What is the recommended treatment for a teenager experiencing anxiety?

Treatment of Anxiety in Teenagers

Cognitive-behavioral therapy (CBT) is the first-line treatment for teenagers with mild to moderate anxiety, while combination treatment with both CBT and an SSRI (preferably sertraline) should be offered for severe presentations. 1

Treatment Algorithm by Severity

Mild to Moderate Anxiety

• Start with CBT monotherapy delivered over 12-20 sessions 1, 2
• CBT components must include: psychoeducation about anxiety, behavioral goal setting with rewards, self-monitoring of worry-thought-behavior connections, relaxation techniques (deep breathing, progressive muscle relaxation), cognitive restructuring to challenge catastrophizing and negative predictions, and graduated exposure therapy 1
• Graduated exposure is the cornerstone for anxiety triggered by specific situations (separation anxiety, social anxiety, specific phobias) 1
• Family involvement is critical—parents need training in anxiety-reducing parenting skills, and school-based interventions should be incorporated into 504 plans or IEPs 1

Severe Anxiety or When Quality CBT is Unavailable

• Offer combination treatment: CBT plus sertraline 1, 2
• Combination therapy produces superior response rates and remission compared to either treatment alone (moderate strength of evidence) 1
• The initial superiority of combination treatment predicts better long-term outcomes, even though the advantage may diminish over extended follow-up 1

Pharmacological Treatment Details

First-Line SSRI: Sertraline

• Start sertraline at 25 mg daily for one week, then increase to 50 mg daily 3
• Expect statistically significant improvement by week 2, clinically meaningful improvement by week 6, and maximal benefit by week 12 or later 2
• Dose range: 50-200 mg/day; increase by 50 mg increments at intervals of at least one week if inadequate response 3
• Common early adverse effects: nausea, diarrhea, heartburn (typically resolve within first few weeks) 2

Alternative SSRI: Fluoxetine

• Adolescents (13-17 years): Start 10 mg daily for 2 weeks, then increase to 20 mg daily 4
• Dose range: 20-60 mg/day for anxiety disorders 4
• May be preferred if once-daily dosing adherence is a concern due to longer half-life 4

Second-Line: SNRIs

• Consider SNRIs (such as venlafaxine extended-release) if SSRIs are ineffective or not tolerated 1
• SNRIs improve clinician-rated anxiety symptoms (high strength of evidence) but have increased risk of fatigue/somnolence compared to placebo 1

Short-Term Adjunct: Hydroxyzine

• Hydroxyzine may be used for situational anxiety as adjunct to SSRIs or as monotherapy for milder cases 2
• Use lowest effective dose to minimize sedation 2

Critical Monitoring Requirements

Suicidality Surveillance

• Close monitoring for suicidal thinking is mandatory, especially in the first months and after dose adjustments 2
• Absolute risk of suicidal ideation with antidepressants: 1% vs 0.2% with placebo (number needed to harm = 143) 2
• This risk must be balanced against number needed to treat for response = 3 2

Behavioral Activation

• Watch for motor/mental restlessness, insomnia, impulsiveness, and aggression—more common in younger adolescents and in anxiety disorders versus depression 2
• If behavioral activation occurs, consider dose reduction or switching agents 2

Common Pitfalls to Avoid

• Do not discontinue treatment prematurely—SSRIs follow a logarithmic response curve, requiring 12+ weeks for maximal benefit 2
• Do not use benzodiazepines—they lack efficacy data in pediatric anxiety and carry dependence risk 5
• Do not use propranolol—beta-blockers are specifically deprecated by Canadian guidelines for anxiety disorders and are not recommended by AACAP 6
• Do not ignore family and school context—anxiety is learned and maintained in social contexts, requiring parent training and school accommodations 1

Maintenance Treatment

• Continue SSRI for 6-12 months after remission to prevent relapse 7
• Periodically reassess need for ongoing treatment using standardized symptom rating scales 1
• Maintain patients on the lowest effective dose 3

When Specialized CBT is Unavailable

• If quality CBT is inaccessible, initiate SSRI monotherapy rather than delaying treatment 2
• Untreated anxiety leads to significant long-term impairments in social, educational, and mental health outcomes extending into adulthood 2
• Consider low-intensity CBT interventions or digital CBT programs as alternatives to traditional face-to-face therapy 8