The presentation of anxiety in children and adolescents was discussed in last week’s e-Weekly. This e-Weekly will focus on treatment for anxiety disorders in pediatric populations, as many patients first present to their primary care providers for assessment and treatment.
Treatment options primarily involve therapy and/or medication. For patients presenting with mild-moderate anxiety symptoms, a therapy approach first is preferred, with a plan to incorporate medication if the therapy is not effective or symptoms worsen. For patients with moderate-severe anxiety symptoms with significant impairment on daily functioning, it might be warranted to consider starting with a combination of medication and therapy. The key message is that therapy is the important component to treatment of anxiety disorders in pediatric patients, and medication can be an effective adjunctive treatment if needed. Therapy to address anxiety can easily be tailored to work with very young patients and is very effective in a dyadic format . Types of therapy used for anxiety disorders include: cognitive behavioral therapy, exposure response prevention therapy, and relaxation techniques, among others. It would be important to refer to a therapist who is well versed in treating anxiety in children and adolescents.
Now we will focus on the medications used to treat anxiety. They fall into two general categories: medications to treat the underlying anxiety and prevent future symptoms of anxiety and medications that treat acute symptoms, like a panic attack. In most cases, if a primary care provider is considering medication treatment for anxiety in a young patient, it will be from the first category. This category includes medications like the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazipine, and buspirone. The SSRIs are the first line agents for this population. This class includes: fluoxetine, citalopram, escitalopram, sertraline, fluvoxamine, and paroxetine. Just like with treating depression, the medication can take 4-6 weeks to see the positive effective. Often a higher dose is needed to fully treat the anxiety symptoms compared to depressive symptoms. There is a motto to “start low and go slow” to limit increasing anxiety and causing activation during the titration process. So, for example if one is considering prescribing citalopram for anxiety for a 10 year-old patient, consider starting at 5 mg qday for one week then 10 mg qday for 1 week then 20 mg qday and assessing the response. Some patients experience akathisia (internal feeling of restlessness), which can feel like a worsening of their anxiety, if the dose is titrated too quickly. Other side effects include sleep disturbance, GI upset and headache but most of these symptoms resolve over time.
The treatment of anxiety disorders in pediatric patients is mostly off label. Only fluoxetine (ages 7+), sertraline (ages 6+) and fluvoxamine (ages 8+) have FDA approval for treatment of obsessive-compulsive disorder (OCD).
When prescribing any antidepressant medication to treat anxiety, it is important to review the FDA black box warning about the increased risk of spontaneous reporting of suicidal thoughts, even if the medication is not being prescribed to treat depression per se.
When deciding on medication treatment, it is standard practice to first use the SSRIs. If a patient has 2 or more adequate (in terms of dose and length of treatment) trials of SSRIs that are ineffective, one could consider an alternative, either an SNRI (venlafaxine or duloxetine) or mirtazipine. If there is some benefit from the SSRI, one could consider augmentation with mirtazipine or buspirone. The primary side effects to be concerned with mirtazipine include sedation and increased appetite. Buspirone has an onset of action of about 2 weeks. The primary side effects to be concerned with include: dizziness, fatigue and GI upset. Occasionally the atypical antipsychotics are considered as adjunctive treatment to treatment-resistant OCD.
The medications that treat acute symptoms of anxiety, like the benzodiazepines, are rarely used in this population. Pediatric patients can have a paradoxical reaction to benzodiazepines and exhibit behavioral disinhibition. Other side effects include: physiological and psychological addiction, confusion, sedation and impaired fine motor coordination. If a medication to treat acute anxiety is needed, for example for a teenager who has very occasional panic attacks, one could consider hydroxyzine 25-50 mg on a prn basis (available in 10mg tablets as well for younger patients), which is not associated with dependence. Side effects include: sleepiness, dizziness, and dry mouth.
It is important for primary care providers to be comfortable assessing anxiety symptoms and helping to establish a treatment plan for their pediatric patients. Sometimes rating scales can be helpful in the assessment process. Here is a useful screening tool with a child version and parent version:
http://www.midss.org/sites/default/files/scaredchild1.pdf
http://www.midss.org/sites/default/files/scaredparent1.pdf
Hopefully this series of articles has been a helpful tool to establish a level of comfort to assess and treat anxiety syndromes in the primary care setting.