What are the recommended anxiety medications for a 14-year-old?

Recommended Anxiety Medications for a 14-Year-Old

Start with sertraline 25 mg daily or escitalopram 5-10 mg daily as first-line pharmacotherapy for anxiety in a 14-year-old adolescent. 1

First-Line Medication Options

Selective serotonin reuptake inhibitors (SSRIs) are the only medications with consistent evidence of efficacy and safety for treating anxiety disorders in children and adolescents. 1, 2

Preferred SSRIs for Adolescents:

• Sertraline: Start at 25 mg daily, increase by 25-50 mg increments every 1-2 weeks as tolerated, with target dose of 50-200 mg/day 1, 3
• Escitalopram: Start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, with target dose of 10-20 mg/day 1, 4

These two agents are prioritized because they have favorable side effect profiles, lower risk of drug interactions, and extensive safety data in adolescents 1, 4

Alternative First-Line SSRIs:

• Fluoxetine: Start at 5-10 mg daily, increase by 5-10 mg every 1-2 weeks, target 20-40 mg daily 4
  • Advantage: Longer half-life may be beneficial if the adolescent occasionally misses doses 4
• Fluvoxamine: Start at 25 mg daily 5
  • Caution: Higher potential for drug-drug interactions and more discontinuation symptoms 1, 4

Second-Line Medication Options

Serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered if SSRIs are ineffective or not tolerated. 1

• Venlafaxine extended-release: 75-225 mg/day 1, 4
  • Critical monitoring requirement: Blood pressure must be monitored due to risk of sustained hypertension 1, 4
• Duloxetine: FDA-approved for generalized anxiety disorder in patients aged 7 years and older 6

Expected Timeline and Response

Expect statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal therapeutic benefit by week 12 or later. 1, 4

The response follows a logarithmic model with diminishing returns at higher doses, which supports gradual titration rather than rapid dose escalation 4

Critical Safety Monitoring

Black Box Warning:

All SSRIs carry an FDA black box warning for increased suicidal thinking and behavior in patients through age 24 years. 6

• Pooled absolute risk: 1% for antidepressants versus 0.2% for placebo 6
• Number needed to harm: 143 4
• Monitor closely during the first months of treatment and after any dose adjustments 1, 4

Common Side Effects to Anticipate:

• Early side effects (first few weeks): Nausea, headache, insomnia, nervousness, behavioral activation/agitation 1, 4
• Ongoing side effects: Sexual dysfunction, gastrointestinal symptoms, somnolence, dizziness, vivid dreams 1, 4
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1, 4

Critical Prescribing Principles

Start Low, Go Slow:

Begin with lower doses specifically to minimize initial anxiety/agitation that can occur with SSRIs in adolescents. 1, 4

• The gradual up-titration prevents unintentionally exceeding the optimal dose 4
• Allow 1-2 weeks between dose increases to assess tolerability 1, 4
• Given the 24-hour elimination half-life of sertraline, dose changes should not occur at intervals less than 1 week 3

Younger Children Require Special Consideration:

For children ages 6-12 with OCD, start sertraline at 25 mg daily (lower than the 50 mg starting dose for adolescents 13-17), as their lower body weights require dose adjustment to avoid excess dosing 3

Medications to AVOID

Paroxetine should be avoided due to higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs. 1, 4

Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity. 4, 6

Benzodiazepines are not recommended for routine use in adolescent anxiety disorders. 7

Treatment Duration

Continue medication for at least 12 months following symptom remission for a first episode of anxiety. 5

• When discontinuing, choose a stress-free time of year 5
• Taper gradually to avoid discontinuation syndrome, particularly with shorter half-life SSRIs like sertraline 1
• Discontinuation syndrome symptoms include dizziness, fatigue, sensory disturbances, paresthesias, anxiety, and irritability 1, 6

Combination with Psychotherapy

Combining medication with cognitive-behavioral therapy (CBT) provides superior outcomes compared to either treatment alone. 1, 5, 8

• Evidence suggests combination of CBT plus sertraline offers additional benefit compared with either treatment alone 5
• CBT has large effect sizes for anxiety disorders (Hedges g = 1.01) and should be prioritized alongside pharmacotherapy 4, 9
• Individual CBT is preferred over group therapy due to superior clinical effectiveness 4

If First SSRI Fails

After 8-12 weeks at therapeutic doses with inadequate response, switch to a different SSRI (e.g., sertraline to escitalopram or vice versa). 4

Consider adding or intensifying CBT if not already implemented 4

Common Pitfalls to Avoid

• Do not escalate doses too quickly: This can cause behavioral activation and anxiety worsening 1
• Do not abandon treatment prematurely: Full response may take 12+ weeks 4
• Do not combine with MAOIs or multiple serotonergic drugs without extreme caution: Risk of serotonin syndrome 1
• Do not abruptly discontinue: Always taper gradually 1