Anxious About the Next Step: Treatment of Teens that Fail SSRI's

-written by Joshua Stein, MD
 
The initial steps in managing a variety of anxiety disorders in teenagers is initiation of an SSRI.  Commonly this class of medications can result in symptomatic improvement with initial notable benefits occurring at 6-8 weeks with additional improvement over time.  At times, the medications do not appear to work or are not tolerable.  The following considerations would be appropriate if SSRI’s do not appear to be the correct option.

1. Is the dose high enough? At times, SSRI trials for anxiety do not reach the appropriate dose, out of concern to keep doses minimal. Please consider, if tolerable, reaching the following doses before giving up on a trial.
   1. Zoloft 100 mg
   2. Lexapro 10 mg
   3. Prozac 20 mg
   4. Celexa 40 mg
   5. (Paxil is not indicated in teens/children)
2. If there is a partial, but not full response at the above doses, consider going higher.
3. If higher dosing is not tolerable, consider augmentation.
   1. Buspar 10 BID at times can benefit anxiety.
   2. Wellbutrin XL 150 to 450 mg can be beneficial.
   3. Low dose second generation atypical augmentation can be beneficial especially in OCD
4. Change classes. Consider a cross titration to Cymbalta/Duloxetine.    It carries an FDA indication for GAD in children 12 and up.  A common starting dose is 30mg.  The introduction of an SNRI offers a novel treatment that often provides substantial benefit when SSRI trials fail.
5. Consider symptomatic relief.  At times, as needed or scheduled hydroxyzine, propranolol, gabapentin or rarely a benzodiazepine can offer immediate relief from panic or catalyze long term treatment.
6. Do not ignore the need for therapy. Anxiety of all kinds is often built upon a foundation of automatic negatives, catastrophic ideations and other problematic misconceptions.   Therapy requires effort, but also leads to long term success that can be generalized. GAD, OCD and social anxiety disorder require therapy, commonly CBT.
7. Call PAL.  We love hearing from, and brainstorming, with other physicians and providers.