Learn about the pros and cons of the main categories of medications that clinicians typically use to treat anxiety in children and adolescents.
Dr. Feder: Anxiety is perhaps the most frequent symptom for which child psychiatrists are consulted. There are many medications to choose from, and clinicians have their different styles of working with this problem that vary depending on the situation. While selective serotonin reuptake inhibitors, SSRIs are generally considered the mainstay medications for anxiety, it's important to consider other options, particularly because of SSRI's potential for side effects. In this podcast, Mara and I will be discussing the pros and cons of the main categories of medications that clinicians typically use to treat anxiety in children and adolescents.
Welcome to The Carlat Psychiatry Podcast. This is a special episode from the child psychiatry team.
I'm Dr. Josh Feder, the editor in chief of the Carlat Child Report and co-author of this second edition of the child Medication Fact book for psychiatric practice.
Mara: And I’m Mara Governman, a licensed clinical social worker in Southern California with a private practice and an avid reader of Carlat reports.
Dr. Feder: So what we're going to do is we're going to talk through our recently published algorithm in that child medication Facebook for psychiatric practice and kind of give you our go-by of how we approach anxiety disorders.
Mara: Dr. Feder, can you summarize what disorders we're looking at here?
Dr. Feder: Well, it's a good question because in 2020, the American Academy of Child Adolescent Psychiatry released their clinical practice guideline. That's sort of the newfangled way of talking about the most recent research on anxiety disorders, and they were able to clarify that in the literature, there's really just four that we think about together this way. We're talking about social anxiety disorder, generalized anxiety disorder, separation anxiety disorder, and panic disorder. Those are the ones where we have some decent information that allows us to treat them kind of as a group in terms of how we think about them.
Mara: Do you have a short list to help a clinician who only has a few minutes to ask the poignant questions to direct the rule outs?
Dr. Feder: So, yeah, there's some great rating scales. There's the generalized anxiety disorder seven scale, the GAD7, the Yale, the children's, Yale Brown, obsessive compulsive scale CY box. I use that a lot. There's this screen for child anxiety related disorders or SCARED. And then there's the Suspense Children's anxiety scale the SCAS, the preschool version, which is also really helpful.
Mara: Do you then get a second assessment from parents as well?
Dr. Feder: So in getting history from kids about anxiety disorders, a lot of times they might present something different from the parents. Right. So we've talked about this before, I think in one of our podcasts where you might have a kid who says they're not anxious, but then when you get the observations from school, they're acting anxious. They're not participating in social activities, things like that, but they'll tell you in the office that they're just fine. So collateral information is really important. You can also get the opposite, where a child comes in and they say they're frightened, but then their behavior on the outside doesn't look frightened, so it gets a little bit confusing. And so when I'm taking a history, I might ask similar questions of the child and of parents and teachers. And when you get those conflicting reports as again, we've talked about. The answer to that isn't that they're not consistent, therefore, you don't believe somebody. The answer to that is to look more deeply into what might be going on. Why are these discrepancies there? Use it as a way to dig deeper, to try to find out what's going on.
Mara: So let's say we've come to a point where we have our diagnosis. What does the clinician do after that? What's the next steps?
Dr. Feder: Well, look, I mean, most of the people listening to this podcast are prescribers, but actually I try to be the surgeon who knows when not to cut. That's what my grandmother always said to me, and so before I start thinking about pills, I'm thinking about non pharmacologic type approaches. Psychoeducation, so helping people understand. What's going on? And trying to think about things like inadvertent accommodation with just being so empathic that the child's anxiety is actually getting worse. So it's not meaning that you need to be too tough with kids, but you need to recognize when you're soothing them and soothing them and soothing them, they may become more sensitized. Teaching things like diaphragmatic breathing is really, really important. If there's if there's a couple skills that we need when we're working with kids who are anxious, one is to have a plan of what we're doing, which we're talking about here. Another is to think about diaphragmatic breathing, also for ourselves when we're anxious. And then the third is to really kind of think about the facts of what's going on, kind of pick it apart.
Mara: And then we're also thinking about cognitive behavioral therapy as an additional treatment option.
Dr. Feder: Well, that's right. So the real question for these four conditions is what do you do first? CBT and SSRI or both? And the research says when you combine them, that's what's most effective. But that's not necessarily the cup of tea for a particular family. Some would rather have therapy than medication. Some would rather have medication than therapy. And so we kind of work with the child's assenting to what they're comfortable with and the family consenting to what works within their culture and values. That's really the heart of good informed consent in a world where there's evidence based practice, right? So you think about what are the studies showing what works? So we know that CBT or SSRIs work, that the combination is better. You let the family know that and then they get to make those choices based on what works for them as a family.
Mara: In my experience in working with children and adolescence, taking a deeper look at the relationship within the family and family dynamics are critically important to understanding what's happening with your patient as well as prescribing effective treatment programs that include parenting, co-parenting, and parent child relationships. And I wonder how that impacts what you're thinking about and prescribing to your clients?
Dr. Feder: Well, prescribing as something that affects everybody psychologically, the meaning to say, oh, I've got something for which I need a medication that's kind of a big deal. And so, depending on parenting styles, you might end up with fights over whether the child is going to take the pill or wants to take the pill. Or alternatively, you may have people really counting on the medication to work right away when it can take, you know many weeks to see anything happening, as usual, with SSRI's in particular. But let's say they go with an SSRI, what are we talking about? Fluoxetine, maybe sertraline, escatalopram. Those are the ones with the research. And by the way, we should be talking about the FDA's lack of approval for marketing for these conditions. The only ones that really have the FDA approval, for OCD are fluoxetine, sertraline and fluvoxamine. So just know that what we do as usual in child psychiatry is a lot of off label work. And what do you watch out for SSRI's? We watch for behavioral activation and we also screen for new onset suicidality, which may happen about 1% of the time.
Mara: What happens if you give an SSRI and it doesn't work? Then what?
Dr. Feder: Well, I'll tell you if you're not already doing CBT, then you add CBT. You can also try a different SSRI because you have a decent chance on the second run or the third, that it will work. Same thing with CBT. If CBT doesn't work well, that's when you're thinking can we add an SSRI? That might be a good thing and if you've done that then it doesn't work well, then you're trying another SSRI.
Mara: What happens if you've done CBT, you've added your SSRI and then you've tried a different SSRI and you've determined it's ineffective. Then what?
Dr. Feder: Well, then you have to think about the differentiation between these four disorders we're talking about. If it's a generalized anxiety disorder, then that's a good time to try Buspirone because that may well work. If it's not a generalized anxiety disorder, then we might go to an SNRI, a serotonin, norepinephrine reuptake inhibitor. To be honest, the research on efficacy for these is poor, but there are certainly cases that respond and so it's then worth a try. What are the side effects we watch out in addition to the usual ones from SSRIs with SNRI? We worry about withdrawal if you miss a dose, you can feel pretty awful. So they're not my favorite medicines. But that would probably be the next line. Same thing if the Buspirone doesn't work and it is generalized anxiety disorder. Then my thought is OK, try an SNRI and go from there.
Mara: And what if that doesn't work?
Dr. Feder: You know, here we're getting down to the tricyclic antidepressants. Right? So maybe imipramine or clomipramine, especially for OCD, is when you end up using a lot of clomipramine, but either of those might be helpful. And remember, with TCAs you need to check an EKG before and during treatment because you can get risk for torsades de pointes, which would be bad and you got to lock up those medications supplies due to the toxicity and overdose.
Mara: What about weight and blood pressure?
Dr. Feder: Oh, that's true. For TCA's we do watch blood pressure and pulse, you can get a little bit hypotensive, so do check those. You can get a little bit of an appetite actually with every medicine we've talked about so far today except for Buspirone. Any of them can you know, make you crave carbs. So that's a thing and we may need to be thinking about diet and exercise. In fact, now that you mentioned it, that's something that should go up with those non pharmacologic treatments in the 1st place. Exercise alone sometimes helps people do a lot better through the day.
Mara: You've tried a tricyclic and it doesn't work, now what?
Dr. Feder: Yeah, you're just beating me up here. OK, so that happens. And that's when we go maybe to anti epileptic drugs, anticonvulants. Valproate, gabapentin, topiramate, any of those might work, they're all very different, as people know. Valproate, you've got to get blood levels, you want to be careful. Anybody who you think ever will want a baby you might not want to give them valproate because it's associated with menstrual irregularities and also, with Polycystic ovary syndrome, things like that. Gabapentin, it's hard to know the dosing. What is it, 100? Is it gonna be 3600? It can be hard to find the dose. Rarely people get a little bit addicted to that. So that's a thing, but it's often helpful for anxiety. And then topiramate, you know, Topamax also known as. Dopamax right. So you've got to go up pretty slowly on it, but at the same time, it could be pretty helpful. One other note about topiramate, that's one of the few medicines we have where people tend to crave fewer carbs than more. So that's something to keep in mind when you're thinking about all these medicines that people are on.
Mara: So how often do you recommend a check in with your clients when you're starting a treatment plan like this?
Dr. Feder: So I like to see people within one to two weeks of starting a new medication or making a significant medication change. I know the reality out there is that sometimes people don't get in as soon as you'd like. I end up on the phone with them a little bit. If you've got the permission to do telehealth sometimes, checking them that way, but you need to watch these things relatively closely.
Mara: All right, so you've tried anticonvulsants and they don't work. Now what? What's your next step?
Dr. Feder: You know at the end of the line is where I would start thinking about second generation antipsychotics, right. And so there's a lot of thinking now that we have about how to use those and we prefer to use weight sparing ones like lorazidone or ziprazidone, if we can. If you've got a BMI that is somewhere between 25 and 30, and if you're trying to use something other than those, then we would suggest you consider pairing that with metformin to prevent weight gain. And if somebody has a BMI over 30, you might even think about a GLP- 1 agonist paired with it to prevent weight gain as well. So newfangled, and it might be hard to get the insurance to pay for it, but we want to try to prevent some of those other potential side effects from the SGAs. They work pretty well, it's just that we put them at the back because of the potential for metabolic changes and of course neurotoxicity.
Mara: How long do you anticipate having your patients on these medications?
Dr. Feder: It's a great question. So if somebody stable for two to six months and hopefully they're also doing more in their life, right? And maybe they're in CBT or some other therapy. That's what I would consider a very gradual taper and discontinuation of any of these medications. So get people going, get them stabilized, and then see if you can very gently reduce. We don't have numbers on long term use of these medications necessarily being effective. We have plenty of kids who seem to “grow out of their dose” and we increase it, but really, let's see if we can't treat and move on. Getting people moving on with their lives, getting them to have more positive experiences. That would be the ideal.
There are some other caveats about these medications. Again, just as reminders, use non pharmacologic approaches first when possible to help reduce the use of medication. If you're using antidepressants, discuss the potential for side effects, including the rare but possible increase in behavioral activation or suicidal thinking. If you do end up using the antipsychotics, check weight and labs like lipids and hemoglobin A1C, and others as indicated at baseline at 12 weeks and annually or sooner if indicated, and check for abnormal and voluntary movements at baseline in every six months or sooner, and consider getting an EKG at baseline and yearly or sooner as well.
The bottom line is that when developing a treatment plan for a child or adolescent suffering from an anxiety disorder, weigh the potential benefits and risks of each pharmacological and psychotherapeutic treatment option within the unique context of each patient's clinical presentation. SSRIs and adjunctive therapies are generally the preferred first line medication.
In this episode, we discussed the use of off-label treatments and we want to express that, as clinicians, we need to do our due diligence before prescribing these off-label interventions. Although everything discussed in this episode is evidence-based, the presented information should not be interpreted as comprehensive. Please do your own research and stay on top of the most recent studies in child and adolescent psychiatry. Make sure to thoroughly discuss side effects with patients and their families. Most importantly, consider each treatment option with the context of your patient's unique presentation; studies often have stringent inclusion criteria which reduces the generalizability of findings to real-world patients with psychiatric and/or other medical comorbidities.
The algorithm is available for people to read in the Carlat Medication Fact Book for Psychiatric Practice, second edition.
Hopefully you'll get a copy of it and check out all our algorithms. For those of you who are Carlat Child Psychiatry report subscribers, you'll get print issues in the mail and e-mail notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website, and CME credits, which support the algorithms that we talked about today.
Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust.
Mara: Thanks for listening and have a great day!