Anxiety and OCD — PRN Medication Use — Clinical Pathway: Outpatient Behavioral Health and Primary Care

Anxiety Disorder and OCD Clinical Pathway — Outpatient Behavioral Health and Primary Care

PRN Medication Use

General Guidance for PRN Medication Use for Anxiety in Children / Teens

  • No evidence currently supports the use of PRN medication for anxiety in children/teens.
  • Consider referral to a Pediatric Psychiatrist for patients who fail evidenced based treatment for anxiety.
  • Augment psychotherapy treatment as indicated
  • Reinforce healthy life habits
  • Reassess co-morbidities, risk factors
  • Review if referral for medical evaluation is clinically indicated
Disadvantages
  • No evidence supports PRN medications as effective anxiety treatment
  • Significant risk is associated with their use, including dependence and tolerance
  • They reduce anxiety for brief periods and then anxiety returns (rebound anxiety)
  • Rebound anxiety is often higher than before taking the PRN medication
  • They can undermine the therapeutic interventions that the patient is being taught
  • For example:
    • When a patient takes a PRN medication prior to an exposure, the patient is learning “I need to take a medication to decrease my anxiety” instead of “I can learn to tolerate my anxiety using my strategies and it will come down over time.”
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  • Challenging to discontinue due to quick onset of action and relief of symptoms compared to using behavioral interventions
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  • In general it is better to avoid PRN medications and follow evidence-based treatments SSRI/SNRI Medication Dosing Recommendations
Considerations for Brief Use of PRN Medications
  • May be helpful in patients with:
    • Severe anxiety/developmental delays that have prevented necessary medical testing
    • Acute severe anxiety occurring over a weekend, and therefore the clinician could not see the patient in clinic for a couple of days.
  • May be adjunctive treatment for treatment resistant anxiety
    • PCP consider BH referral if this may be needed
Prescribing PRN
  • If indicated for special circumstance:
    • Prescribe maximum of 2 doses
    • See patient as soon as possible
    • Review risks associated including rebound anxiety, dependence, tolerance
    • Discuss with patient/family that prescription is time limited
  • Document rationale for brief use of PRN medication, treatment discussion and plan for follow up
  • Consider need to start/titrate SSRI/SNRI at visit
Medications
  • PRN anti-anxiety therapies are not approved by the FDA for pediatrics
  • They may be tried in exceptional circumstances and include (in no particular order):
    • Hydroxyzine
    • Diphenhydramine
    • Lorazepam