DOI: 10.1177/10445463261462882 ISSN: 1044-5463

Beyond the Wait-and-See: Data-Driven Decision Points for Guiding Selective Serotonin Reuptake Inhibitor Treatment and Cognitive Behavioral Therapy in Pediatric Anxiety Disorders

Julia N. Stimpfl, Jeffrey A. Mills, Katherine K. Dahlsgaard, Tara S. Peris, John C. Piacentini, John T. Walkup, Jeffrey R. Strawn
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Objectives:

To identify early markers of acute treatment response among youth with anxiety disorders receiving cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitor (SSRI) monotherapy, or their combination.

Background:

Although many youth with anxiety disorders benefit from CBT or SSRIs, response trajectories vary. Identifying early indicators of nonresponse may guide sequencing strategies and improve timely treatment delivery.

Methods:

Using data from the Child/Adolescent Anxiety Multimodal Study, improvement trajectories were modeled for youth (age 7–17) randomized to sertraline monotherapy ( N = 133), CBT monotherapy ( N = 139), their combination ( N = 140), and placebo ( N = 76). Patients were stratified by percent change in Pediatric Anxiety Rating Scale (PARS) scores at multiple time points, and logarithmic and logistic time-trend regression models were used to estimate the probability of response. Receiver operating characteristic (ROC) analyses were used to identify thresholds of improvement for predicting response.

Results:

In the sertraline group, ≥25% improvement in PARS score at week 4 had a higher probability of response by week 12 (60.8%) than <25% improvement (31.7%, p = 0.001). In CBT-treated youth, week 4 PARS improvement was less predictive of response, with ≥25% improvement predicting a 47.9% chance of response compared with 28.6% for <25% improvement ( p = 0.025). In the combined treatment, ≥25% improvement predicted a73.3% probability of response, whereas <25% improvement yielded a 51.3% likelihood of response ( p < 0.001). ROC analyses similarly suggested that week 4 improvement in PARS scores in the CBT group had near equivocal predictive value, though this improved by week 6 to levels comparable to those of the other treatment groups. At week 6, roughly 25% improvement in PARS score in the combined treatment had the best sensitivity and specificity for predicting response.

Conclusions:

Early improvement can predict treatment response in youth with anxiety disorders receiving sertraline monotherapy or combination treatment (sertraline and CBT). Conversely, the absence of early improvement in CBT-treated youth does not reliably predict treatment nonresponse. Treatment-specific thresholds may inform clinical decision making, and support earlier SSRI optimization while allowing more time to observe CBT-related gains.

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