PRN Anxiety Medication for Teenagers
For as-needed (PRN) anxiety management in teenagers, selective serotonin reuptake inhibitors (SSRIs) are strongly recommended as the first-line pharmacological treatment, with sertraline being the preferred option due to its established safety profile and efficacy. 1
First-Line Medication Approach
SSRI Recommendation
- Sertraline is the preferred SSRI for teenagers with anxiety due to:
- Established efficacy for various anxiety disorders
- Better tolerability compared to other medications
- Lower risk of withdrawal effects compared to other SSRIs
- Flexible dosing options
Dosing Guidelines for Sertraline
- Starting dose: 25 mg once daily 2
- After one week, increase to 50 mg once daily
- Dose can be titrated up to a maximum of 200 mg daily based on response
- Dose changes should not occur at intervals less than 1 week due to the 24-hour elimination half-life 2
Alternative Options
If sertraline is not suitable or not effective:
Other SSRIs
- Fluoxetine: Starting dose 10 mg daily 1
- Escitalopram: Starting dose 10 mg daily 1
- Fluvoxamine: Starting dose 50 mg daily 1
SNRIs (Second-Line)
SNRIs could be offered if SSRIs are ineffective or not tolerated 1:
- These medications inhibit the presynaptic reuptake of both norepinephrine and serotonin
- Shown to improve primary anxiety symptoms in clinical trials
- May cause more side effects than SSRIs, particularly fatigue/somnolence
Important Considerations
Monitoring Requirements
- First 4 weeks: Weekly monitoring for adverse effects and clinical response
- Subsequent period: Every 2-4 weeks until stable
- Monitor specifically for:
- Suicidal ideation or behavior (boxed warning for all antidepressants through age 24)
- Behavioral activation/agitation
- Sleep disturbances
- Gastrointestinal symptoms
Side Effect Profile
- Common side effects: Dry mouth, nausea, diarrhea, headache, somnolence, insomnia, dizziness
- Serious but rare adverse effects: Suicidal thinking/behavior, behavioral activation, hypomania, sexual dysfunction 1
- The pooled absolute rates for suicidal ideation across all antidepressants for anxiety are approximately 1% (vs 0.2% with placebo) 1
Combination Treatment Approach
- SSRI + Cognitive Behavioral Therapy (CBT) is more effective than either treatment alone 1, 3
- Consider combination treatment particularly for:
- Moderate to severe anxiety
- Poor response to monotherapy
- Complex presentations with comorbidities
Cautions and Contraindications
Avoid benzodiazepines as PRN anxiety medication in teenagers due to:
- Risk of dependence
- Potential for abuse
- Cognitive impairment
- Paradoxical behavioral disinhibition, especially in younger children 1
Contraindications:
- Concurrent use of MAOIs (must allow 14-day washout period) 2
- Known hypersensitivity to the medication
Implementation Timeline
- Weeks 1-2: Begin with starting dose, assess tolerability
- Weeks 2-4: Titrate dose if needed based on response
- Weeks 4-6: Evaluate initial therapeutic response
- Weeks 6-12: Continue to optimize dose for maximal benefit with minimal side effects
Remember that SSRIs typically take 4-6 weeks for full therapeutic effect, so they should be used as daily scheduled medications rather than true "PRN" medications. For immediate anxiety relief while waiting for SSRIs to take effect, non-pharmacological approaches such as relaxation techniques, deep breathing exercises, and cognitive strategies should be employed.
The treatment of anxiety in teenagers requires parental oversight of medication regimens and regular follow-up to ensure safety and efficacy 1.