When film producer Karin Gornick made a documentary about teens and anxiety, she purposely didn’t mention one thing: anxiety drugs.
That’s because medicating children for anxiety is so controversial that Gornick feared the topic would detract from the film’s core message, which is that the nation is awash in anxious teens who need help.
Getting a prescription isn’t normally so contentious. In fact, doctors say some parents demand antibiotics even when their children don’t need them.
But when a doctor recommends that a teen take a drug for anxiety, parents often hesitate. They worry about side effects, which can range from the benign (insomnia or drowsiness) to the terrifying (suicidal thoughts and behavior). They wonder about the long-term effects, which cannot be known with certainty since these drugs have been on the market for three decades or less.
They also worry the child will be fundamentally changed after taking the pills or that the child will become dependent. These were among the concerns Gornick had when a doctor first suggested medication for her teen son.
“I feared it would change the brain chemistry of my child, and he would never be able to function without medication again. I was worried it would change his personality,” Gornick said.
So what's true and what's a parent to do?
Amid a cacophony of competing voices on the subject, one thing is clear: Not every anxious teen needs medication.
Teens with mild anxiety may benefit from breathing and relaxation techniques, journaling, art and music therapies and exercise, and most teens with moderate anxiety improve with cognitive behavioral therapy, according to Dr. Henry Berman, a pediatrician specializing in adolescent medicine at Seattle Children's Hospital and a clinical professor at the University of Washington School of Medicine.
Berman and many other doctors believe, however, that medication is necessary once anxiety goes from moderate to severe. They don’t see a prescription as a panacea, but as one stepping stone on the road to peace.
Reasons for an Rx
There is no medical test that can diagnose extreme anxiety like a throat culture confirms strep throat. The diagnostic manual of the American Psychiatric Association gives six criteria for a diagnosis of generalized anxiety disorder. Chief among them is excessive worry — about a variety of things — that persists for at least six months.
Most people worry about something, so what constitutes excessive worry?
According to the Diagnostic and Statistical Manual of Mental Disorders, it's anxiety that impairs basic functioning, making it difficult for a teen to go to school or participate in activities he used to enjoy.
Also required for a diagnosis is one or more of these symptoms consistently present for at least six months: feeling restless or on edge, being easily fatigued, having difficulty concentrating, irritability, muscle tension and difficulty falling or staying asleep.
According to the National Institutes of Health, about 32 percent of American teens suffer from some type of anxiety disorder, and about 8 percent have cases that are severe. But although diagnoses of anxiety disorders are increasing, prescriptions for the most commonly prescribed class of anxiety medication remain stable.
A recent study published in JAMA examined prescription drug use among children and adolescents between 1999 and 2014 and found no clinically significant change in the number of teens who take selective serotonin reuptake inhibitors, or SSRIs.
This may be, in part, because of parental fears like the ones that troubled Gornick.
Dr. Ian Kodish, a pediatric psychiatrist and researcher at Seattle Children’s Hospital, understands the concern. “I think being cautious is a really good instinct,” Kodish said.
But, he added, “I think there is a converse risk, the effects of not treating anxiety, and how that is going to play out in terms of disability and consequences,” he said.
While parents worry that medication may conceal a child’s personality, sometimes the reverse is true, and anxiety is suppressing the child’s true self, Kodish said, adding that the right medication, used for the right amount of time, can allow the child to flourish.
Head of the class: SSRIs
The most commonly prescribed drugs for anxiety are SSRIs. In an examination of 84,500 children prescribed medication for anxiety between 2004 and 2014, researchers in North Carolina and New York found that 70 percent received an SSRI alone, and 7 percent took an SSRI and another medication.
Serotonin is a chemical messenger present in the brain and gut, one of the “feel-good” neurotransmitters that contribute to our sense of well-being. The more serotonin we have, the happier and calmer we are, scientists believe.
SSRIs work by stopping the neural train that shuttles serotonin into our brain, blocking its reabsorption and making more of it available to make us feel good.
Fluoxetine (sold under the brand name Prozac) was the first SSRI to enter the market, in January 1988. The Food and Drug Administration later approved five other types of medicine in this class. Widely known brands include Celexa, Lexapro, Paxil and Zoloft, the most prescribed psychiatric drug in 2016.
Filling up our bodies with feel-good chemicals, however, isn’t as simple as it sounds. Too much serotonin can cause a fatal condition called serotonin syndrome. And in some people, before SSRIs start to work, they temporarily block serotonin production, leading to a deficit.
SSRIs carry the FDA’s infamous “black box” warning of an increased risk of suicidal thoughts and behavior in children, teens and young adults up to age 24. The risk, which declines as we age, is greatest in the first two weeks of taking the medication.
In other words, people sometimes get worse before they get better. It can take about three months to see if a particular brand of medicine will work and to establish the optimal dose, Kodish said. During that time, a teen may also have to adjust to temporary side effects that can include drowsiness, insomnia, nausea, dizziness and headaches.
The medicine does not cure anxiety; it works in the background to ramp down the incessant “fight or flight” sensation that torments people with severe anxiety, allowing them to think more clearly and realistically about what is making them fearful.
With the right medicine, “you usually start seeing some relief at four to six weeks. Sometimes the child might not notice it, but the parent or caregiver notices. By eight to 12 weeks, you should start seeing a change,” said Dr. Moira Rynn, consulting professor and chair of the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center.
This process can take months, so parents should expect their teens to be on the medicine they settle on for at least six months to a year, before going off it gradually, Rynn said.
The B team
Faster, but short-term, relief is found in benzodiazepines, or “benzos,” which work by suppressing nerve activity; in short, they act as a sedative.
These drugs, which include Xanax, Valium and Ativan, are also used to treat seizures, depression and insomnia. They are highly addictive and should only be taken short-term. Benzos were involved in nearly a third of drug overdose deaths in the past 30 years.
Increasingly popular for short-term use are beta blockers, which are primarily used to treat heart conditions and high blood pressure. The drugs, which mute adrenaline in our bodies, work quickly to reduce physical symptoms of anxiety and fear, such as shaky hands, rapid heartbeat and shallow breathing. A new startup called Kick, based in San Francisco, proposes to prescribe and provide these pills over the internet, saying they can help people calm down before an important work presentation or a date.
Beta blockers are sometimes prescribed to teens with social phobias or performance anxiety. Side effects include constipation, upset stomach and headaches.
If the thought of treating your anxious teenager with their grandparents’ heart medicine isn’t anxiety-inducing enough, there’s also a new treatment for anxiety that was previously primarily used for tuberculosis.
D-cycloserine is being tested, in conjunction with exposure therapy, for a type of anxiety called social phobia.
Other research is looking into how antibiotics can help mental health disorders; for example, one recent trial investigated if minocycline, an antibiotic prescribed for acne and some sexually transmitted infections, helps children with obsessive-compulsive disorder. (The results have not yet been published.)
But for now, an SSRI, used in conjunction with a minimum of 16 sessions of cognitive behavioral therapy, is the gold standard for treating anxiety in teens and effective in 70 to 80 percent of cases, Rynn said.
When cognitive behavioral therapy or medication is used alone, the effectiveness rate drops to 50 or 60 percent, she said.
But, she added, “Sometimes you have to try other medication when they’re not responding to that first line of treatment.”
A family decision
New research suggests that untreated anxiety affects not only the teens, but also can span subsequent generations, since anxiety seems to be heritable in some families.
“We need to support kids as best we can, while being mindful of doing it in the most conservative way we can, in terms of adjusting their neurochemistry,” Kodish said.
Rynn said it’s important that both the parents and teen be comfortable with the treatment they choose, and she doesn’t believe teens should be compelled to take medicine if they are strongly against it.
“It is a serious decision to prescribe a medication, and not every family is comfortable with that,” Rynn said. “You have to meet the family where they are.
“The good news is, you have cognitive behavioral therapy, and you can try that first. The hard part is, you’ve got to do it. There’s homework between the sessions. It's work; it's not easy,” she said.
“That’s one challenge. The other challenge is finding professionals who are really trained in delivering that treatment properly and someone who knows how to work with children and teenagers. You really have to look at people's credentials.”
Because there’s a nationwide shortage of pediatric psychologists and psychiatrists, some families might not be able to find a suitable therapist, or the teen may decide he just doesn’t want to do the work and would rather take pills. Pediatricians can prescribe them, but because of the risks, Rynn says the parents and doctor should carefully monitor the teen.
Suicidal ideation is not a common side effect, and it's even less so when an SSRI is used to treat anxiety, but there’s still a small risk that it can occur.
Beyond drugs, supporting anxious teens may also mean parents need to make changes. Parents often want to alleviate their children’s distress, “but usually in doing so, you start to accommodate it,” said Kodish, at Seattle Children's Hospital.
“There needs to be a balance between the parents’ ability to validate their child’s distress and support them, but not to take them away from experiences that might be mildly stressful.”
That's one thing Gornick learned while dealing with her son's anxiety as a single parent: that she had to step back and trust him to deal with difficulties. Another thing that changed was her initial resistance to medication, which she feared would fundamentally change her son and get him hooked. "I was wrong," she says.
Her son will be a senior in high school this fall, she said. Without debilitating anxiety and without drugs.
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