What is the best treatment for anxiety in a teenager?

Best Anxiety Treatment for Teens

Cognitive-behavioral therapy (CBT) is the recommended first-line treatment for adolescents aged 6-18 years with anxiety disorders, including social anxiety, generalized anxiety, separation anxiety, panic disorder, and specific phobia. 1, 2

Treatment Algorithm Based on Severity

Mild to Moderate Anxiety

• Start with CBT monotherapy delivered over 12-20 structured sessions targeting the three core dimensions of anxiety: cognitive distortions, behavioral avoidance, and physiologic arousal 1, 2
• CBT produces moderate to large effect sizes, with approximately two-thirds of adolescents achieving freedom from their primary diagnosis at post-treatment 3, 4
• Essential CBT components include: psychoeducation about anxiety, behavioral goal setting with contingent rewards, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure to feared situations (the cornerstone for situation-specific anxiety) 2, 5

Severe Anxiety Presentations

• For severe anxiety, initiate combination treatment with both CBT and an SSRI from the outset, as this approach demonstrates superior efficacy compared to either treatment alone 2
• Sertraline is the preferred first-line SSRI: start at 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day 6, 7
• Fluoxetine is an alternative first-line option with FDA approval for pediatric anxiety: for adolescents ages 13-17, start at 50 mg daily; for children ages 6-12, start at 25 mg daily, with dose increases up to maximum 200 mg/day 1, 8, 9
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 2, 7

When Quality CBT is Unavailable

• SSRIs become the appropriate first-line treatment when access to trained CBT providers is limited 2, 8
• SNRIs (duloxetine 60-120 mg/day or venlafaxine extended-release 75-225 mg/day) may be considered as alternatives when SSRIs are ineffective or not tolerated 2, 6

Critical Safety Monitoring for SSRIs

• Monitor closely for suicidal ideation and behavior, especially during the first months of treatment and after any dose adjustments 2, 8
• The pooled absolute risk of suicidal ideation with antidepressants is 1% versus 0.2% with placebo (number needed to harm = 143), while the number needed to treat for response is only 3 2, 8
• Common adverse effects emerging in the first few weeks include gastrointestinal symptoms (nausea, diarrhea, heartburn), headache, insomnia, dizziness, and sexual dysfunction—most resolve with continued treatment 2, 6
• Behavioral activation or agitation (motor restlessness, insomnia, impulsiveness, aggression) occurs more commonly in younger children and in anxiety disorders versus depression 2

Medications to Avoid

• Do not use benzodiazepines for pediatric anxiety disorders 8
• Avoid paroxetine due to higher risk of discontinuation syndrome and potentially increased suicidal thinking 8
• Tricyclic antidepressants, venlafaxine (for depression), and St. John's Wort should not be used in pediatric populations 8

Treatment Duration and Maintenance

• Continue medication for at least 12-24 months after achieving remission, and in some cases indefinitely for panic disorder 6
• Gradually discontinue medications to avoid withdrawal symptoms 6
• Periodically reassess patients to determine ongoing need for treatment, maintaining them on the lowest effective dose 1, 7

Important Clinical Pitfalls

• Do not underestimate the importance of comprehensive diagnostic evaluation before initiating treatment to confirm the specific anxiety disorder and rule out medical conditions that mimic anxiety 2
• Anxiety disorders in adolescents are often chronic with waxing and waning symptoms, requiring ongoing monitoring and potential treatment adjustments 2
• Screen for comorbid depression, as anxiety and depressive disorders co-occur in 56% of cases 2
• Despite availability of effective treatments, less than half of youth needing mental health treatment receive appropriate care—actively address barriers to accessing CBT and psychiatric care 2