Study Explores Drivers of Medication Hesitancy in Young Patients With Anxiety Disorders


Cognitive behavioral therapy and pharmacotherapy have been found equally effective treating anxiety disorders, yet some patients are less likely to begin medication treatment.

Certain populations are more hesitant than others to initiate medication treatment in children and adolescents with anxiety disorders when cognitive behavioral therapy (CBT) is unsuccessful, according to a study published in the Journal of Clinical Psychiatry.

The study noted that both medication and CBT are effective evidence-based treatments for anxiety disorders in younger patients. However, some patients are hesitant to opt for pharmacotherapy when CBT does not improve the condition.

The researchers, led by Jeffrey Strawn, MD, and Jeffrey Mills, PhD, of the University of Cincinnati, performed a reanalysis of the Child/Adolescent Anxiety Multimodal Study (CAMS). This large trial enrolled approximately 500 children and adolescents with generalized separation and/or social anxiety disorders.

CAMS indicated that CBT and pharmacotherapy are equally effective treating anxiety disorders; however, the combination of both treatments produced superior results.

As such, the investigators evaluated a subset of patients with anxiety disorders who did not improve with CBT. ​​They noted that the underlying mechanism driving patient decision-making on further treatment choices for anxiety was not explored in the CAMS trial.

“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,” Strawn said in a press release.

The investigators found that only approximately 10% of those whose conditions did not improve with CBT opted to initiate pharmacotherapy.

“What we did with this dataset 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.”

The researchers noted that racial and ethnic minority patients were 3 times less likely to initiate pharmacotherapy compared to white patients. Further, the study showed that younger patients were also significantly less likely to opt for pharmacotherapy.

The investigators found that parent and patient expectations regarding the efficacy of treatments predicted whether these patients would initiate pharmacotherapy.

“We were able to leverage more recently developed statistical methods to better model the relationship between medication uptake and patient characteristics,” Mills said in a press release. “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.”

The investigators said that the next step is to gain insight into why there is hesitancy to begin medication treatment.

They noted that anxiety expert Katherine Dahlsgaard hypothesizes that there is a “sell by” date in the course of CBT when patients will give up if they feel they are not improving. A potential strategy to address this medication hesitancy may be to explain the efficacy of pharmacotherapy for anxiety disorders.

The investigators said that patients in the CAMS study who opted to initiate medication after CBT was not effective experienced a significant improvement.

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


Strawn, J.R. et al. (2022) Initiation of pharmacotherapy following CBT in anxious youth: Results from the child/adolescent anxiety multimodal study (CAMS), The Journal of Clinical Psychiatry. Available at: Accessed December 8, 2022.

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