Treatment of Anxiety and Depression in Children

Introduction to Treatment Algorithms

The American Academy of Child and Adolescent Psychiatry recommends cognitive-behavioral therapy (CBT) as the first-line treatment for both anxiety and depression in children and adolescents, particularly for mild to moderate presentations, with SSRIs reserved as an alternative for severe cases or when quality CBT is unavailable 1, 2, 3, 4

For mild to moderate anxiety, the American Academy of Child and Adolescent Psychiatry suggests starting with CBT as monotherapy, delivered over 12-20 structured sessions targeting cognitive, behavioral, and physiologic dimensions of anxiety 5, 6
CBT should include specific elements such as psychoeducation about anxiety, behavioral goal setting with contingent rewards, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure to feared stimuli, with the latter being the cornerstone for situation-specific anxiety 5
The American Academy of Child and Adolescent Psychiatry recommends considering SSRIs as first-line pharmacotherapy for children 6-18 years with social anxiety, generalized anxiety, separation anxiety, or panic disorder, with fluoxetine being specifically recommended due to its robust evidence and FDA approval for pediatric anxiety 5, 7
Fluoxetine should be started at 5-10 mg daily, increased by 5-10 mg increments every 1-2 weeks, targeting 20-40 mg daily by weeks 4-6, with expectations of statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 7, 8

For children ages 6-12 years, antidepressants should not be used in non-specialist settings for depressive episodes, and CBT or interpersonal therapy (IPT) should be initiated as first-line treatment, with referral to a specialist if pharmacotherapy becomes necessary 9, 10, 11
For adolescents ages 13-18 years, CBT or IPT should be started as first-line treatment for mild to moderate depression, with fluoxetine being the only antidepressant recommended for adolescents with depressive episodes in non-specialist settings 9, 10, 11
The American Academy of Child and Adolescent Psychiatry recommends monitoring closely for suicidal ideation/behavior when using fluoxetine, especially in the first months and after dose adjustments, with a pooled absolute risk of suicidal ideation with antidepressants being 1% versus 0.2% with placebo 9, 7, 8

Common side effects of SSRIs emerge within the first few weeks and include nausea, headache, insomnia, diarrhea, heartburn, somnolence, dizziness, sexual dysfunction, sweating, and tremor, with most adverse effects resolving with continued treatment 5, 7, 8
Close monitoring is mandatory for suicidal thinking and behavior, especially in the first months and following dose adjustments, with a number needed to treat for response being 3 and a number needed to harm for suicidal ideation being 143 9, 7, 8

The American Academy of Child and Adolescent Psychiatry recommends against the use of benzodiazepines for pediatric anxiety, paroxetine due to its higher risk of discontinuation syndrome and potentially increased suicidal thinking, and tricyclic antidepressants, venlafaxine, and St. John's Wort for pediatric depression 4, 7, 10, 11, 12