What is the recommended treatment for adolescent anxiety?

Treatment of Adolescent Anxiety

Cognitive-behavioral therapy (CBT) is the first-line treatment for mild to moderate adolescent anxiety, while combination therapy with CBT plus an SSRI (starting with sertraline) is recommended for severe presentations. 1, 2

Treatment Algorithm by Severity

Mild to Moderate Anxiety

• Begin with CBT monotherapy consisting of 12-20 sessions that target cognitive, behavioral, and physiologic dimensions of anxiety through education, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving skills training 1, 2
• CBT demonstrates a moderate effect size with approximately 36% of adolescents achieving remission post-treatment compared to 9% of controls 3
• If quality CBT is unavailable or the adolescent does not respond after 6-8 weeks, initiate SSRI monotherapy 1

Severe Anxiety

• Start combination therapy with CBT plus sertraline simultaneously, as this approach is more effective than either treatment alone for adolescents with significant functional impairment 1, 2, 4
• Sertraline dosing: Begin at 25 mg daily for one week, then increase to 50 mg daily 5
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 1
• Titrate slowly up to 200 mg/day maximum if needed, with dose changes no more frequently than weekly given the 24-hour elimination half-life 5

SSRI Selection and Management

First-Line SSRI: Sertraline

• Sertraline is the preferred first-line SSRI based on strong evidence in adolescent anxiety disorders 1, 5
• Adolescent dosing (ages 13-17): Start 50 mg daily, titrate as needed up to 200 mg/day 5
• Children (ages 6-12): Start 25 mg daily for OCD presentations 5

Common Adverse Effects to Monitor

• Gastrointestinal symptoms (nausea, diarrhea, heartburn) are most common in the first few weeks 1
• Behavioral activation or agitation manifests as motor restlessness, insomnia, impulsiveness, and aggression—more common in younger children and anxiety disorders versus depression 1
• Close monitoring for suicidal ideation is required, especially in the first months and after dose adjustments, with an absolute risk increase of 0.7% (number needed to harm = 143) 1

Alternative SSRIs

• Escitalopram: Start 5-10 mg daily, titrate gradually over 1-2 weeks 6
• Fluvoxamine: Effective but requires twice-daily dosing at low doses and has higher discontinuation symptom risk 1

Alternative Pharmacological Options

SNRIs

• Consider SNRIs when SSRIs are ineffective or not tolerated 1
• Have some empirical support but are not first-line 1

Hydroxyzine

• Appropriate for short-term or situational anxiety management as an adjunct to SSRIs or as monotherapy for milder cases 1, 6
• Use the lowest effective dose to minimize sedation 1

Propranolol: NOT Recommended

• Do not use propranolol for adolescent anxiety—the Canadian Clinical Practice Guideline specifically deprecates beta-blockers for social anxiety disorder based on negative evidence, and no international guidelines (NICE, S3, Canadian CPG) recommend propranolol for anxiety disorders in any age group 6
• Using propranolol delays effective intervention and risks long-term impairments 6

Essential Assessment Components

Before Initiating Treatment

• Confirm specific anxiety disorder diagnosis using semistructured interviews and validated measures 7, 4
• Obtain input from multiple sources: adolescent, parents/guardians, teachers, and other caregivers 1
• Screen for comorbid depression (56% prevalence with anxiety disorders) and other psychiatric conditions 1
• Rule out medical conditions that mimic anxiety symptoms 1

Ongoing Monitoring

• Use standardized symptom rating scales to systematically assess treatment effectiveness 1, 2
• Monitor functional impairment across social, academic, and family domains 2
• Reassess regularly as anxiety disorders often have a chronic, waxing-and-waning course requiring treatment adjustments 2

Critical Pitfalls to Avoid

• Do not abandon treatment prematurely—maximal SSRI benefit occurs by week 12 or later, following a logarithmic response model 1, 6
• Do not exceed optimal SSRI dosing—use slow up-titration to avoid overshooting the therapeutic window 1
• Do not substitute non-evidence-based treatments (like propranolol) for CBT or SSRIs, as this delays effective intervention for a condition that can cause significant long-term social, educational, and health impairments extending into adulthood 1, 6
• Do not neglect parental anxiety—parents who struggle with anxiety themselves benefit from additional psychoeducation and support, with referral for parental treatment when appropriate 7

Maintenance Treatment

• Major depressive disorder and anxiety require several months or longer of sustained pharmacologic therapy beyond initial response 5
• Sertraline efficacy is maintained for up to 44 weeks in depression and 28 weeks in PTSD at doses of 50-200 mg/day 5
• Periodically reassess to determine the need for continued treatment and maintain patients on the lowest effective dose 5
• Incorporate relapse prevention strategies into treatment plans with regular follow-up 2