Psychopharmacology for Pediatric Anxiety Disorders

Anxiety disorders are among the most common mental health disorders of childhood and adolescence. The first-line treatment for moderate to severe anxiety disorders is cognitive behavioral therapy in combination with antidepressant medications. Selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) are the medications of choice and are well tolerated. While all medications in this class are likely effective, they may not all be equally effective for an individual child. Further studies are needed to guide medication choice to precisely match patients to the most effective and tolerable SSRI or SNRI. Other medications have been studied in childhood anxiety disorders, but none have demonstrated as much safety and efficacy as the SSRIs and SNRIs. Tricyclic antidepressants (TCAs), while effective, are less well tolerated than the SSRIs and SNRIs. Benzodiazepines (BZDs), while commonly used short-term across the age span, have not demonstrated efficacy in long-term treatment of pediatric anxiety. Other medications commonly considered to have antianxiety properties, such as buspirone, antihistamines, alpha agonists, and propranolol, lack positive high-quality or any high-quality studies supporting their efficacy. Other antidepressants, such as mirtazapine and vortioxetine, may be effective based on their mechanism of action but have not been studied in youth and, thus, are clearly second-line. This chapter reviews information that helps guide specific medication choices, including quality of evidence for medication efficacy and safety as well as approaches to partial, full, and no response; side effect; and polypharmacy management.