Pharmacological management of childhood and adolescent anxiety disorders

Introduction Psychotropic medications were first studied in anxious children and adolescents in the late 1950s. Early studies evaluated antipsychotic agents and minor tranquilizers, but did not find them to be more effective than placebo (for review, see Reinblatt & Walkup, 2005). However, in the early 1970s the efficacy of tricyclic antidepressants (TCAs) for panic disorder in adults and adult reports of anxiety onset in childhood led to the first demonstrated efficacy of medication – TCAs – in anxious children (Gittelman-Klein & Klein, 1971). For the next 20 years few pharmacological treatment studies of anxious children were conducted. However, in the early 1990s the arrival of the selective serotonin reuptake inhibitors (SSRIs) and safety concerns with the TCAs (Riddle, Geller, & Ryan, 1993) led to a number of studies of SSRIs in childhood obsessive–compulsive disorder (OCD)(Geller et al., 2001, 2004; March et al., 1998; Riddle et al., 2001). Positive efficacy studies and a benign safety profile resulted in United States Food and Drug Administration (FDA) approval of fluoxetine, sertraline, and fluvoxamine for childhood OCD. With the success of the SSRIs in childhood OCD, studies focusing on the usefulness of SSRIs for separation, social, and generalized anxiety have been conducted subsequently (Birmaher et al., 2003; RUPP, 2001). Although the SSRIs have demonstrated efficacy for these conditions, these studies have not led to FDA approval. Given a solid evidence base for the acute efficacy and safety of SSRIs for OCD and other anxiety disorders (Ipser, Stein, Hawkridge, & Hoppe, 2009), future studies will focus on four main issues: (1) the long-term durability and safety of medication treatment; (2) strategies for non-responders or partial responders, (3) identification of predictors and moderators of pharmacological and psychotherapeutic intervention to help determine which treatment is best for whom, and (4) how long to treat a child before he or she can safely discontinue medication with minimal risk for relapse. This chapter is a guide for prescribing anxiolytics for children and adolescents focusing on SSRIs. The current evidence base for treatment will be reviewed, and the processes of prescribing to terminating treatment will be discussed.