Review of: Bushnell GA et al, J Clin Psychiatry 2018;79(1):pii:16m11415

Anxiety disorders are some of the most common conditions we encounter in children and adolescents, and clinicians employ a variety of medications to treat them. This study examined prescribing patterns for the initial treatment of pediatric anxiety.

Researchers analyzed a large commercial claims database for information on patients ages 3–17 years who were diagnosed with an ICD-9 anxiety disorder (including OCD and PTSD) and started on an anti-anxiety medication between 2004 and 2014.

Overall, a majority of the 84,500 medicated patients were older teenagers, with 58% being 14–17, and 58% were female. Half of the patients (50%) were diagnosed with unspecified anxiety disorder. More than half received both a diagnosis and a prescription on the same day (57%). While 41% of patients had attended a psychotherapy session within the 30 days prior to medication initiation, it is unclear if the rest had seen a therapist in the past or were referred to one while being started on medications.

Unsurprisingly, most children were started on an SSRI (70%), while some received benzodiazepines (11%), hydroxyzine, guanfacine/clonidine, an atypical antipsychotic, or an antidepressant/antianxiety medication combination (3%–5% each). Children with OCD and selective mutism were more likely to be given SSRIs (83% and 82% respectively) as compared to those with panic disorder (54% SSRI, 30% benzodiazepine) or PTSD (53% SSRI, 14% atypical antipsychotic). Almost a third of children with no other recent psychiatric comorbidity were prescribed a non-SSRI. When compared to psychiatrists, primary care providers were more likely to prescribe non-SSRIs to kids with panic disorder and social phobia.

In a promising trend, across the decade of the study period, teens ages 14–17 were more likely to be started on SSRIs (55% in 2004 vs 65% in 2014) and less likely to be started on benzodiazepines (20% in 2004 vs 10% in 2014). SSRIs were more likely to be refilled after the first prescription (81%) as well as continued for at least 6 months (55%) as compared to benzodiazepines (25% and 5%) or atypical antipsychotics (71% and 41%). Moreover, almost a quarter of those who were initiated on benzodiazepines or atypical antipsychotics eventually got a prescription for an SSRI within 3 months.

CCPR’s take
Frequency of prescribing does not imply best practice for everyone. While SSRIs are the most commonly prescribed medications with the lowest discontinuation rates in this study, antipsychotics came second, and both have potentially significant side effects in context of a paucity of evidence-based research independent of manufacturer-sponsored studies, the lack of FDA support notwithstanding. It is good to see reductions in benzodiazepine use, as they have few truly legitimate indications (surgery, catatonia) and their potential short- and long-term risks in children and adolescents almost always outweigh their immediate benefits. Although devoid of FDA approval, medications like propranolol, hydroxyzine, and guanfacine/clonidine have an important role to play in mitigating acute anxiety episodes, as well as anxiety stemming from trauma, while minimizing risk of long-term adverse effects like metabolic syndrome.

Lastly, as AACAP guidelines note, psychotherapy should be the first-line treatment, with medications considered in cases of moderate to severe anxiety or a lack of response or access to psychotherapy. Unless children and youth are equipped with anxiety management techniques, family and/or school interventions that reduce any relevant stressors, and psychotherapy that deals with underlying ­anxiety-provoking memories and schemata, then cessation of pharmacotherapy—even if partially or fully effective—is more likely to lead to relapse.