Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated. These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980–2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines. These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions. Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.

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Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth meta-analysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatment (0.15). ESs differed across control conditions, with "usual care" emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science. (PsycINFO Database Record

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What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice.

BACKGROUND: Anxiety and depression in children and adolescents are undertreated. Computer- and Internet-based cognitive behavioral treatments (cCBT) may be an attractive treatment alternative to regular face-to-face treatment.This meta-analysis aims to evaluate whether cCBT is effective for treating symptoms of anxiety and depression in youth. METHODS AND FINDINGS: We conducted systematic searches in bibliographical databases (Pubmed, Cochrane controlled trial register, PsychInfo) up to December 4, 2013. Only randomized controlled trials in which a computer-, Internet- or mobile-based cognitive behavioral intervention targeting either depression, anxiety or both in children or adolescents up to the age of 25 were compared to a control condition were selected. We employed a random-effects pooling model in overall effect analyses and a mixed effect model for sub-group analyses. Searches resulted in identifying 13 randomized trials, including 796 children and adolescents that met inclusion criteria. Seven studies were directed at treating anxiety, four studies at depression, and two were of a transdiagnostic nature, targeting both anxiety and depression. The overall mean effect size (Hedges' g) of cCBT on symptoms of anxiety or depression at post-test was g=0.72 (95% CI:0.55-0.90, numbers needed to be treated (NNT)=2.56). Heterogeneity was low (I²=20.14%, 95% CI: 0-58%). The superiority of cCBT over controls was evident for interventions targeting anxiety (g=0.68; 95% CI: 0.45-0.92; p < .001; NNT=2.70) and for interventions targeting depression (g=0.76; 95% CI: 0.41-0.12; p < .001; NNT=2.44) as well as for transdiagnostic interventions (g=0.94; 95% CI: 0.23-2.66; p < .001; NNT=2.60). CONCLUSIONS: Results provide evidence for the efficacy of cCBT in the treatment of anxiety and depressive symptoms in youth. Hence, such interventions may be a promising treatment alternative when evidence based face-to-face treatment is not feasible. Future studies should examine long-term effects of treatments and should focus on obtaining patient-level data from existing studies, to perform an individual patient data meta-analysis.

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Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Youth: A Meta-Analysis of Randomized Controlled Outcome Trials

. The majority of mental health disorders remain untreated. Many limitations of traditional psychological interventions such as limited availability of evidence-based interventions and clin...

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Internet- and Mobile-Based Psychological Interventions: Applications, Efficacy, and Potential for Improving Mental Health: A Report of the EFPA E-Health Taskforce

Background
Individual randomized controlled trials (RCTs) have demonstrated the efficacy of cognitive behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) for the treatment of youth with obsessive–compulsive disorder (OCD). Although meta-analyses have confirmed these results, there has been minimal examination of treatment moderators or an examination of treatment response and symptom/diagnostic remission for these two treatment types. The present report examined the treatment efficacy, treatment response, and symptom/diagnostic remission for youth with OCD receiving either CBT or SRIs relative to comparison conditions, and examined treatment moderators.

Method
A comprehensive literature search identified 20 RCTs that met inclusion criteria, and produced a sample size of 507 CBT participants and 789 SRI participants.

Results
Random effects meta-analyses of CBT trials found large treatment effects for treatment efficacy (g = 1.21), treatment response (relative risk [RR] = 3.93), and symptom/diagnostic remission (RR = 5.40). Greater co-occurring anxiety disorders, therapeutic contact, and lower treatment attrition were associated with greater CBT effects. The number needed to treat (NNT) was three for treatment response and symptom/diagnostic remission. Random effects meta-analyses of SRI trials found a moderate treatment effect for treatment efficacy (g = 0.50), treatment response (RR = 1.80), and symptom/diagnostic remission (RR = 2.06). Greater methodological quality was associated with a lower treatment response for SRI trials. The NNT was five for treatment response and symptom/diagnostic remission.

Conclusions
Findings demonstrate the treatment effects for CBT and SRIs across three important outcome metrics, and provide evidence for moderators of CBT across trials.

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A meta-analysis of cognitive behavior therapy and medication for child obsessive-compulsive disorder: moderators of treatment efficacy, response, and remission.

This study reports a waitlist controlled randomized trial of family-based cognitive-behavioral therapy delivered via web-camera (W-CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty-one primarily Caucasian youth with OCD (range=7-16years; 19 male) were randomly assigned to W-CBT or a Waitlist control. Assessments were conducted immediately before and after treatment, and at 3-month follow-up (for W-CBT arm only). Primary outcomes included the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), clinical global improvement rates, and remission status. When controlling for baseline group differences, W-CBT was superior to the Waitlist control on all primary outcome measures with large effect sizes (Cohen's d≥1.36). Thirteen of 16 youth (81%) in the W-CBT arm were treatment responders, versus only 2/15 (13%) youth in the Waitlist arm. Similarly, 9/16 (56%) individuals in the W-CBT group met remission criteria, versus 2/15 (13%) individuals in the Waitlist control. Gains were generally maintained in a naturalistic 3-month follow-up for those randomized to W-CBT. This preliminary study suggests that W-CBT may be helpful in reducing obsessive-compulsive symptoms in youth with OCD. Given considerable access issues, such findings hold considerable promise for treatment dissemination.

Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder

Background: Many youth with tic disorders experience distress about having tics and how others may perceive them. Such symptoms are often more impairing and distressing than the tics themselves and negatively impact self-concept, psychosocial functioning, and quality of life. Objective: Although there exist pharmacological and behavioral treatments that target the frequency and severity of tics, no intervention has been developed specifically to help youth with tics cope with their condition and limit associated functional impairment and distress. With this in mind, we report an intervention case series of eight youth (ages 8-16 years) supporting the initial efficacy of a cognitive-behavioral therapy program entitled "Living with Tics" that promotes coping and resiliency among youth with tics. Method: Eight youth with a principal diagnosis of a tic disorder (i.e., Tourette syndrome [N 5 6]; Chronic Tic Disorder [N 5 2]) and associated psychosocial impairment participated. Assessments were conducted at screening, pretreatment, and posttreatment by trained raters. Treatment consisted of 10 weekly individual psychotherapy session focused on improving coping with having tics. Results: Six of eight youth were considered treatment responders. On average, participants exhibited meaningful reductions in tic-related impairment, anxiety, and overall tic severity as well as improvements in self-concept and quality of life. Conclusions: These data provide preliminary evidence for conducting a larger controlled trial to examine the utility of the Living with Tics psychosocial intervention for promoting adaptive functioning among youth with tics. Keywords: Tourette syndrome; cognitive-behavioral therapy; treatment; chronic tic disorder; Yale-Global Tic Severity Scale Tourette syndrome and chronic tic disorders (hereafter collectively referred to as TD) are neuropsychiatric disorders with an early childhood onset characterized by the presence of multiple motor and/or phonic tics persisting for at least 1 year (American Psychiatric Association, 2000). Recent estimates suggest incidence rates from 1 to 3 per 1,000 (Centers for Disease Control and Prevention, 2009; Scahill, Tanner, & Dure, 2001) to 10 per 1,000 (Kadesjo & Gillberg, 2000) in child and adolescent populations. Although having tics in childhood for a short period is not uncommon (Kurlan, Behr, Medved, & Como, 1988), full-blown TD is associated with a wide range of behavioral and psychological difficulties, including disruptive behavior (Sukhodolsky et al., 2003), interpersonal difficulties (Carter et al., 2000), and anxiety and mood disturbances (Robertson, Banerjee, Eapen, & Fox-Hiley, 2002). Consequently, there is a high comorbidity between TD and other psychiatric disorders, such as attention-deficit/hyperactivity disorder (ADHD; 50%-75% of cases; Robertson et al.) and obsessive-compulsive disorder (OCD; ~50% of cases; Robertson, 1995). In addition to a high comorbidity rate, individuals with TD and their families often report impairments in daily functioning. Storch, Lack, et al. (2007) showed that more than half of 59 youth with TD reported one significant problem area because of the presence of tics, with more than a third reporting two or more problem areas. Erenberg, Cruse, and Rothner (1987) reported that 41% of adolescents and young adults with TD (age range 5 15-25 years) reported some difficulty coping with their tics. Whereas 35% of respondents felt that tics caused the greatest detrimental impact, 45% reported that comorbid psychiatric or learning issues caused the greatest interference; the remaining 10% held that the direct and indirect factors were equally detrimental. Between 36% and 65% of youth experience some degree of impairment in academic functioning because of their tics (Abwender et al., 1996; Conelea et al., 2011; Erenberg, Cruse, & Rothner, 1986). For example, a recent study reported that 65% of youth reported that tics interfere with studying, and 60% reported that tics contribute to classroom difficulties. …

Psychosocial Treatment to Improve Resilience and Reduce Impairment in Youth with Tics: An Intervention Case Series of Eight Youth

Obsessive-compulsive symptoms among youth with Prader-Willi Syndrome (PWS) are frequently present and associated with considerable problems in the daily functioning of the child and his/her family. Although pharmacological and psychosocial treatments exist that target obsessive-compulsive symptoms among typically developing youth, these treatments have not been systematically adapted and/or evaluated for this population. Furthermore, although psychotropic medications have shown promising support in addressing obsessive-compulsive symptoms in several case reports involving youth with PWS, associated efficacy is modest and potential for side effects is a realistic concern. Given efficacy and tolerability of cognitive-behavioral treatment for obsessive-compulsive symptoms in typically developing youth, an adapted version of this approach may hold promise in treating clinically problematic obsessive-compulsive symptoms in youth with PWS. Thus, we report on a case series of behavioral treatment for obsessive-compulsive symptoms in three youth with PWS. Diagnostic and symptom severity assessments were conducted at screening, pre-treatment, and post-treatment by a trained independent evaluator. All youth were considered treatment responders and exhibited meaningful reductions in compulsion severity, overall obsessive-compulsive severity, and obsessive-compulsive related impairment. These data provide preliminary evidence for the utility of behavioral therapy in treating obsessive-compulsive symptoms in youth with PWS.

Case Series of Behavioral Psychotherapy for Obsessive-Compulsive Symptoms in Youth with Prader-Willi Syndrome

Obsessive-compulsive disorder (OCD) is marked by incessant distressing thoughts or images (obsessions) and/or overt or covert behaviors (or mental rituals) aimed to reduce anxiety (compulsions). The disorder affects 1-2% of children and adults, with up to 80% of adults reporting symptom onset prior to the age of 18 years. Without appropriate intervention, symptoms tend to run a chronic course from childhood into adulthood. Obsessive-compulsive disorder contributes to considerable impairment across multiple domains of functioning, and as a result calls for effective and efficient treatment. To date, both psychological and pharmacological interventions have shown efficacy for pediatric OCD although there are associated advantages and disadvantages that must be considered in treatment planning. The intent of this review is to discuss the current state of literature regarding treatment for pediatric OCD, highlight efficient and cost-effective means of reducing impairment, and conclude with directions for future study.

Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder

Cognitive-behavioral therapy (CBT) is a first-line treatment for obsessive-compulsive disorder (OCD) in adults and children due to its efficacy, maintenance of therapeutic gains after treatment withdrawal, safety, and tolerability. The current article reviews research regarding the theoretical underpinnings of CBT, pragmatics regarding CBT implementation, and efficacy findings, while also highlighting barriers to efficacious treatment (ie, age, comorbidity, geography), methods of addressing such issues, and areas in need of further study.

Lindsay Brauer

Papers

Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder

Psychosocial Treatment to Improve Resilience and Reduce Impairment in Youth with Tics: An Intervention Case Series of Eight Youth

Case Series of Behavioral Psychotherapy for Obsessive-Compulsive Symptoms in Youth with Prader-Willi Syndrome

Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder

A Review of Psychotherapy for Obsessive-Compulsive