Psychological therapies for anxiety and depression in children and adolescents with long-term physical conditions

Why is this review important?

More than one in ten children and adolescents have long-term physical conditions such as asthma, diabetes, and cancer. They are more likely to develop psychological problems like anxiety or depression. Treating these problems early can prevent difficulties with family life, school, and future mental health problems. It is currently unclear whether psychological therapies (talking therapies) designed for children and adolescents without medical issues are appropriate for use with this population.

Who will be interested in this review?

This review will be of interest to mental and medical healthcare providers, service users, and service commissioners.

What questions does this review aim to answer?

This review aims to answer the following questions: 1) Are psychological therapies better than a range of other therapies in reducing symptoms of anxiety and depression in children and adolescents with long-term physical conditions? and 2) Are psychological therapies acceptable to this audience?

Which studies were included in the review?

We searched a number of databases to find all high-quality trials of psychological therapies for anxiety or depression in children and adolescents aged 18 years or less with long-term physical conditions and symptoms of anxiety or depression, published from 1970 to September 2018. We included twenty-nine studies with a total of 1349 people in the review and rated the overall quality of the studies as 'low to moderate'.

What does the evidence from the review tell us?

A handful of psychological therapies have been researched in children and adolescents with long-term physical conditions. Most of these were developed for use with children and adolescents who do not have long-term physical conditions. Some of these, particularly those based on principles of cognitive behaviour therapy (CBT) and therapies specifically designed to treat depression or anxiety, are effective at reducing mild symptoms of these conditions in the short term. There is limited evidence that such therapies are acceptable to young people and that they can improve quality of life and symptoms of long-term physical conditions. There is currently a lack of therapies for addressing health-related anxiety in this population.

What should happen next?

Further research should be undertaken to develop more effective psychological therapies to treat anxiety and depression in children and adolescents with long-term physical conditions.

Authors' conclusions: 

A limited number of trials of variable quality have been undertaken to assess whether psychological therapies are effective for treating anxiety and depression in children and adolescents with long-term physical conditions. According to the available evidence, therapies specifically designed to treat anxiety or depression (especially those based on principles of cognitive behaviour therapy (CBT)) may be more likely to work in children and adolescents who have mild to moderate levels of symptoms of these disorders, at least in the short term. There is a dearth of therapies specifically designed to treat health-related anxiety in this age group.

Read the full abstract...
Background: 

Long-term physical conditions affect 10% to 12% of children and adolescents worldwide. These individuals are at greater risk of developing psychological problems, particularly anxiety and depression, sometimes directly related to their illness or medical care (e.g. health-related anxiety). There is limited evidence regarding the effectiveness of psychological therapies for treating anxiety and depression in this population. Therapies designed for children and adolescents without medical issues may or may not be appropriate for use with those who have long-term physical conditions.

Objectives: 

This review was undertaken to assess the effectiveness and acceptability of psychological therapies in comparison with controls (treatment-as-usual, waiting list, attention placebo, psychological placebo, or non-psychological treatment) for treating anxiety and depression in children and adolescents with long-term physical conditions.

Search strategy: 

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 27 September 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). In addition, we searched the Web of Science (Core Collection) (12 October 2018) and conducted a cited reference search for reports of all included trials. We handsearched relevant conference proceedings, reference lists of included articles, and grey literature.

Selection criteria: 

Randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for treating anxiety or depression in children with long-term physical conditions were included.

Data collection and analysis: 

Abstracts and complete articles were independently reviewed by two authors. Discrepancies were addressed by a third author. Odds ratio (OR) was used for comparing dichotomous data and standardised mean differences (SMD) for comparing continuous data. Meta-analysis was undertaken when treatments, participants, and the underlying clinical question were similar. Otherwise, narrative analysis of data was undertaken.

Main results: 

Twenty-eight RCTs and one cross-over trial with 1349 participants were included in the review. Most participants were recruited from community settings and hospital clinics in high-income countries. For the primary outcome of treatment efficacy, short-term depression (versus any control), there was low-quality evidence from 16 trials involving 1121 participants suggesting that psychological therapies may be more effective than control therapies (SMD -0.31, 95% CI -0.59 to -0.03; I2 = 79%). For the primary outcome of treatment efficacy, short-term anxiety (versus any control), there was inadequate evidence of moderate-quality from 13 studies involving 578 participants to determine whether psychological therapies were more effective than control conditions (SMD -0.26, CI -0.59 to 0.07, I2 = 72%). Planned sensitivity analyses could not be undertaken for risk of bias due to the small number of trials that rated high for each domain. Additional sensitivity analysis demonstrated that psychological interventions specifically designed to reduce anxiety or depression were more effective than psychological therapies designed to improve other symptoms or general coping. There was some suggestion from subgroup analyses that they type of intervention (Chi² = 14.75, df = 5 (P = 0.01), I² = 66.1%), the severity of depression (Chi² = 23.29, df = 4 (P = 0.0001), I² = 82.8%) and the type of long-term physical condition (Chi² = 10.55, df = 4 (P = 0.03), I² = 62.1%) may have an impact on the overall treatment effect.There was qualitative (reported), but not quantitative evidence confirming the acceptability of selected psychological therapies for anxiety and depression. There was low-quality evidence that psychological therapies were more effective than control conditions in improving quality of life (SMD 1.13, CI 0.44 to 1.82, I2 = 89%) and symptoms of long-term physical conditions (SMD -0.34, CI -0.6 to -0.06, I2 = 70%), but only in the short term. There was inadequate low-quality evidence to determine whether psychological therapies were more effective than control conditions at improving functioning in either the short term or long term. No trials of therapies for addressing health-related anxiety were identified and only two trials reported adverse effects; these were unrelated to psychological therapies. Overall, the evidence was of low to moderate quality, results were heterogeneous, and only one trial had an available protocol.

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