had an average of 6.5 therapeutic visits (vs. an average of 11.2 sessions of BBT). But even the referral group youth with the most therapeutic sessions had worse outcomes than those in BBT.

An important impetus for the development of the therapy tested in this trial was to provide an intervention that is easy to disseminate, and in particular, adaptable for use in primary care settings where many children and adolescents get regular care. “In order to reach the very large number of youth suffering from emotional problems, we need to explore treatment delivery settings, like pediatrics, with a wide reach and low stigma,” said Dr. Weersing. “This has great promise for improving access to care, particularly for Latino youth.”

Joel Sherrill, Ph.D., deputy director of NIMH’s Division of Services and Intervention Research, said “This study is remarkable in its attention to testing a brief intervention that lends itself to scale-up in settings readily accessible to youth; and in the deployment-focused approach to matching the intensity of the intervention to the capacity within the primary care setting.”

The study is reported in the journal JAMA Psychiatry, online April 19, 2017.