The Role of Comorbid Mood Disorders in Cognitive Behavioral Therapy for Childhood Social Anxiety

Cognitive Therapy and Research https://doi.org/10.1007/s10608-022-10312-1 ORIGINAL ARTICLE The Role of Comorbid Mood Disorders in Cognitive Behavioral Therapy for Childhood Social Anxiety Jeanine M. D. Baartmans1,2 · F. J. A. van Steensel3 · Anke M. Klein2 · Susan M. Bögels3 Accepted: 24 May 2022 © The Author(s) 2022 Abstract Background Children with a social anxiety disorder have worse treatment outcomes after Cognitive Behavior Therapy (CBT) than children with other anxiety disorders. Anxiety disorders and mood disorders are strongly related and especially social anxiety is related to high comorbidity rates with mood disorders. The aim of the study was to investigate how comorbid mood disorders are related to treatment outcomes after CBT and whether this can explain the worse outcomes for childhood social anxiety. Methods Participants were 152 referred clinically children (7–18 years) with either a social anxiety disorder (n = 52) or another anxiety disorder (n = 100) of whom 24.3% (n = 37) had a comorbid mood disorder. Child anxiety, internalizing symptoms, and quality of life were measured pre-treatment, post-treatment, 3 months and 1 year after treatment, using child and both parents’ report. Results Children with a primary social anxiety disorder more often had a comorbid mood disorder than children with another primary anxiety disorder. Children with a mood disorder had more severe anxiety problems before treatment. Comorbid mood disorders were related to greater anxiety reductions after treatment. The worse outcomes for children with a primary social anxiety disorder remained after controlling for comorbid mood disorders. Conclusions Findings stress the importance of future studies examining why the presence of a comorbid mood disorder is associated with greater anxiety reductions, and other factors that explain the worse treatment outcomes found for childhood social anxiety disorder. Keywords Social anxiety · Depression · Children · Comorbidity · Treatment outcome · CBT Introduction Anxiety disorders are common in childhood and adolescence with an estimated prevalence ranging up to twenty percent (American Psychiatric Association, 2013). Children who suffer from anxiety disorders often have comorbid mood disorders (Brady & Kendall, 1992; Cummings et al., 2014). It has even been debated that anxiety and depression should * Jeanine M. D. Baartmans 1 UvA Minds: Academic Treatment Centre, Amsterdam, The Netherlands 2 Department of Developmental Psychology, University of Amsterdam, Nieuwe Achtergracht 129‑B, 1018 WS Amsterdam, The Netherlands 3 Department of Child Development and Education, University of Amsterdam, Amsterdam, The Netherlands be seen more as unitary than as discrete problems (Persons et al., 2003), as the disorders seem to have comparable developmental features, the symptoms partly overlap and symptoms correlate highly with each other (e.g. Erwin et al., 2002; Wright et al., 2010). Clark and Watson’s (1991) tripartite model is a theoretical model to explain the overlap between anxiety and depression. In this model anxiety is characterized by high levels of physiological hyperarousal and depression is characterized by low levels of positive affect. A negative affect (which can also be described as emotional distress) is a characteristic of both anxiety and depressive disorders. Perhaps not very surprising, it has been noted that having a comorbid mood disorder in addition to an anxiety disorder can be related to treatment outcomes for both the anxiety and depressive symptoms in adults (e.g., see review of Bauer et al., 2012). For children and adolescents, comorbidity with a mood disorder could increase the severity of the (anxiety) symptoms 13 Vol.:(0123456789) Cognitive Therapy and Research and is related to the presence of other comorbid symptoms like somatic problems and attention problems (e.g., see review of Melton et al., 2016). In addition, having a comorbid mood disorder is also related to less involvement in out of school activities and worse relations with peers (Franco et al., 2007). However, the empirical evidence for a less favourable treatment outcome for children with anxiety disorders and comorbid mood disorders is inconsistent. That is, some studies found that the presence of a comorbid mood disorder (or depressive symptoms) is related to less favorable treatment outcomes (Berman et al., 2000; Ollendick et al., 2008; O’Neil et al., 2010; Rapee et al., 2013), whereas other studies found no relation between comorbid mood disorders (or depressive symptoms) and treatment effectiveness for childhood anxiety (Kendall et al., 1997; Southam-Gerow et al., 2001). A more robust finding is that previous studies do demonstrate that children with a social anxiety disorder have less favorable treatment outcomes compared to children with other anxiety disorders (Compton et al., 2014; Crawley et al., 2008; Evans et al., 2021; Ginsburg et al., 2011; Hudson et al., 2015a, 2015b; Kodal et al., 2018; Manassis et al., 2002; Scharfstein & Beidel, 2011; Waters et al., 2018). The question that remains to be answered is why social anxiety disorder is related to a lesser treatment effect. One factor to consider is the presence of comorbid mood disorders (which seems to occur more frequently in children with social anxiety disorders; Hudson et al., 2015a). Only a few studies focused on the role of comorbid mood disorder on treatment outcome specifically for children with social anxiety disorder. Hudson et al. (2015a) conducted a large multisite study in which they compared treatment outcomes after Cognitive Behavioral Therapy (CBT) for different anxiety disorders and found that treatment outcomes for children with social anxiety disorder were worse also after controlling for comorbid depression. Also, Alfano et al. (2009) investigated depression as a moderator of the treatment for social anxiety in children and adolescents and found that depressive symptoms did not moderate treatment effects of CBT for childhood social anxiety. Turning back to the Clark and Watson’s (1991) tripartite model, this model was originally developed to describe the overlap between anxiety and depression in adults, however, it is also applicable to youth (Laurent & Ettelson, 2001). Therefore, it might be helpful to look into studies with adult participants. Some studies involving adults found worse outcomes after treatment when patients with a social anxiety disorder had a comorbid mood disorder or that patients had a higher chance of aggravation in social anxiety symptoms after treatment finished (Chambless et al., 1997; Erwin et al., 2002; Ledley et al., 2005), while other studies using adults samples found no relation between depression and treatment outcomes (Marom et al., 2009; Moscovitch et al., 2005). One 13 important aspect that was noted was that the majority of the studies relied on dimensional measures of depression instead of mood disorder diagnoses (Ba (...truncated)