What is the recommended treatment approach for anxiety and depression in children?

Treatment of Anxiety and Depression in Children

Cognitive-behavioral therapy (CBT) is the first-line treatment for both anxiety and depression in children and adolescents, particularly for mild to moderate presentations, with SSRIs reserved as an alternative for severe cases or when quality CBT is unavailable. 1

Treatment Algorithm for Anxiety Disorders

Mild to Moderate Anxiety

• Start with CBT as monotherapy delivered over 12-20 structured sessions targeting cognitive, behavioral, and physiologic dimensions of anxiety 1
• CBT should include specific elements: psychoeducation about anxiety, behavioral goal setting with contingent rewards, self-monitoring, relaxation techniques (deep breathing, progressive muscle relaxation), cognitive restructuring to challenge catastrophizing and negative predictions, and graduated exposure to feared stimuli 1
• Graduated exposure is the cornerstone for situation-specific anxiety (separation anxiety, specific phobias, social anxiety) and should be calibrated in intensity similar to medication dosing 1
• Family-directed interventions should supplement individual treatment to improve parent-child relationships, reduce parental anxiety, and foster anxiety-reducing parenting skills 1

Severe Anxiety or CBT Unavailable

• Consider SSRIs as first-line pharmacotherapy for children 6-18 years with social anxiety, generalized anxiety, separation anxiety, or panic disorder 1
• SSRIs improve primary anxiety symptoms, treatment response, remission rates, and global function compared to placebo (moderate to high strength of evidence) 1
• Fluoxetine is specifically recommended as it has the most robust evidence and FDA approval for pediatric anxiety, though other SSRIs show efficacy 2, 3
• Start fluoxetine at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, targeting 20-40 mg daily by weeks 4-6 2
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 2, 3

Combination Therapy

• Combination of CBT plus SSRI is more effective than either treatment alone for severe anxiety presentations 1
• This approach should be prioritized when initial monotherapy (either CBT or SSRI) produces insufficient response 3, 4

Treatment Algorithm for Depression

Children Ages 6-12 Years

• Antidepressants should NOT be used in non-specialist settings for children 6-12 years with depressive episodes 1
• Initiate CBT or interpersonal therapy (IPT) as first-line treatment 1, 4
• Refer to specialist if pharmacotherapy becomes necessary 1

Adolescents Ages 13-18 Years

• Start with CBT or IPT as first-line treatment for mild to moderate depression 1, 4
• Fluoxetine is the ONLY antidepressant recommended for adolescents with depressive episodes in non-specialist settings 1
• Tricyclic antidepressants (TCAs) and other SSRIs should NOT be used in non-specialist settings 1
• Monitor closely for suicidal ideation/behavior when using fluoxetine, especially in the first months and after dose adjustments 1, 2, 3
• The pooled absolute risk of suicidal ideation with antidepressants is 1% versus 0.2% with placebo (risk difference 0.7%, number needed to harm = 143) 3

Severe Depression

• Combination of CBT (or IPT) plus fluoxetine is most effective for severe adolescent depression 4
• All four high-quality depression guidelines recommend fluoxetine as first-line medication when symptoms are severe or unresponsive to psychotherapy 1

Critical Monitoring and Safety Considerations

SSRI Adverse Effects

• Common side effects emerge within first few weeks: nausea, headache, insomnia, diarrhea, heartburn, somnolence, dizziness, sexual dysfunction, sweating, tremor 1, 2, 3
• Behavioral activation/agitation is more common in younger children and anxiety disorders versus depression, manifesting as motor restlessness, insomnia, impulsiveness, and aggression 3
• Most adverse effects resolve with continued treatment, supporting gradual dose escalation 2

Suicide Risk Monitoring

• Close monitoring is mandatory for suicidal thinking and behavior, especially in first months and following dose adjustments 1, 2, 3
• Number needed to treat for response is 3, while number needed to harm for suicidal ideation is 143 3

Medications to Avoid

• Pharmacological interventions should NOT be considered for anxiety disorders in children/adolescents in non-specialist settings 1
• Benzodiazepines are not recommended for pediatric anxiety 1
• Paroxetine should be avoided due to higher risk of discontinuation syndrome and potentially increased suicidal thinking 2, 5
• Tricyclic antidepressants, venlafaxine, and St. John's Wort are actively recommended against for pediatric depression 1

Common Pitfalls to Avoid

• Do not abandon treatment prematurely: Full SSRI response may take 12+ weeks, requiring patience in dose escalation 2
• Do not escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 2
• Do not use antidepressants for subthreshold symptoms: Antidepressants should not be used for depressive symptoms in absence of current/prior moderate or severe depressive episode 1
• Do not discontinue SSRIs abruptly: Taper gradually to avoid discontinuation syndrome, particularly with shorter half-life SSRIs like sertraline 5
• Do not underestimate the importance of comprehensive assessment: Accurate diagnosis and clinical formulation enhance evidence-based treatment outcomes 1