pidemiologic studies have consistently shown that anxiety disorders often are the most common mental health diagnoses in children and adults. Moreover, anxiety disorders are frequently comorbid with other primary diagnoses such as depression, bipolar disorder, attention-deficit/hyperactivity disorder, and substance abuse. In this issue of the Journal, 3 original studies focus on anxiety in youth using quite distinct approaches: Copeland and colleagues (p. 21) looked at data from the Great Smoky Mountains Study to examine the longitudinal course of anxiety symptoms. Children from rural counties in North Carolina have been followed for almost 20 years in this study. One of the key questions addressed by the investigators was whether individual anxiety disorders should be grouped as a broad anxiety category in children or whether there were benefits in considering their course and outcome separately. Their results showed that the overall prevalence of anxiety followed a U-shaped curve, with a sharp decrease in middle childhood followed by an increasing prevalence of any anxiety disorder diagnoses in early adolescence. However, no individual anxiety disorder explained the Ucurve; rather, distinct diagnoses produced different developmental curves, with some forms of anxiety more prevalent at younger ages and rare later in life (e.g., separation anxiety) and vice versa (e.g., panic, agoraphobia). Moreover, cumulative comorbidity curves showed that anxiety disorders overlapped with one another and with other disorders. Once again, individual diagnoses had distinct comorbid patterns, with social and specific phobia having a high degree of overlap, whereas generalized anxiety overlapped more commonly with depression. The modest overlap between the anxiety disorders and the dramatic increases in rates of anxiety during the transition from adolescence to adulthood found in this study have clear implications for future research in this area. Sala and colleagues (p. 72) examined the role of comorbid anxiety in bipolar disorder. Using data from the Course and Outcome of Bipolar Youth Study, a large longitudinal study of youth 7 to 17 years old who met criteria for bipolar

disorder and were followed for about 5 years, the investigators reported that anxiety not only is highly comorbid with bipolar disorder but also affects its outcome: of the more than 400 youth assessed, 62% met diagnostic criteria for at least 1 anxiety disorder and 50% for more than 2 disorders at some point of follow-up, with separation and generalized anxiety disorders as the most prevalent. Moreover, youth with anxiety showed significantly higher rates of recurrence after recovering from the index affective episode and spent less time asymptomatically during followup. These findings bring forth a challenging clinical decision, because the main pharmacologic treatment for anxiety (i.e., selective serotonin reuptake inhibitors) may trigger mood instability in bipolar youth. Psychotherapy trials are sorely needed for this population. Indeed, in this issue Shechner and colleagues (p. 61) present a randomized clinical trial of a novel, computer-based treatment modality for anxiety disorders: attention bias modification treatment (ABMT). Anxiety usually involves an excessive vigilance toward minor threats, and ABMT aims to modify this by altering implicit and involuntary attention biases. Because ABMT and cognitive-behavioral therapy (CBT) target different aspects of anxiety and may be complementary to each other, Shechner and colleagues examined whether CBT combined with ABMT would provide a greater decrease of anxiety symptoms than CBT alone. Fifty-five participants completed the trial, which included a placeboABMT condition. The results suggest that active and placebo ABMT augment the response to standard CBT, but with only the active ABMT group showing a significant decrease in self-/ parent-rated anxiety symptoms. Aman and colleagues (p. 47) report a multisite, double-blinded, placebo-controlled clinical trial confirming the efficacy of risperidone as augmentation to stimulants and parent training for children with attention-deficit/hyperactivity disorder and aggressive behaviors. Given that concomitant pharmacotherapy is often a clinical reality in these children, this study addressed an important and common treatment combination.




ABSTRACT THINKING How Do We Know What We Know? Cautionary Tales in Medical Publishing deally, new medical practices should become the standard of care if they have good evidence of clinical superiority to older practices. When better designed studies contradict standard practice, a reversal of medical practices that do not work is a necessary and welcomed change, although it is unsettling to see how often this occurs. Prasad et al.1 examined the frequency of medical reversals from 2001 to 2010 within a single but high-impact medical journal, the New England Journal of Medicine. Of all studies that tested an existing medical practice, 40.2% found it ineffective compared with a previous standard. Importantly, studies that tested new practices were more likely to find them beneficial than studies that tested existing ones, a concerning trend in medical research. Some practices reversed in the past decade included routine hormonal therapy in postmenopausal women and arthroscopic surgery of the knee for osteoarthritis. Many reversals have followed a similar path: a vocal and prominent group advocates for a certain practice based on initial evidence, which is supported by what seems to be a sound mechanism of action. Future trials show the therapy to be ineffective, but changing already established practice standards is often challenging. The New England Journal of Medicine is a prestigious journal, and many findings that were later reversed came from high-quality studies subjected to scrupulous peer review. The same cannot be said about many of the open-access journals created in recent years. In a clever investigative piece published in Science,2 a team led by John Bohannon created a spoof article purportedly showing anticancer properties of a compound extracted from lichen. The article was profoundly flawed, and any credible peer reviewer should


have rejected it. Bohannon submitted versions of this article to 304 open-access journals and, unfortunately, full acceptance was the norm: 157 of the journals accepted the article, with about 60% of the final decisions occurring with no sign of peer review. These journals benefit from the fees paid by the authors when their articles are accepted for publication, generating a perverse incentive. Open access, although a sound academic ideal, has multiplied the number of journals with poor quality control, making it challenging to find good-quality data among all the noise. Beyond good peer review, reporting guidelines can improve the quality of the trials being published and thus enhance the usefulness of the randomized controlled trials. The Consolidated Standards of Reporting Trials (CONSORT), adopted by the present Journal, has proposed an extension for Social and Psychological Interventions.3 This project aims to improve several aspects of internal validity that are unique in child psychology and psychiatry trials. Improving the quality of the evidence we produce and publish is key to make sure that what we know is indeed worth knowing. Roberto B. Sassi,


McMaster University Hamilton ON, Canada

The author thanks Samuele Cortese, MD, PhD, of the New York University Child Study Center, for his edits and thoughtful suggestions. Disclosure: Dr. Sassi has received research support from the National Alliance for Research on Schizophrenia and Depression, Hamilton Health Sciences, the Canadian Institutes for Health Research, the March of Dimes, and the McMaster University Department of Psychiatry and Behavioural Neurosciences Alternate Funding Plan award. He has served as a consultant to and on the advisory board for BristolMyers Squibb and has received speaker honoraria from Bristol-Myers Squibb, Janssen, and AstraZeneca.

REFERENCES 1. Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;88:790-798. 2. Bohannon J. Who’s afraid of peer review? Science. 2013;342:60-65.

3. Gardner F, Mayo-Wilson E, Montgomery P, et al. Editorial perspective: the need for new guidelines to improve the reporting of trials in child and adolescent mental health. J Child Psychol Psychiatry. 2013;54:810-812.




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