Brief Behavioral Therapy in Primary Care Setting Effective for Youth With Anxiety & Depression

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Although depression and anxiety are prevalent in youth, treatment rates for these disorders are low in this population.
Although depression and anxiety are prevalent in youth, treatment rates for these disorders are low in this population.

A recent randomized clinical trial demonstrated the efficacy of a brief behavioral intervention delivered in a primary care setting for youth with anxiety and depression.1

Although depression and anxiety are prevalent in youth, treatment rates for these disorders are low in this population — 20% and 40%, respectively.2 Treatment is even less prevalent in Hispanic youths, who may experience higher rates of these disorders.3,4

Previous findings support the effectiveness of a unified cognitive behavioral approach for depression and anxiety in adults and youth.5,6 The present study investigated the effectiveness of transdiagnostic brief behavioral therapy (BBT) in youth with one or both disorders per DSM-IV criteria. BBT integrates behavioral elements of evidence-based treatments and does not include the cognitive restructuring components typically included in CBT programs.

“In brief, exposure and behavioral activation were combined in the current protocol as graded engagement in avoided activities, supplemented by relaxation to manage somatic symptoms common among internalizing youth in primary care and by problem-solving skills to aid in stress management,” the investigators explained.

The sample included 185 participants age 8.0 to 16.9 (57.8% female; 77.8% white; 20.7% Hispanic) from 9 clinics in San Diego, California, and Pittsburgh, Pennsylvania. Participants were assigned to receive either BBT (n=95) in a pediatric primary care setting or assisted referral to mental healthcare (ARC; n=90). BBT was provided by master's-level clinicians across 8 to 12 weekly sessions lasting 45 minutes each, while ARC consisted of personalized referrals and check-in calls to facilitate access to care.

Clinically significant improvement (a score ≤2) on the Clinical Global Impression-Improvement scale served as the main outcome. Secondary outcomes were scores on the Children's Global Adjustment Scale (CGAS) to assess functioning, the Pediatric Anxiety Rating Scale (PARS), and the Children's Depression Rating Scale-Revised (CDRS-R).

The results reveal significantly higher rates of clinical improvement in the BBT group vs the ARC group (56.8% vs 28.2%; χ21 = 13.09, P <.001; number needed to treat, 4). The BBT group also showed greater symptom reduction (F2,146 = 5.72;

P =.004; Cohen f = 0.28) and better functioning (mean [SD], 68.5 [10.7] vs 61.9 [11.9]; t156 = 3.64; P <.001; Cohen d = 0.58). Hispanic participants were found to have a greater response to BBT (76.5%) than ARC (7.1%) (χ21 = 14.90; P <.001; number needed to treat, 2).

Although these results need to be replicated in trials with larger samples, they “reflect the value of successfully bringing these structured behavioral services to primary care compared with the common option of external referral to community mental health,” the investigators concluded. “Effects were especially strong for Hispanic youth, suggesting that the protocol may be a useful tool in addressing ethnic disparities in care.”

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References

  1. Weersing VR, Brent DA, Rozenman MS, et al. Brief behavioral therapy for pediatric anxiety and depression in primary care a randomized clinical trial. JAMA Psychiatry. 2017;74(6):571-578. doi:10.1001/jamapsychiatry.2017.0429
  2. Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32-45. doi:10.1016/j.jaac.2010.10.006
  3. Glover SH, Pumariega AJ, Holzer CE, Wise BK, Rodriguez M. Anxiety symptomatology in Mexican American adolescents. J Child Fam Stud. 1999;8(1):47-57. doi:10.1023/A:1022994510944
  4. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN. Prevalence of and risk factors for depressive symptoms among young adolescents. Arch Pediatr Adolesc Med. 2004;158(8):760-765. doi:10.1001/archpedi.158.8.760
  5. Twomey C, O'Reilly G, Byrne M. Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Fam Pract. 2015;32(1):3-15. doi:10.1093/fampra/cmu060
  6. Chu BC, Crocco ST, Esseling P, Areizaga MJ, Lindner AM, Skriner LC. Transdiagnostic group behavioral activation and exposure therapy for youth anxiety and depression: Initial randomized controlled trial. Behav Res Ther. 2016;76:65-75. doi:10.1016/j.brat.2015.11.005
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