Anxiety and OCD — Treatment of Resistant Anxiety — Clinical Pathway: Outpatient Behavioral Health and Primary Care

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

Treatment of Resistant Anxiety or Non-Responders

  • Ensure behavioral therapy is maximized.
  • If no clinical response first or second line medications, pediatricians should refer to or consult with psychiatry for review of patient treatment plan before proceeding.
Definition of Resistant Anxiety
  • Failure of adequate response after at least 12 weeks of adequate dose of medication
  • SSRI Example:
    • At least 12 weeks in duration, with the last 4 weeks at a
      dosage equivalent to Fluoxetine 40mg or Sertraline 150 mg
Evaluate for Potential Causes
  • Assess for:
    • Non compliance with medication
    • Presence of psychiatric or medical comorbidities
    • Quality of sleep
    • Psychosocial stressors
Predictors of
Poorer Treatment Response
  • Assess for:
    • Severity and chronicity of symptoms
    • Presence of co-morbidities
    • Substance use/abuse
    • Family stressors
    • History of abuse
    • Hopelessness
    • Parental depression
Medical Causes
  • Consider need for referral for further medical evaluation
  • Medical conditions associated with anxiety:
    • Hyperthyroidism
    • Epilepsy
    • Asthma
    • Migraine
    • Functional GI disorders
    • Cardiac arrhythmias
    • Chronic Pain
    • Dysmenorrhea
    • Diabetes
    • SLE
    Medications
    • Medications that can increase risk of anxiety symptoms:
      • Steroids
      • Asthma medications
      • Sympathomimetics
      • Antihistamines
      • OTC cold medications
    Treatment
    • Switch to another SSRI and/or add psychotherapy or other psychosocial interventions
    • PCP’s consider referral/consultation with a Pediatric Psychiatrist
    Escalation
    • If incomplete response after 2nd SSRI, consider switch to SNRI with continued psychotherapeutic/psychosocial interventions
    • No pediatric data exists to guide the management of poor response to 2nd line medications
    • Alternative anti-anxiety therapies not FDA approved for use in children and adolescents and for which there is very little evidence for use but may have benefit include (in no particular order):
      • Switch to another SSRI including Citalopram (non-formulary)
      • Switch to another SNRI including Venlafaxine (non-formulary)
      • Switch to Mirtazapine (atypical anti-depressant)
      • Switch to Buspirone (increases free serotonin, NE, DA)
    • For additional information on medications, please refer to formulary