At a recent pharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry, John Walkup MD, vice chair of child and adolescent psychiatry at the Presbyterian Hospital/Weill Cornell Medical Center. He stated that using a subtherapeutic dose continues to stigmatize children for being on medications and having continued symptoms while not getting the benefit of the treatment. Dr. Walkup was a principle investigator of a large clinical trial of sertraline in pediatric anxiety disorders that appeared in the New England Journal of Medicine in 2008. The average daily dose of sertraline in that study was 134mg and was generally well tolerated. Many patients responded to sertraline alone (55%), cognitive behavior therapy alone (60%), and especially to the combination (81%).
This story first appeared in Clinical Psychiatry News.
In addition to many residual symptoms, the practice of using too low of a dose can lead to physicians and families believing that a medication is ineffective when it may not be, which in turn can lead to frequent switching of agents.
It is quite reasonable to attempt to treat many children and adolescents with mood and anxiety disorders first with a trial of cognitive-behavioral therapy. If pharmacologic treatment is indicated, however, physicians should consider titrating the dose upwards if a patient has not had a robust response at a lower dose for an extended period of time (at least a month). During that interim period, it can be very useful to discuss with the family other nonpharmacological interventions for anxiety including exercise, mindfulness practices, and even listening to classical music.
Physicians should also be aware, however, that SSRIs can sometimes lead to worsening symptoms of irritability, so a good review of how dose is related to symptoms can be very useful. In addition, new cardiac warnings have been released for higher doses of citalopram and escitalopram.