Pediatric Social Phobia and Selective Mutism Medication

Updated: Apr 14, 2020
  • Author: Bettina E Bernstein, DO, DFAACAP, DFAPA; Chief Editor: Caroly Pataki, MD  more...
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Medication Summary

SSRIs, especially fluoxetine, have demonstrated effectiveness for disabling social anxiety disorder and selective mutism. Experts postulate that SSRIs modulate anxiety symptoms both in the brain and peripherally in the gastrointestinal/autonomic nervous system. Peripheral gastrointestinal and autonomic nervous system activation account for the usual anxiety symptoms experienced (ie, cramping, dry mouth, tightness of the chest, palpitations, lightheadedness, dizziness). Drugs should be used only when symptoms significantly affect a patient's daily activities. Many people are mildly socially anxious, and only a small percentage need medication. Medical supervision including a cardiology consultation is advised if using a higher than usual dose range as may be needed to achieve symptom remission with SSRIs and SNRIs due to the increased risk of cardiac arrhythmia. [55]

Before starting treatment with SSRIs and whenever increasing or decreasing medication dosage, question the patient and family whether there is a prior history of self-harm and potentially suicidal behavior. When using SSRIs, suicidal behavior and a history of self-harm can be potential contraindications to treatment with fluoxetine (or other SSRIs or SNRIs). It is also important to ask about the presence of other conditions that could potentially worsen SSRI-induced hyponatremia. [2]


Selective serotonin reuptake inhibitors

Class Summary

These antidepressant agents are chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT) and may have a weak effect on norepinephrine and dopamine neuronal reuptake. They have been used to treat anxiety, phobias, and obsessive-compulsive disorders.

These agents potentiate serotonergic activity in the CNS that results from inhibition of neuronal reuptake of serotonin and also block the influx of serotonin into platelets. Receptor and neurohistochemical changes result in changes in modulation of emotions.

SSRIs are greatly preferred over the other classes of antidepressants because of their increased tolerability, which tends to lead to improved compliance. Recent studies by the US Food and Drug Administration (FDA) have shown an association of increased risk of suicidal ideation or attempts with SSRIs. 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 a 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 FDA issued a public health advisory regarding reports of suicidality in pediatric patients 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 recent 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. This is the largest study to date to address this issue.

The FDA continues to closely monitor the risk of suicidality, particularly in children younger than 18 years who are treated with antidepressants, antiseizure medications, mood stabilizers, and stimulants. Preliminary findings have shown that longer-acting antidepressants seem less likely to cause newly onset suicidality than shorter-acting antidepressants. [56]

A cohort study looked at suicide risk for individuals younger than 24 years in the context SSRIs and SNRIs antidepressant use in the context of the current “Black Box” warning regarding increased risk of suicidal ideation in this cohort. [57] This retrospective cohort study included 36,842 children aged 6-18 years enrolled in Tennessee Medicaid from 1995-2006 who were new users of 1 of the antidepressant medications of interest (defined as filling no prescriptions for antidepressants in the preceding 365 d). It found that there was increased risk for suicide attempts among users of multiple antidepressants concomitantly; however, there was no evidence of increased risk of suicide attempts when one medication was prescribed, and the adjusted rate of suicide attempts did not differ significantly among current users of SSRIs and SNRIs compared with current users of fluoxetine. [57]

Fluoxetine (Prozac)

DOC for social anxiety disorder because it has specific approval by the FDA for that disorder. DOC for selective mutism because this disorder is often associated with social anxiety disorder when untreated. Recommended to be administered bid to prevent withdrawal reactions. The FDA has not established the safety of this medication for children, except for those with major depressive disorders. Not recommended for use in children unless very closely supervised; FDA "Black Box" warning issued because of concerns about the risk of new-onset suicidal ideation, new-onset homicidal ideation, or self-injurious behavior. Clinical trials in the United Kingdom found a 1.5-3.2 times greater risk of self-harm and potentially suicidal behavior in children and teenagers treated with paroxetine than in those treated with placebo.

Generally, begin with 10 mg/d in divided doses bid because the half-life of the medication is 10-16 h after 1 dose and 21 h after multiple doses so that after the medication has been administered for 2-4 wk, once daily administration may give almost as good a blood level as twice daily dosage with improved patient compliance; increase dosage by not more than 10 mg/wk; morning administration recommended to minimize GI adverse effects; if giving syrup (10 mg/5 mL), instruct the parent on how to avoid overdosage. Steady-state levels take 2-6 wk to achieve.

Sertraline (Zoloft)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. First SSRI used in children and adolescents. Relatively safe in overdose. May cause more gastrointestinal adverse effects than other SSRIs. May be given as a liquid or capsule. May give as once daily dose or in divided doses. Presence of food does not appreciably alter levels of the medication. May take up to 4-6 wk to achieve steady-state levels of the medication, as it has a long half-life. FDA approved in children 6 y and older for obsessive-compulsive disorder.