Pediatric Anxiety Disorders: What's the Best Approach?

Data suggests that SSRIs and SSNRIs are well tolerated and beneficial for fear-based anxiety among youth
Data suggests that SSRIs and SSNRIs are well tolerated and beneficial for fear-based anxiety among youth

An Opinion Statement published in Current Treatment Options in Psychiatry concluded that based on current data, selective serotonin reuptake inhibitors (SSRIs) and and selective serotonin norepinephrine reuptake inhibitors (SSNRIs) are effective in the treatment of pediatric anxiety disorders in addition to some forms of psychotherapy (eg, cognitive-behavioral therapy [CBT]).

Researchers reviewed recent psychopharmacologic studies of youth with anxiety disorders, including generalized anxiety disorder, social phobia/social anxiety disorder, panic disorder, and mixed anxiety disorders. They searched randomized, controlled trials of SSRIs, SSNRIs, benzodiazepines, and atypical anxiolytics.  

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Existing data suggests that SSRIs and SSNRIs are well tolerated and beneficial for fear-based anxiety disorders (eg, generalized anxiety disorder, social phobia/social anxiety disorder, and separation anxiety disorder). The beneficial effects of these drug classes in pediatric anxiety disorders are consistently increased with the addition of psychotherapy, especially in those with social anxiety disorder. 

While there are no randomized clinical trials regarding a severity-based treatment algorithm, expert opinion suggests that pharmacotherapy be reserved for patients with moderate to severe anxiety. An SSRI is considered a first-line intervention but a switch to another SSRI or SSNRI may be considered for patients who experience persistent symptoms despite titration of the drug and optimization of psychotherapy. In regards to cross-titration of antidepressants, an overlap in administration of the two medications is preferred. 

Some key factors, including male sex, younger age, non-minority status, and better family functioning predicted greater symptomatic improvement in youth with fear-based anxiety disorders. In contrast, older age and having a first-degree relative with an anxiety disorder predicted poorer outcomes. 

The American Academy of Child and Adolescent Psychiatry recommends multimodal treatments for youth with generalized anxiety disorder, social anxiety disorder, and separation anxiety disorders. Greater improvements may be seen when combining CBT and an SSRI compared to what is expected with either treatment as monotherapy, the authors concluded. Since some youth may show partial response to current drug therapies, possible adjunctive therapies may include benzodiazepines, antihistamines, and others.

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