Posttraumatic Stress Disorder in Children Medication
- Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD more...
Medication Summary
Selective serotonin reuptake inhibitors (SSRIs) are the medications of choice in managing anxiety, depression, avoidance behavior, and intrusive recollections. Beta-blockers and alpha-adrenergic agonists (eg, guanfacine, clonidine) are helpful in reducing arousal, decreasing forced reexperiencing of the trauma, and avoiding the neurophysiologic kindling that can contribute to chronic illness. These medications are most helpful if used very soon after the onset of symptoms.
Mood stabilizers can be helpful in dealing with increased arousal, impulsivity, and already established kindling once the illness has become chronic. The mood stabilizers are not interchangeable. Carbamazepine may ameliorate persistent reexperiencing of the event, whereas valproic acid may ameliorate symptoms of avoidance.
Atypical antipsychotics are infrequently used compared with the medications listed above. They should only be used for patients unresponsive to other medications or when marked agitation or psychosis is present.
Selective serotonin reuptake inhibitors (SSRIs)
Class Summary
These agents are the first-line medications for managing anxiety, depression, avoidance behavior, and intrusive recollections. Antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT) and may also have a weak effect on norepinephrine and dopamine neuronal reuptake.
SSRIs are greatly preferred to the other classes of antidepressants because the adverse effect profile of SSRIs is less prominent and improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.
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 by 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 (both 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 both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.[7] This is the largest study to date to address this issue.
Currently, evidence does not associate obsessive compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.
Sertraline (Zoloft)
FDA approved for OCD in children >6 y. FDA approved for PTSD in adults. PO liquid concentrate available.
Fluoxetine (Prozac)
FDA approved for depression and OCD in children and adolescents. Half-life is 7-9 d. Most activating of SSRIs. Some believe most effective for depression. Many people require adjuvant medication to help sleep (eg, trazodone 100 mg). Liquid formulation available.
Paroxetine (Paxil)
Not approved by FDA for use in children. PO susp available.
Citalopram (Celexa)
Newest SSRI. Appears to have the most benign side effect profile, with fewer sexual adverse effects than other SSRIs. Not FDA approved for children. PO solution available.
Beta-adrenergic–blocking agents
Class Summary
These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.
Propranolol (Inderal)
May be useful for treatment of hyperarousal.
Alpha-adrenergic agonists
Class Summary
The centrally acting antihypertensives clonidine and guanfacine have been used to treat children with attention deficit hyperactivity disorder. An inhibition of norepinephrine release in the brain may be the mechanism of action.
Clonidine (Catapres)
Not approved by FDA for any psychiatric uses in children. Available in tab or transdermal skin patches. Frequently given to children. Affects alpha1-, alpha2-, and alpha3-adrenergic receptors.
Guanfacine (Tenex)
Action similar to clonidine, but has a longer half-life and less sedation. More selective alpha-agonist. Not recommended for children < 12 y. Effects alpha2-adrenergic receptors only.
Mood stabilizers
Class Summary
These agents are helpful in dealing with increased arousal, impulsivity, and already established kindling when posttraumatic stress disorder (PTSD) becomes chronic.
Carbamazepine (Tegretol)
Initially used as an antiseizure medication and mood stabilizer. Also used for explosive outbursts.
Valproic acid (Depakene, Depakote)
Useful in certain types of epilepsy, bipolar disorder, migraine headaches, impulsivity, dissociation, and PTSD. Extended-release (ie, qd administration) form is available. Requires higher dosing because 80% absorbed.
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