Patterns of Initial Medication Use for Pediatric Anxiety

Anxiety disorders are prevalent in children in the United States. Many medications are used to treat anxiety across all ages, including antidepressants, benzodiazepines, beta blockers, antihistamines, selected atypical antipsychotics, and others. Based on multiple randomized controlled trials (Wang et al, Ipser et al, Mohatt et al), selective serotonin reuptake inhibitor (SSRI) antidepressants are the recommended first-line antianxiety medication for children and adolescents with anxiety.

To determine which antianxiety medications were most commonly used as first-line pharmacotherapy in pediatric anxiety, we examined a large commercial insurance claims database for the years spanning 2004 to 2014 and identified children aged 3–17 years who had a medical claim with an anxiety disorder diagnostic code. We then identified the subset of children who had newly initiated a prescription antianxiety medication, for a total sample of 84,500.

Seventy percent of children filled an SSRI prescription as their initial antianxiety medication, with variation by specific anxiety disorder. A smaller fraction within that group, 7% of children overall, initiated with an SSRI and another antianxiety medication class. The most common non-SSRI antianxiety initial medication was benzodiazepines at 8%, with greater use in older children (14–17 years = 11% vs 5% for 3–13 years). Non-SSRI antidepressants (7%), hydroxyzine (4%), clonidine/guanfacine (4%), and atypical antipsychotics (3%) were also used as initial medications in children.

Consistent with treatment recommendations, SSRIs were the most commonly used first-line medication class for pediatric anxiety, suggesting reasonable penetration of evidence-based approaches to care in the community. However, a small subset of children initiated pharmacotherapy with two antianxiety medication classes or with a non-SSRI antianxiety medication, for which there is less evidence on effectiveness. While potential reasons exist for using those initial pharmacotherapies, we cannot determine from the data whether prescribing practices were consistent with good therapeutic rationales. We hope this report on the initial antianxiety pharmacotherapy of pediatric anxiety disorders will inform future efforts to improve medication selection.

Financial disclosure:Dr Bushnell has received grant/research support from the National Institute of Mental Health under award numbers F31MH107085 and T32MH013043. Dr Gaynes has received grant/research support from M3 Information. Dr Rynn has received grant/research support from Pfizer, Shire, NIMH, NICHD, and NYP-Houth Anxiety Center Funds.

Disclaimer: This research was supported by the National Institute of Mental Health; the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Please see the publication for author disclosures and the funding sources of the database used in the study.