Examining medication hesitancy to treat childhood anxiety disorders

UC research published in Journal of Clinical Psychiatry

Both medication and a specific form of talk therapy called cognitive behavioral therapy (CBT) are proven evidence-based treatments for children and adolescents with anxiety disorders. 

But when CBT does not lead to improvement, do parents and their children opt to begin medication treatment? And what factors contribute to this decision?

These were the questions researchers led by the University of Cincinnati’s Jeffrey Strawn and Jeffrey Mills asked in a recent study, with the results published Dec. 5 in the Journal of Clinical Psychiatry.

Strawn, MD, said the research was a  reanalysis of the Child/Adolescent Anxiety Multimodal Study (CAMS), a large trial that enrolled nearly 500 children and adolescents with generalized separation and/or social anxiety disorders. The original trial found that CBT, or talk therapy, and medications were equally effective, while the combination of the two treatments led to even better results. 

The research team looked at a subset of patients who were treated with CBT but did not improve. ​​Although the data from the CAMS trial has been available for some time, the question of what drives patient decision-making on further treatment choices had yet to be examined.

“For the folks who got therapy and didn’t get completely better, we wanted to try to understand if they started medication, the other effective evidence-based treatment for anxiety disorders,” said Strawn, professor in the Department of Psychiatry and Behavioral Neuroscience in UC’s College of Medicine and a UC Health child and adolescent psychiatrist.

Jeffrey Mills and Jeffrey Strawn looking at a computer

Jeffrey Mills, PhD, left, and Jeffrey Strawn, MD, right, have become close collaborators taking a transdisciplinary approach to research. Photo/University of Cincinnati.

The researchers found only about 10% of patients that didn’t get fully better with CBT elected to begin taking medication.

“What we did with this data set was really try to understand why there was this hesitancy to use an evidence-based treatment,” Strawn said. “What we found was that there were some predictors of not starting medication treatment.”

Patients from racial and ethnic minorities were three times less likely to begin medication treatment compared to white patients, and younger patients were also significantly less likely to begin medication. Parent and patient expectations of the effectiveness of treatments were also a predictor of whether they would opt to start medication treatment. 

“We were able to leverage more recently developed statistical methods to better model the relationship between medication uptake and patient characteristics,” said Mills, PhD, professor of economics in UC’s Carl H. Lindner College of Business. “This allowed us to identify which of these potential predictors were important in driving a patient’s decision of whether or not to begin medication treatment.” 

Among those people who were able to get over the reluctance and started a medication, they actually got significantly better.

Jeffrey Strawn, MD

Strawn said further research will aim to understand why there is hesitancy to begin medication. He said one hypothesis proposed by psychologist and anxiety expert Katherine Dahlsgaard is that there is a “sell by” date where patients give up after a certain period of treatment because they feel they are not improving.

One potential avenue for reducing medication hesitancy may lie in explaining the effectiveness of the treatment. For patients in the CAMS study who opted to begin medication after CBT was not effective, Strawn said it “made a huge difference” in improvement.

“Among those people who were able to get over the reluctance and started a medication, they actually got significantly better,” he said. “On average, folks went from moderate to mild or from severe to moderate, so that’s a clinically noticeable difference.”

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Featured photo at top of Strawn and Mills. Photo/University of Cincinnati.

The original CAMS study was supported by the National Institute of Mental Health (NIMH). The current analyses were supported by the Yung Family Foundation, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; Grant R01HD098757), and PCORI.

Strawn has received research support from AbbVie, the National Institutes of Health (NIH, 5R01HD098757 and 1R01HD099775); NICHD, NIMH, National Institute of Environmental Health Sciences, Clinical and Translational Science Award program (UL1TR001425) and the Yung Family Foundation. He receives royalties from Springer Publishing for three texts and from UpToDate and has received material support from Myriad Genetics and honoraria from the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, Genomind and Neuroscience Educational Institute. He provides consultation to Cerevel and Intracellular and the U.S. Food and Drug Administration as a special government employee. 

Mills has received financial support from the Yung Family Foundation.

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