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

Abstract

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
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