NEW YORK — Aggressive treatment of child and adolescent anxiety disorders is the key to clinical success, according to Dr. John T. Walkup.
“The biggest mistake you can make is to half treat,” Dr. Walkup, vice chair of psychiatry and director of the division of child and adolescent psychiatry at Cornell University, New York, said at a pharmacology update sponsored by the American Association of Child and Adolescent Psychiatry.
The biggest issue in consultation is underdosing. “As long as they're safe, I'm monitoring carefully, and they haven't had full recovery, I increase [the] dose,” he said.
Cognitive-behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) also must be done energetically, Dr. Walkup said.
He cited the proactive approach taken largely by investigators at the University of Pennsylvania, Philadelphia, in the Pediatric OCD Treatment Study (POTS). That multisite, placebo-controlled, double-blind trial compared sertraline alone, CBT alone, and combination therapy for the treatment of OCD. The investigators found that CBT alone and sertraline alone did not bring results that were significantly different (JAMA 2004;292:1969–76).
The University of Pennsylvania providers “are not quiet, easygoing therapists. These are tough, fast, energizing, engaging,” he said. “But if you're going to be an effective OCD therapist, you have to be.”
Whatever the treatment modality, the first step is proper diagnosis. Mistaking the disorder for variants of attention-deficit/hyperactivity disorder (ADHD) or bipolar disorder can lead to lost months and poor outcomes, Dr. Walkup said.
“Both ADHD and anxiety tend to develop around the same age, ages 6–10. But the anxious kids tend to be inattentive because they're worried about their mom; they're worried about the nurse; their mind is just cluttered with worry; and the last thing they can do is pay attention,” he said.
A similar case of mistaken diagnosis is sometimes made with bipolar disorder. Dr. Walkup drew applause from the audience when he said: “If you see something affective in a kid before 12, think anxiety, don't think bipolar. The rate of anxiety to bipolar is 20 or 40 to 1.”
The stakes are high, he emphasized, when it comes to making an accurate diagnosis and offering adequate treatment for anxiety disorders. “The morbidity is high: suicide, depression, performance,” Dr. Walkup said.
Asked by an audience member how quickly he raises an initial dose of sertraline, he said: “When you start a drug trial, get going. You offer hope and encouragement, and a brisk response that make kids and families responsive to treatment. I start at 25 mg the first week, 50 the second week, and hold at 50.
“If the symptoms are nonresponsive, at week 4, I go to 100. If still nonresponsive, after another 2 weeks, I go to 150, and up to 200 if necessary by week 8.”
When the highest safe dose is ineffective, he considers switching to a second selective serotonin reuptake inhibitor or lithium, Dr. Walkup said. His protocol is a slow cross-taper, gradually adding the second drug and seeing a benefit before even considering a reduction of the first.
“You're usually recommended to discontinue the first medication before you start the new,” he said. “The problem is that even the nonresponders probably had some benefit on that first drug. When you begin to discontinue, those symptoms that got better begin to creep back.”
Instead, he prefers what he calls “getting stuck in the middle.”
“You've got them on one drug; you add another,” Dr. Walkup said. “You want an enhancement on the second medication before you begin to discontinue the first. Within a brief period, you see what seems to be a lithium augmentation…. I stop, I hold, and I do not discontinue. I get stuck in the middle of a cross-taper.
“The process is not 2 or 3 weeks. It's much longer. How long? Families are impatient. Insurers are impatient. You've got to educate, educate, educate.”
Once significant relief of anxiety is achieved, he prefers to wait a year before attempting to reduce or eliminate medication. “Those who deteriorate during discontinuation usually do so within 6 weeks. If I can get them through that 6-week period, I know I have a pretty good chance of taking them down another notch,” he said.
Disclosures: Dr. Walkup has served on the advisory board of the Tourette Syndrome Association (TSA); received grant support from the TSA; and received honorarium and travel support from AACAP, and additional support from Abbott Laboratories, the Centers for Disease Control and Prevention, Eli Lilly & Co., and Pfizer Inc.