Treatment of GAD in Adolescents and Children
The treatment of GAD in adolescents and children should be multifaceted, including psychotherapy for the patient, psych-oeducation for the parents, and pharmacotherapy when other psychotherapeutic interventions have not produced satisfactory outcome. CBT is successful in treating GAD in children. The addition of family anxiety management skills taught to parents appears to increase treatment success.
Pharmacotherapy in children and adolescents differs from that of the adult population primarily because of the difference in the hepatic biotransformation and elimination of many psy-chotropic drugs that may require some adjustments in treatment regimen. Hepatic metabolic rate is faster in children and adoles-cents than in adults, reaching adult values around 15 years of age. Thus a particular milligram per kilogram (mg/kg) dose will yield a lower blood level in a child than in an adult, and higher mg/kg doses than based on those for adults may be necessary. This ap-plies for all liver-metabolized drugs, such as antidepressants, anx-iolytics, anticonvulsants and neuroleptics. In addition, the higher clearance of these drugs requires more frequent administration of medications (i.e., small divided doses rather than one large dose).
Over the years, a number of medications have been used in the treatment of childhood GAD (previously classified as over-anxious anxiety disorder). Unfortunately, only a few studies have been conducted in children with overanxious anxiety disorder. Given these limited findings and the reported occurrence of sig-nificant behavioral activation, other side effects, and their addic-tive potential, the use of benzodazepines to treat children with GAD is suspect.
The use of SSRIs in the treatment of GAD in children and adolescents appears promising; however, no controlled trials with large samples have been conducted. Buspirone may also be effective in the treatment of GAD in children and adolescents. No controlled studies have been completed for the treatment of GAD with buspirone in children to date. TCAs have not been studied in overanxious anxiety disorder. It should be noted that cardio-vascular side effects may occur more frequently in children and adolescents than in adults, and preexisting conduction abnormal-ities may be associated with significant TCA effect on cardiac conduction. However, the clinical significance of TCA-induced changes in cardiac conduction is not clear. Given this lack of ef-ficacy data for GAD and the concern of significant cardiovascular side effects in children, TCAs should not be a first-line treatment in children and adolescents with GAD.
The clinician is frequently faced with a patient whose anxiety symptomatology is not responding satisfactorily to the standard treatment. Different factors, such as inadequate length of treat-ment, low dose and noncompliance, may contribute to treatment failure in the management of patients with GAD. Pharmacologic treatment is often complicated by the occurrence of side effects, which may impair quality of life, deter clinicians from prescrib-ing adequate doses and contribute to noncompliance. For exam-ple, some antidepressants, including SSRIs, TCAs and venlafax-ine, are associated with activation, overstimulation, or “jitters” primarily during the initial stage of treatment. When evaluating noncompliance, clinicians should also assess for akathisia and worsening of anxiety and hypomania or mania. Further, the pres-ence of comorbid general medical and psychiatric conditions in GAD patients may be associated with nonresponse or lower re-sponse rates and should be carefully assessed during patient eval-uation. Finally, the use of concurrent medications that can pre-cipitate anxiety symptoms may affect the response to treatment.
The clinician should always evaluate whether an adequate treatment trial was complete. We believe that an attempt should be made to maintain the patient on medication for at least 6 weeks. Although there are no data suggesting that certain doses may be particularly effective in the treatment of GAD, it is ad-visable to titrate the medication up to maximally tolerated doses prior to discontinuing the medication for nonresponse. It is im-portant to inquire about the presence of side effects such as seda-tion, anticholinergic effects, or sexual side effects, which may limit the attainment of a therapeutic dosage and reduce compli-ance. Additionally, many patients with GAD fear that they may become “drug-dependent” and thus avoid dose increases. Some estimate of the patient’s compliance may be helpful in determin-ing whether a treatment was adequate, as indicated by blood plasma levels or pill counts. Drug plasma levels may also be useful to identify patients who are rapid metabolizers. A careful evaluation for the presence of psychiatric comorbid conditions that may contribute to treatment refractoriness should follow. As mentioned, comorbidity which may reflect more severe loading for psychopathology is often associated with increased sever-ity of illness and poorer response to treatment in comparison to patients with an uncomplicated (i.e., single) disorder. Thus, treatment strategies in GAD patients with a concurrent disorder may differ from those in an uncomplicated disorder, often requir-ing multiple drug therapy. The clinician should also be alert to the presence of underlying general medical conditions such as hyperthyroidism which may present with refractory anxiety, or conditions/medications which may alter the effects of treatment such as hepatic disease or medications (e.g., steroids) that affect hepatic clearance.
The use of psychotherapy, such as cognitive–behavioral therapy, in conjunction with pharmacotherapy may also enhance response in the treatment-resistant patient. Finally, education and psychological support for patients and their families may help them better to understand and deal with their illness, especially during periods of increased stress, and consequently improve treatment outcome.