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Pediatric Considerations
Black box warning (SSRIs): Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults.
However, studies have also shown increase in suicide attempts in adolescents after SSRI discontinuation.
Medications other than SSRIs have not been well-tested in pediatric populations.
Anxiety and ADHD often co-occur.
Pregnancy Considerations
Buspirone: Category B: secreted in breast milk; inadequate studies to assess risk
Benzodiazepines: Category D: may cause lethargy and weight loss in nursing infants; avoid breastfeeding if the mother is taking chronically or in high doses
SSRIs: if possible, taper and discontinue. After 20 weeks' gestation, there is increased risk of pulmonary hypertension; mild transient neonatal syndrome of CNS; and motor, respiratory, and GI signs. Studies regarding risk of autism show mixed results. Most are Category C:
ALERT
Precautions
- Benzodiazepines: age >65 years, hepatic insufficiency, respiratory disease/sleep apnea, renal insufficiency, suicidal tendency, contraindicated with narrow-angle glaucoma, precaution with open-angle glaucoma; sudden discontinuation, especially of alprazolam, increases seizure risk. Long-term use has potential for tolerance and dependence; use with caution in patients with history of substance abuse.
- Buspirone: hepatic and/or renal dysfunction; monoamine oxidase inhibitor (MAOI) treatment
- TCAs: advanced age, glaucoma, benign prostatic hypertrophy, hyperthyroidism, cardiovascular disease, liver disease, urinary retention, MAOI treatment
- SSRIs: use caution in those with comorbid bipolar disorder; may trigger mania. Avoid with medications that may increase risk of serotonin syndrome.
ISSUES FOR REFERRAL
Concomitant depression or other comorbidities may warrant a psychiatric evaluation in light of increased suicide risk.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Patients frequently engage in complementary and alternative medicine (CAM); providers should be familiar with common therapies.
- Probable benefit but more study needed on several complementary therapies, including acupuncture, yoga, tai chi, and aromatherapy (8)[A].
- Kava: Some evidence for benefit over placebo in mild to moderate anxiety, but concern regarding potential hepatotoxicity persists. Safety is potentially affected by many factors, including manufacturing quality, plant part used, dose, and interactions with other substances (8)[A].
- Limited evidence to support other herbal medicines and St. John's wort likely not effective (8)[A]
- Strong evidence to support regular physical activity to relieve anxiety symptoms (8)[A]
INPATIENT CONSIDERATIONS
Patients at risk of suicide should be treated as inpatients; may be considered as well for patients with substantial interference in daily function.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Follow up within 2 to 4 weeks from starting new medications.
- Medications should be continued past the initial period of response and probably for at least 6 months (6)[A].
- Monitor mental status on benzodiazepines and avoid drug dependence.
- Monitor BP, heart rate, and anticholinergic side effects of TCAs.
- Monitor all patients for suicidal ideation but especially those on SSRIs, SNRIs, and imipramine.
DIET
- Limit caffeine intake.
- Avoid alcohol (drug interactions, high rate of abuse, potential for increased anxiety).
PATIENT EDUCATION
- Regular exercise, especially yoga, may be beneficial for both anxiety and comorbid conditions.
- Psychoeducation regarding normal versus pathologic anxiety, the fight or flight response, and the physiology of anxiety can be extremely helpful.
- Moderate caffeine use; avoid alcohol and nicotine if possible.
PROGNOSIS
- Probability of recovery is approximately 40-60%, but relapse is common.
- Comorbid psychiatric disorders and poor relationships with spouse or family make relapse more likely (1).
REFERENCES
11 Weisberg RB. Overview of generalized anxiety disorder: epidemiology, presentation, and course. J Clin Psychiatry. 2009;70(Suppl 2):4-9.22 Hilbert K, Leuken U, Beesdo-Baum K. Neural structures, functioning and connectivity in generalized anxiety disorder and interaction with neuroendocrine systems: a systematic review. J Affect Disord. 2014;158:114-126.33 Patel G, Fancher TL. In the clinic. Generalized anxiety disorder. Ann Intern Med. 2013;159(11):ITC6-1-ITC6-11.44 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.55 Cuijpers P, Sijbrandij M, Koole S, et al. Psychological treatment of generalized anxiety disorder: a meta-analysis. Clin Psychol Rev. 2014;34(2):130-140.66 Baldwin DS, Waldman S, Allgulander C. Evidence-based pharmacological treatment of generalized anxiety disorder. Int J Neuropsychopharmacol. 2011;14(5):697-710.77 Depping AM, Komossa K, Kissling W, et al. Second-generation antipsychotics for anxiety disorders. Cochrane Database Syst Rev. 2010;(12):CD008120.88 Sarris J, Moylan S, Camfield DA, et al. Complementary medicine, exercise, meditation, diet, and lifestyle modification for anxiety disorders: a review of current evidence. Evid Based Complement Alternat Med. 2012;2012:809653.
SEE ALSO
Algorithms: Depressive Episode, Major; Anxiety
CODES
ICD10
- F41.9 Anxiety disorder, unspecified
- F41.1 Generalized anxiety disorder
- F41.8 Other specified anxiety disorders
- F41.0Panic disorder without agoraphobia
- F41.3 Other mixed anxiety disorders
ICD9
- 300.00 Anxiety state, unspecified
- 300.02 Generalized anxiety disorder
- 300.09 Other anxiety states
- 300.01 Panic disorder without agoraphobia
SNOMED
- 197480006 Anxiety disorder (disorder)
- 21897009 Generalized anxiety disorder (disorder)
- 80583007 Severe anxiety (panic) (finding)
- 56576003 Panic disorder without agoraphobia (disorder)
- 386810004 Phobic disorder (disorder)
- 231504006 Mixed anxiety and depressive disorder (disorder)
CLINICAL PEARLS
- Psychiatric comorbidities, especially depression, are extremely common with GAD; patients are at increased risk for suicidality.
- CBT and SSRIs (possibly in combination) are the treatments of choice.
- Starting antidepressant medication at low doses, with careful titration to full therapeutic dosing, helps minimize side effects while maximizing efficacy.
- Benzodiazepines may be used initially but should be tapered and withdrawn if possible.
- CAM use is common, and certain therapies may be effective.