In a 16‑year‑old female with exam‑related anxiety presenting with tremor, restlessness, palpitations and fear, is treatment with vortioxetine and propranolol appropriate and effective?

Treatment of Exam-Related Anxiety in a 16-Year-Old Female

The proposed combination of vortioxetine and propranolol is not appropriate for this adolescent; first-line treatment should be cognitive-behavioral therapy (CBT) combined with an SSRI (sertraline or escitalopram), not vortioxetine, and propranolol is deprecated for chronic anxiety management in this age group. 1, 2, 3

Why This Combination Is Inappropriate

Vortioxetine Is Not First-Line for Adolescent Anxiety

• SSRIs and SNRIs—not vortioxetine—are the established first-line pharmacologic treatments for anxiety disorders in adolescents aged 13 years and older. 1
• Vortioxetine is a multimodal antidepressant developed primarily for major depressive disorder with some evidence for anxiety symptoms in adults, but it lacks the robust evidence base that SSRIs possess for adolescent anxiety disorders. 2, 4, 5
• The American Academy of Child and Adolescent Psychiatry specifically recommends sertraline, escitalopram, or fluoxetine as first-choice medications for adolescents with anxiety, based on 126 placebo-controlled RCTs demonstrating statistically significant improvement in anxiety symptoms. 1, 2

Propranolol Is Not Recommended for Chronic Anxiety in Adolescents

• Canadian guidelines explicitly deprecate beta-blockers (including propranolol) for social anxiety disorder based on negative evidence, and they should not be used for chronic anxiety management in adolescents. 3
• While propranolol may have historical use for acute performance anxiety in adults (such as musicians before a concert), this represents off-label use with limited controlled evidence and is not appropriate for the chronic, generalized exam-related anxiety described in this case. 3
• The symptoms described—tremors, restlessness, anxiety, palpitations, and fear in the exam hall—represent test anxiety, which is a form of performance anxiety that requires treatment as a chronic anxiety disorder, not acute situational management. 1, 3

Evidence-Based Treatment Algorithm for This Patient

Step 1: Initial Treatment Approach

• Start with combination therapy: CBT plus an SSRI (sertraline or escitalopram). 2, 6
• Combination treatment provides superior outcomes compared to either CBT alone or medication alone for adolescents with anxiety disorders, with moderate to high strength of evidence from the Child-Adolescent Anxiety Multimodal Study (CAMS). 2, 6

Step 2: Specific SSRI Recommendations

• Sertraline: Start at 25 mg daily for the first week to minimize initial anxiety or agitation, then increase to 50 mg daily after week 1, with a target therapeutic dose of 50-200 mg/day. 2
• Escitalopram: Start at 5-10 mg daily and titrate by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day. 2, 3
• Allow 6-12 weeks at therapeutic dose before declaring treatment failure, as statistically significant improvement may begin by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later. 2, 3

Step 3: CBT Specifications for Test Anxiety

• Individual CBT targeting test-related anxiety should include 12-20 structured sessions focusing on:
  • Cognitive restructuring to challenge catastrophic thoughts about exam performance 1, 3
  • Exposure-based interventions targeting exam situations that trigger panic and fear 6
  • Relaxation techniques, breathing exercises, and grounding strategies 2
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness. 2, 3

Step 4: Critical Monitoring Requirements

• Monitor closely for suicidal ideation 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). 2
• Assess for common early side effects including nausea, headache, insomnia, nervousness, and initial anxiety/agitation, which typically resolve with continued treatment. 1, 2
• Evaluate functional impairment in school performance and social interactions using standardized scales. 3

Step 5: School Accommodations

• Coordinate with school to implement accommodations for anxiety symptoms, such as extended time on exams, ability to take breaks, or testing in a separate quiet room. 6
• Consider a 504 plan or IEP modifications to address functional impairments in schoolwork. 6

If First-Line Treatment Fails

• If inadequate response after 8-12 weeks at therapeutic SSRI doses: Switch to a different SSRI (e.g., from sertraline to escitalopram or vice versa) or consider an SNRI such as venlafaxine extended-release 75-225 mg/day. 2, 3
• Avoid paroxetine and fluvoxamine due to higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs. 2, 3

Critical Pitfalls to Avoid

• Do not use benzodiazepines as first-line treatment despite their rapid anxiolytic effect, due to risks of dependence, cognitive impairment, disinhibition in younger patients, and lack of evidence for long-term efficacy. 2, 7
• Do not abandon SSRI treatment before 12 weeks, as full response requires patience due to the logarithmic response curve. 2
• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 2
• Do not ignore parental anxiety, which can inadvertently reinforce avoidance behaviors; consider parental treatment if indicated. 6
• Do not delay treatment waiting for symptoms to resolve spontaneously—early effective treatment predicts better long-term outcomes. 6

Additional Supportive Measures

• Provide psychoeducation to the patient and family about anxiety symptoms, the treatment timeline, and the importance of adherence. 2
• Encourage regular cardiovascular exercise, which provides moderate to large reduction in anxiety symptoms. 3
• Address sleep hygiene, as insomnia commonly co-occurs with anxiety and the bidirectional relationship means improved sleep facilitates anxiety treatment response. 2
• Recommend avoidance of excessive caffeine, which can exacerbate anxiety symptoms. 3