PHARMACOTHERAPY OF SOCIAL ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS
Authors: Fujii *Yutaka , Asakura Satoshi , Mitsui Nobuyuki 
Published: February 2025

Background

Social anxiety disorder (SAD) is one of the most common psychiatric disorders in Japan, with teenagers being the most common age of onset, although the recently published Japanese guidelines for SAD 1 are intended for adults and not for children and adolescents.

Aims & Objectives

Review placebo-controlled drug trials for SAD in children and adolescents. Method Placebo-controlled trials in children and adolescents with SAD published from April 1986 to August 2023 were reviewed and summarized.

Results

There were one randomized placebo-controlled trial (RCT) of paroxetine 2, one of venlafaxine 3, and one of fluoxetine plus psychotherapy versus placebo 4 in children and adolescents. There have been no further RCTs in child and adolescent subjects reported since the earlier National Institute for Health and Care Excellence (NICE) clinical guidelines reviewed them in 20135. The three RCTs showed efficacy with mild to moderate effect sizes compared to placebo in the treatment of SAD, but all agents had significantly more side effects, including gastrointestinal symptoms, compared to placebo. In addition, for paroxetine and venlafaxine, suicidal ideation, which was not reported with placebo, was reported in the actual drug group. Psychotherapy was more effective than fluoxetine. Other than RCTs, one open- label study each of sertraline 6 and escitalopram 7 have been reported. Open trials have also shown efficacy, but severe side effects have been reported: tremor, nausea, headache, insomnia, and restlessness.

Discussion & Conclusion

A network meta-analysis of anxiety disorder treatment in children and adolescents8 has shown that serotonin reuptake inhibitors (SSRIs) are the only class of drugs that are superior to placebo in both anxiety reduction and treatment response rate. However, the high dropout rates due to activation and gastrointestinal symptoms, as well as the high incidence of suicidal ideation, should be treated cautiously. NICE clinical guidelines state that drugs should not be routinely offered for the treatment of social anxiety disorder in children and adolescents due to the high risk of side effects. On the other hand, others argue that SSRIs can be considered in the initial phase of treatment for anxiety if the anxiety is severe or causing significant functional impairment, or if the child does not benefit from psychotherapy9. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines point out that the increased risk of suicide and self-harm with antidepressants for major depressive disorder may not apply to anxiety disorders and suggest that medication should be reserved for patients who do not respond to psychotherapy10. In any case, careful observation will be required when considering prescriptions. Although evidence is insufficient, SSRIs and serotonin noradrenaline reuptake inhibitors, which have been shown to be effective in adults with SAD, may also be effective in children and adolescents with SAD. Further RCTs are warranted to establish the medication's efficacy and tolerability.

References

1.Asakura S, Yoshinaga N, Yamada H, et al. Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology: Clinical practice guideline for social anxiety disorder (2021). Neuropsychopharmacol Rep 2023;43:288-309.

2.Wagner KD, Berard R, Stein MB, et al. A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Arch Gen Psychiatry 2004;61:1153-62.

3.March JS, Entusah AR, Rynn M, Albano AM, Tourian KA. A Randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder. Biol Psychiatry 2007;62:1149-54.

4.Beidel DC, Turner SM, Sallee FR, Ammerman RT, Crosby LA, Pathak S. SET-C versus fluoxetine in the treatment of childhood social phobia. J Am Acad Child Adolesc Psychiatry 2007;46:1622-32.

5.National Collaborating Centre for Mental Health. Social Anxiety Disorder: Recognition, Assessment and Treatment. Leicester: British Psychological Society; 2013.

6.Compton SN, Grant PJ, Chrisman AK, Gammon PJ, Brown VL, March JS. Sertraline in children and adolescents with social anxiety disorder: an open trial. J Am Acad Child Adolesc Psychiatry 2001;40:564- 71.

7.Isolan L, Pheula G, Salum GA, Jr., Oswald S, Rohde LA, Manfro GG. An open-label trial of escitalopram in children and adolescents with social anxiety disorder. J Child Adolesc Psychopharmacol 2007;17:751- 60.

8.Dobson ET, Bloch MH, Strawn JR. Efficacy and Tolerability of Pharmacotherapy for Pediatric Anxiety Disorders: A Network Meta-Analysis. J Clin Psychiatry 2019;80.

9.Korczak DJ, Canadian Paediatric Society MHaDDC. Use of selective serotonin reuptake inhibitor medications for the treatment of child and adolescent mental illness. Paediatr Child Health 2013;18:487-91.

10.Bandelow B, Allgulander C, Baldwin DS, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders. World J Biol Psychiatry 2023;24:79-117.