A systematic review and meta-analysis of pharmacotherapy and psychotherapy for anxiety disorders and obsessive-compulsive disorder in children and adolescents

Abstract

Background Anxiety and obsessive-compulsive disorder (OCD) are two significant and potentially disabling mental health problems in youth. Prompt and optimal management of these disorders reduce disease burden on the individual, family and society. Pharmacotherapy, psychotherapy and combined treatment are well-established modalities for treating these disorders, yet evidence for their comparative efficacies is limited and warrants further study.

Objectives To assess the relative efficacies of pharmacotherapy, psychotherapy and combination treatment in the management of anxiety and OCD in children and adolescents.

Search strategy Electronic searches of Medline(1946-), EMBASE(1947-) and PsycINFO(1967-) were performed in May 2015. Various electronic registries were searched for ongoing and unpublished studies. Reference lists of included studies were also perused.

Selection criteria All randomised controlled trials (RCTs) of pharmacotherapy versus psychotherapy, and combination therapy versus pharmacotherapy/psychotherapy for anxiety and OCD in youth.

Data collection and analysis A solo researcher undertook a systematic review and meta-analysis to address the research objectives. Systematic review and meta-analysis encompass rigorous examination of all relevant evidence using standardised criteria in literature search, study selection, bias assessment, quantitative data extraction and outcome appraisal. In this review, primary outcomes included remission and treatment response. Post-treatment severity, quality of life, treatment tolerability and major adverse effects were secondary outcomes.

Main results Five studies on anxiety (822 participants) and six studies on OCD (364 participants) were included in the meta-analysis.

Comparison between pharmacotherapy and psychotherapy for anxiety revealed inconclusive results, although summary effects tended to favour psychotherapy. Remission and treatment response insignificantly favoured psychotherapy over pharmacotherapy. Anxiety severity was insignificantly lower in patients receiving psychotherapy than pharmacotherapy [Standardised Mean Difference (SMD) 0.25, 95% Confidence Interval (CI) -0.73 to 1.23].

Findings were more consistently showing the superiority of combination therapy over psychotherapy for anxiety. Remission and treatment response were both significantly greater for combination than psychotherapy, while post-treatment severity was insignificantly lower (SMD -0.46, 95% CI -1.02 to 0.11).

Findings in OCD mostly echoed with those of anxiety. Remission almost reached statistical significance favouring combination over psychotherapy [Odds Ratio (OR) 1.88, 95% CI 0.79 to 4.43]. Treatment response insignificantly favoured combination over pharmacotherapy (OR 3.36, 95% CI 0.86 to 13.20). Post-treatment severity was significantly lower for combination compared with pharmacotherapy (SMD -0.52, 95% CI -0.82 to -0.22), but not with psychotherapy (SMD -0.13, 95% CI -0.53 to 0.27); while those who received psychotherapy had insignificantly lower severity compared with medications alone (SMD 0.36, 95% CI -0.01 to 0.73).

Author’s conclusions This review offers cautious support for psychotherapy over pharmacotherapy in both paediatric anxiety and OCD. Evidence favouring combination therapy over monotherapy is stronger, especially in patients with higher baseline severity and co-morbidities, where earlier commencement of combination therapy might have been more desirable. Further research is needed to assess different therapeutic subclasses, discern predictors and moderators to response, and evaluate long-term outcomes.