What is the recommended medication for a teenager with anxiety?

Medication for Anxiety in Teenagers

For adolescents with anxiety disorders, sertraline 25 mg daily for the first week, then 50 mg daily thereafter, is the recommended first-line medication, with combination treatment of sertraline plus cognitive behavioral therapy providing superior outcomes to either treatment alone. 1

First-Line Pharmacotherapy

SSRIs are the gold standard medication class for adolescent anxiety, with sertraline and escitalopram having the strongest evidence base. 1, 2

Sertraline Dosing Strategy

• Start at 25 mg daily for the first week to minimize initial anxiety or agitation that commonly occurs when initiating SSRIs 1
• Increase to 50 mg daily after week 1, which serves as the initial therapeutic dose 3
• Titrate by 25-50 mg increments every 1-2 weeks as tolerated, targeting a therapeutic range of 50-200 mg/day 1, 3
• Single daily dosing (morning or evening) is sufficient due to sertraline's 24-hour elimination half-life 3

Alternative First-Line SSRIs

• Escitalopram 10-20 mg/day or fluoxetine 20-40 mg/day are reasonable alternatives if sertraline is not tolerated 1
• Avoid paroxetine and fluvoxamine due to higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs 1

Expected Response Timeline and Monitoring

Patience is critical—do not abandon treatment prematurely. 1

• Week 2: Statistically significant improvement may begin 1
• Week 6: Clinically significant improvement expected 1
• Week 12 or later: Maximal therapeutic benefit achieved 1

Critical Safety Monitoring

• Monitor closely for suicidal thinking and behavior, especially in the first months and after dose changes, with a pooled risk of 1% versus 0.2% for placebo (number needed to harm = 143) 1
• Common early side effects include nausea, headache, insomnia, nervousness, and initial anxiety/agitation—most resolve with continued treatment 1

Combination Treatment: The Superior Approach

Combining medication with cognitive behavioral therapy provides superior outcomes to either treatment alone for adolescent anxiety. 4, 1

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 1, 2
• A structured course of 12-20 CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques is recommended 1
• The superiority of combination therapy is demonstrated across multiple anxiety disorders in adolescents 4

Second-Line Options

If inadequate response after 8-12 weeks at therapeutic SSRI doses:

• Switch to a different SSRI (e.g., sertraline to escitalopram or fluoxetine) 1
• Consider venlafaxine (SNRI) 75-225 mg/day as an alternative, though it ranks lower in tolerability and requires blood pressure monitoring 1, 2
• Duloxetine 30-120 mg/day is FDA-approved for generalized anxiety disorder in ages 7-17 and may be considered 1

Treatment Duration

• Continue medication for at least 9-12 months after achieving remission to prevent relapse 1
• Taper gradually when discontinuing to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 1

Critical Pitfalls to Avoid

• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not abandon treatment before 12 weeks, as full response requires patience due to the logarithmic response curve of SSRIs 1
• Avoid benzodiazepines for chronic anxiety management in adolescents due to concerns about disinhibition, dependence, and potential worsening of long-term outcomes 1
• Do not use bupropion for anxiety—it lacks efficacy and may worsen anxiety symptoms 2

Special Considerations for Specific Anxiety Disorders

Panic Disorder with Anxiety

• Same sertraline dosing applies, with combination treatment (SSRI + CBT) providing superior outcomes compared to medication alone 1

Generalized Anxiety Disorder

• Duloxetine is the only FDA-approved medication for pediatric GAD (ages 7-17), starting at 30 mg daily and titrating to 30-120 mg daily 1
• However, SSRIs like sertraline and escitalopram have strong off-label evidence and are often preferred due to better tolerability 1

Social Anxiety Disorder

• Fluvoxamine, paroxetine, escitalopram, and sertraline all demonstrate efficacy, though sertraline and escitalopram are preferred due to lower discontinuation rates 2, 5