What is the recommended treatment adjustment for a 13-year-old female with a mood disorder, taking lithium (lithium carbonate) 300 mg daily, who has developed intense morning anxiety about school, resulting in vomiting and inability to attend school?

Management of School Anxiety in a 13-Year-Old Female with Mood Disorder on Lithium

For a 13-year-old female with mood disorder on lithium 300 mg daily who has developed intense morning anxiety about school resulting in vomiting and school avoidance, the recommended approach is to add a selective serotonin reuptake inhibitor (SSRI) while maintaining lithium therapy, and implement cognitive behavioral therapy (CBT) with specific focus on graduated school exposure.

Medication Management

Primary Recommendation

1. Maintain current lithium therapy at 300 mg daily

   • Lithium remains the gold standard for mood disorder management 1
   • Continue monitoring lithium levels, renal function, and thyroid function

2. Add an SSRI for anxiety symptoms

   • The American Academy of Child and Adolescent Psychiatry (AACAP) strongly recommends SSRIs for children 6-18 years old with anxiety disorders 2
   • SSRIs have demonstrated improvement in primary anxiety symptoms, response to treatment, and remission of disorder with moderate strength of evidence 2
   • Start with a low dose ("test dose") as initial adverse effects can include increased anxiety or agitation 2
   • Gradually titrate the dose at 1-2 week intervals for shorter half-life SSRIs (sertraline, citalopram) or 3-4 week intervals for longer half-life SSRIs (fluoxetine) 2

Medication Selection Considerations

• When adding medication for a comorbid condition, maintain the medication for the underlying mood disorder (lithium) 2
• For patients with bipolar disorder and anxiety, mood stabilizer therapy should be established before adding medications for anxiety 3
• Parental oversight of medication regimens is essential in children and adolescents 2

Psychotherapeutic Interventions

1. Cognitive Behavioral Therapy (CBT)

   • AACAP identifies CBT as the cornerstone of treatment for anxiety disorders 2
   • Key CBT elements should include:
     • Education about anxiety
     • Behavioral goal setting with rewards
     • Self-monitoring of anxiety triggers
     • Relaxation techniques
     • Cognitive restructuring to challenge distorted thinking
     • Graduated exposure to school setting
     • Problem-solving and social skills training 2

2. Family-Directed Interventions

   • Improve parent-child relationships
   • Strengthen family problem-solving and communication
   • Reduce parental anxiety
   • Foster anxiety-reducing parenting skills 2

3. School-Directed Interventions

   • Educate teachers about the student's anxiety
   • Develop specific plans for anxiety management at school
   • Consider a 504 plan or individualized education plan with:
     • Graduated school re-entry with rewards
     • Structured practice opportunities 2

Combination Approach

Consider combination treatment (CBT + SSRI) over monotherapy

• AACAP suggests combination treatment could be offered preferentially over either treatment alone 2
• Combination treatment has shown superior outcomes in improving anxiety symptoms, global function, response to treatment, and remission 2

Monitoring Plan

1. Regular assessment of:

   • Anxiety symptoms using standardized rating scales
   • Mood symptoms to ensure lithium remains effective
   • Medication side effects
   • School attendance and functioning

2. Extended monitoring period

   • Patients with mood and anxiety disorders may experience return of symptoms weeks to months after medication changes 2
   • Monitor for potential interactions between lithium and SSRIs

Pitfalls and Caveats

1. Avoid abrupt discontinuation of lithium

   • Could lead to rebound worsening of mood symptoms 2
   • Gradual tapering is recommended if changes are needed

2. Be cautious with SSRI initiation

   • Initial anxiety or agitation can occur as a side effect
   • Start with lower doses and titrate gradually

3. Monitor for serotonin syndrome

   • Particularly when combining lithium with an SSRI

4. School avoidance can become entrenched

   • Implement graduated exposure promptly
   • Avoid prolonged absence from school which can reinforce anxiety

5. Consider vomiting in differential diagnosis

   • Rule out lithium-related gastrointestinal side effects
   • Assess for other medical causes of vomiting

This approach addresses both the underlying mood disorder and the newly developed anxiety symptoms, with the goal of improving the patient's quality of life and ability to attend school regularly.