GENERALIZED ANXIETY DISORDER
Chamomile May Be Effective for GAD
Everybody knows that chamomile tea is calming, or at least is supposed to be. But it had never been tested in a placebo controlled study, until now. A recent trial compared chamomile capsules to placebo in the treatment of 57 patients with mild to moderate generalized anxiety disorder. Active capsules each contained 220 mg of chamomile herb. Placebo capsules included inactive material and a drop of chamomile oil to provide the distinctive smell of chamomile and maintain the double-blind. Participants took one capsule daily during the first week, increased to two capsules during the second week, and could go up to five per day if they did not respond. At the end of the eight-week study, chamomile significantly outperformed placebo on the primary outcome measure (Hamilton Anxiety Rating Scale). There were no statistically significant differences on several secondary measures, though the measures numerically favored patients receiving chamomile; for instance, 57% of patients achieved a response to chamomile compared to 38% on placebo. There was no significant difference between chamomile and placebo in number of adverse events reported. There was a nonsignificant trend for resting pulse rate to decrease more in the chamomile group (5.2 bpm more) than in the placebo group (Amsterdam J et al., J Clin Psychopharmacol 2009; 29:378-382).
TCPR’s Take: Given the small sample size of 57 patients, it’s possible that chamomile’s good performance was a statistical artifact, and replication will be needed before we can confidently conclude that the herb is an effective GAD treatment. Nonetheless, it is harmless, and might well be helpful, so it is certainly worth recommending to your anxious patients who are not responding to usual treatment. Spectrum Pharmacy Products manufactured the chamomile capsules used in this study; it is not clear if other chamomile capsules or various forms of the herb (tea, oil, etc.) would work as well.
Long-Term Outcomes of Adolescent Depression Treatment
The treatment of adolescent depression has stirred much controversy in recent years. Many have raised doubts about the efficacy of both antidepressants and psychotherapy, and whether medications increase the risk of treatment— emergent suicidality is a divisive issue. Recently, the long-term results from the Treatment for Adolescents with Depression (TADS) study were published and they provide some guidance.
A total of 439 depressed adolescents were assigned to receive one of four treatments: a) cognitive-behavioral therapy (CBT); b) Prozac (fluoxetine); c) CBT + Prozac; or d) placebo. After 12 weeks of treatment, patients getting combined Prozac and CBT improved more than those assigned to other active treatments or placebo. The study was then extended beyond 12 weeks, although all treaments were unblinded and patients originally assigned to placebo were treated “openly” by researchers, meaning that they could choose whatever treatment they wanted. By week 36, all active treatments yielded the same overall remission rate of 60%, meaning that both CBT alone and Prozac alone “caught up” with combined treatment. After 36 weeks, all patients were switched to community treatment and were observed for one year. At the end of this follow-up period (nearly two years from the beginning of the study) about three-quarters of patients in all groups showed a treatment response and two-thirds of patients showed remission (TADS Team Am J Psychiatry; online ahead of print). One concerning finding was that patients receiving Prozac were most likely to show significant suicidal ideation or behavior (15% for fluoxetine, 8% for combined, and 6% for CBT; no completed suicides occurred).
TCPR’s Take: These results suggest that combining Prozac with CBT leads to the most rapid improvement in adolescent depression but that CBT or fluoxetine monotherapy eventually “catch up” in their efficacy. Also, adding CBT to treatment appears to protect against the suicidal ideation associated with Prozac treatment. Do these results extend to antidepressants other than Prozac? Maybe not, because trials of other antidepressants for pediatric depression have been unimpressive, with treatments showing little to no efficacy over placebo (Bridge JA et al., JAMA 2007;297:1683-1696). And Prozac remains the only medication with an FDA indication for depression in children.