Pediatric Specific Phobia Medication
- Author: William R Yates, MD, MS; Chief Editor: Caroly Pataki, MD more...
Although behavioral therapy is the main route of intervention for specific phobias that interferes with functioning, case reports have documented improvement of symptoms with the use of selective serotonin reuptake inhibitors (SSRIs).
Benzodiazepines have not been shown to be effective and play a limited role for most severe, chronic specific phobias. However, they may be helpful in specific situations in which intense fear as a result of exposure to a specific phobic stimulus cannot be avoided. For example, in an adolescent with severe claustrophobia who has an urgent need for a head MRI, a course of behavioral therapy is not feasible owing to time constraints and SSRI drugs would not be helpful. In this setting, pre-MRI scan treatment with a benzodiazepine may be quite helpful.
Selective serotonin reuptake inhibitors (SSRIs)
These antidepressant agents have been used as antianxiety medications to treat such conditions as panic disorders (with or without agoraphobia), generalized anxiety disorders, obsessive-compulsive disorders, and specific phobias.
SSRIs are now strongly preferred over other classes of antidepressants owing to their clinical efficacy and tolerability. The adverse effect profile of SSRIs is less prominent, with improved compliance. These agents also do not have the cardiac arrhythmia risk associated with tricyclic antidepressants (tertiary and secondary amine). Arrhythmia risk is especially pertinent in accidental and intentional overdose. The suicide risk must always be considered when a child or adolescent with mood disorder is treated with any psychotropic medication, including SSRIs.
Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use in persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed, because suicidality occurred in treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
A 2006 study did not support an increase in suicide risk or attempts after antidepressant medication was started or a higher risk with the newer types of antidepressant medication. The study evaluated records of more than 65,000 children and adults treated for depression over a 10-year period.
Despite the results of this investigation, close, frequent monitoring of any patient treated with psychotropic medications remains imperative.
Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. Selective serotonin inhibitors such as fluoxetine have less sedation, cardiovascular, and anticholinergic effects than the tricyclic antidepressants.
Citalopram enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. Citalopram is FDA approved for depression but has been used for the treatment of anxiety disorders. SSRIs are the antidepressants of choice because of their minimal anticholinergic effects.
Escitalopram is an SSRI and S-enantiomer of citalopram. It is used for the treatment of depression and has been used to treat other anxiety disorders. Its mechanism of action is thought to be potentiation of serotonergic activity in the CNS, resulting from inhibition of CNS neuronal reuptake of serotonin.
Fluvoxamine enhances serotonin activity due to selective reuptake inhibition at neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer side effects than tricyclic antidepressants.
It is FDA-approved for obsessive-compulsive disorder in children (8-17 y) and adults. It may also be helpful for the treatment of other anxiety disorders.
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. It is FDA approved for panic disorder, depression, social anxiety disorder, and obsessive-compulsive disorder. It may also be helpful for other anxiety disorders..
Sertraline is a selective serotonin inhibitor that is FDA approved for panic disorder, posttraumatic stress disorder, social anxiety, and obsessive-compulsive disorder. Sertraline may also be helpful for the treatment of anxiety disorders.
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