Best practices for prescribing medication
More and more, pediatricians are called on to treat symptoms of anxiety and depression. Here’s what to do before prescribing.
Anxiety and depression were relatively common in children and adolescents before the COVID-19 pandemic1; not surprisingly, study findings suggest that these conditions’ prevalence has increased.2 Typical support systems for children and adolescents—friends, family, school, and extracurricular activities—look much different during the current pandemic. With these factors in mind, it is reasonable to consider the question of when to use medication to help alleviate these symptoms. Medication can be extremely helpful, but several considerations are important prior to prescribing.
Be clear about the diagnosis
The first step: Take a thorough history, supported by diagnostic questionnaires. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides diagnostic criteria that form a road map for taking histories.3 In general, medication is reserved for the diagnosis of an actual disorder, such as major depressive disorder or anxiety disorder.
Medication for depression is typically considered when a diagnosis of major depressive disorder is warranted and symptoms are in the moderate range4; according to DSM-5, symptoms of depression must be present for 2 or more weeks and negatively affect a child’s level of functioning.
DSM-5 describes a number of anxiety disorders, but all have a similar theme: significant levels of worry, with accompanying behavior change, that impair functioning and cause significant distress and have been present for 6 or more months.3 Generalized, social, and separation anxiety disorders are some of the more common types in the pediatric population.
The presenting symptoms of anxiety disorders and major depressive disorder—irritability, low mood, sadness, and worry—can also occur with other conditions that can be discerned by a comprehensive history. Disturbances in sleep and nutrition can contribute to these types of symptoms and also be disrupted when depression or anxiety disorders occur. Other important aspects of the history include questions about trauma, abuse, and other potential stressors that can mimic or exacerbate depression and anxiety. Substance use can also present similarly and may co-occur, sometimes due to an effort to alleviate underlying symptoms.
Consider nondrug approaches
In many cases, pediatricians see patients with symptoms of depression or anxiety that don’t rise to the level of major depressive disorder or an anxiety disorder. In those situations, nonpharmacologic interventions should be considered. Even though a prescription may not be indicated, a pediatrician can take several steps to support patients who are struggling with these symptoms. Offering hope, empathy, partnership, and other communication strategies have been shown to improve care.5 Statements such as “What you’re going through sounds really hard” and “I’m confident that we can figure out a plan together to help you feel better” can be therapeutic. Talking with families to identify stressors and brainstorming ways to reduce them can help make overwhelming problems seem more manageable and provide a sense of control over difficult situations.
Referral for counseling should be considered and is typically recommended prior to the use of or, for more moderate to severe symptoms, in conjunction with medication. Cognitive behavioral therapy helps children and adolescents recognize negative thinking patterns and engage in behavioral change to improve their mood or reduce worry. Having an embedded mental health professional in the office can help reduce barriers to care.
Choosing the right medication
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for anxiety or depression.6 Four medications in particular— fluoxetine (Prozac), escitalopram (Lexapro), sertraline (Zoloft), and fluvoxamine (Luvox)—have either a US Food and Drug Administration (FDA) indication or significant data to support their use. Anxiolytic medications such as benzodiazepines are rarely used due to the risk of dependency and diversion, their lack of efficacy, and their adverse effect (AE) profile. More recently, a serotonin and norepinephrine reup- take inhibitor, duloxetine (Cymbalta), was approved for the treatment of generalized anxiety disorder. When comparing AEs, the SSRIs win out, and duloxetine is typically considered second line—that is, after an unsuccessful trial of 2 SSRIs.
For treating major depressive disorder in children, fluoxetine and escitalopram have FDA approval starting at ages 8 and 12 years, respectively. Treatment of anxiety requires looking at both FDA approval and foundational studies that have helped shape our understanding of effective treatment. Fluoxetine, sertraline, and fluvoxamine are approved to treat children with a related condition, obsessive compulsive disorder, starting at ages 7, 6, and 8 years, respectively. Although these medications don’t carry an FDA indication for anxiety disorders per se, they have shown efficacy in large, randomized, controlled trials for treatment of anxiety disorders in children and adolescents.7,8
Put the plan into action
UNDERSTAND PATIENT AND FAMILY PERSPECTIVES
Patients and their families have unique priorities. Some wish to avoid medication altogether, whereas others are eager to get started. There are many misconceptions about psychotropic medications and stigmas because of mental health problems in general. Before recommending a particular therapy, it’s best to understand the perspective of the patient and family, including goals for treatment and how best to meet them. This approach helps foster shared decision-making and partnership and provides an opportunity to address misinformation or biases that may interfere with treatment.
SET REASONABLE EXPECTATIONS
Although medication can be helpful, it won’t make difficult feelings disappear. Experiencing strong emotions is an integral part of the human condition, so worry and sadness will occur even when major depressive disorder or an anxiety disorder is treated. The goal of treatment is to decrease the distress associated with emotions that are extreme or interfere with functioning.
Before prescribing medication, have a frank conversation about AEs, including the boxed warning for suicidal ideation. Discuss the way in which these medications are prescribed: starting low, titrating slowly, and waiting around 6 weeks for peak efficacy before making further adjustments. A clear explanation can help avoid frustration or confusion when “the medicine isn’t working” a week or two into treatment.
IDENTIFY RESOURCES AND LIMITATIONS
For some pediatricians, using these medications is a new endeavor. Others have dabbled in prescribing but don’t yet feel comfortable. Pediatricians who want to learn more can turn to an increasing number of resources. Many states have child psychiatry access hotlines (see https://www.nncpap.org) that pediatricians can call to ask about treating mental health disorders; these programs often provide regional resources and, sometimes, facilitated referral. National organizations such as the American Academy of Pediatrics and the American Association of Child and Adolescent Psychiatry have developed resources to help pediatricians feel more comfortable with offering mental health care, and groups such as The REACH Institute offer postgraduate training programs that provide education and ongoing support.
As can happen with other medical conditions, there will likely come a time when a patient’s symptoms fall outside a pediatrician’s expertise. Being prepared allows pediatricians to be more agile when these situations arise.
Resources for more information
References
1. Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Treatment of depression, anxiety, and conduct problems in US children. J Pediatr. 2019;206(3):256-267. doi:10.1016/j.jpeds.2018.09.021
2. Racine N, McArthur BA, Cooke JE, Eirich R Zhu J, Madigan S. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. JAMA Pediatr. 2021;175(11):1142-1150. doi:10.1001/jamapediatrics.2021.2482
3. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). American Psychiatric Association; 2013.
4. Cheung AH, Zuckerbrot RA, Jensen PS, Laraque, Stein REK; GLAD-PC Steering group. Guidelines for adolescent depression in primary care (GLAD-PC): part II. treatment and ongoing management. Pediatrics. 2018;141(3):e20174082. doi:10.1542/peds.2017-4082
5. Foy JM, Green CM, Earls MF; Committee on Psychosocial Aspects of Child and Family Health Mental Health Leadership Group. Mental health competencies for pediatric practice. Pediatrics. 2019;144 (5):e20192757. doi:10.1542/peds.2019-2757
6. Group 1 medications for anxiety and depression. In: Riddle MA. Pediatric Psychopharmacology for Primary Care. American Academy of Pediatrics; 2021:113-130
7. Wang, Z, Whiteside SPH., Sim L, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis. JAMA Pediatrics. 2018;171(11):1049-1056. doi:10.1001/jamapediatrics.2017.3036
8.Locher C, Koechlin H, Zion SR, et al. Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(10):1011-1020. doi:10.1001/jamapsychiatry.2017.2432
