When your child has an anxiety disorder, the decision to medicate isn’t one you take lightly. You worry about near-term side effects and long-term consequences. You wonder which medication has the best chance at helping, and you hope that relief will come sooner rather than later.
Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are the most common antidepressant medications prescribed for young people with generalized anxiety disorder and obsessive-compulsive disorder (OCD). But there might be a key difference between the two, according to a recent report in the Journal of the American Academy of Child and Adolescent Psychiatry.
In patients younger than 18 years old, SSRIs are associated with side effects that can lead to the discontinuation of medication. And compared with SNRIs, SSRIs are more likely to cause an adverse event known as activation syndrome. Symptoms include irritability, impulsivity, insomnia, and restlessness.
The catch: SSRIs, which are generally effective for pediatric anxiety and OCD, are the recommended first-line medications for the conditions.
So how do you balance a promising treatment and the risk of side effects? If you’re considering SSRIs or SNRIs for your child, here’s what to know.
SSRIs and SNRIs: What’s the Difference?
Serotonin is a neurotransmitter, or a chemical substance responsible for sending messages from one nerve cell to another throughout your body. It plays a role in how your heart, lungs, and gastrointestinal system work, but it’s best known for its regulation of mood and behavior. Low serotonin is linked to anxiety, OCD, and other mental health conditions.
SSRIs work by preventing the reuptake, or reabsorption, of serotonin in the brain—which increases serotonin levels. In most cases, clinicians prescribe SSRIs for pediatric anxiety and OCD before trying other medications. That’s because there’s strong evidence that SSRIs are effective for these conditions, according to a review in Current Psychiatry.
Typically, if SSRIs don’t have the desired effect, SNRIs are then considered. SNRIs work by preventing the reuptake of two neurotransmitters: serotonin and norepinephrine.
Side Effects of SSRIs and SNRIs
Good news for parents: Most commonly prescribed antidepressants have been used safely in pediatric patients for two to three decades, according to a review in Current Psychiatry.
That said, it’s always important to discuss any potential side effects with your child’s clinician.
Both SSRIs and SNRIs have similar side effects:
- Trouble sleeping
- Weight gain
- Activation syndrome, which can include irritability, impulsivity, insomnia, and restlessness
Nausea and upset stomach are typical side effects when starting any SSRI or SNRI—or when the dose is increased. These side effects usually go away after about a week. With some of these drugs, dizziness, constipation, and blurred vision are also possible.
Go Low and Slow for the Right Treatment
Preventing side effects from psychotropic medication isn’t as simple as switching all children from SSRIs to SNRIs, says Aleksandra Krunic, MD, a psychiatrist and founder of the Child and Adult Clinical Psychiatry Center in Huntington, New York.
“Many individual factors impact the efficacy of medications, including our body’s ability to metabolize particular medicines,” says Dr. Krunic.
“A common side effect of SSRIs is activation syndrome, and it can be related to the dose of serotonin medication that could either be too high for the child or increased too fast,” she says. “The slower we start medication and the lower the dosing we use, the better we’re able to avoid activation syndrome.”
This low-and-slow approach is also true for minimizing other side effects.
Find the Right Expert for Your Child
Equally important is that your child be seen by a child psychiatrist or clinician who understands proper dosing for the pediatric population, says Dr. Krunic.
“The problem becomes when someone doesn’t recognize activation, so instead of lowering the dose, they increase it,” says Dr. Krunic. “They think, ‘Oh, the anxiety is getting worse.’ No, the anxiety isn’t getting worse—they’re just getting activated by the medication.”
Parents often take their child to see a child psychiatrist after trying other avenues first, says Dr. Krunic. “I will often get a child as the second or third opinion after the child has been treated with medications for years,” she says. “It isn’t the medication that’s the problem—it’s the expertise.”
Often, children and teens have been quickly moved from one anti-anxiety drug to another. “This practice is also common in adults unfortunately, but adults aren’t as sensitive as children,” says Dr. Krunic. “They won’t have such extreme side effects, and side effects will not be easily confused with age-appropriate behaviors.”
Sometimes even the minimum prescribed dosage for certain SSRIs is too high for some children, she says. For these children, child psychiatrists will use a liquid version to achieve the lowest possible initial dose.
Know When to Make the Switch
For children who continue to experience activation and other side effects after low-and-slow dosing of SSRIs, then a careful switch to SNRIs may be warranted, Dr. Krunic says.
Of course, as with any medication changes, you’ll want to discuss the benefits and risks with your child’s clinician.
Want a little more science on your side? Your child’s treatment should be unique to your child, and pharmacogenetic testing (PGx) is a way to help clinicians understand how your child’s genes may affect their body’s response to certain medications.
Genomind® Professional PGx Express™ can provide therapeutic guidance related to SSRIs and SNRIs. The test, which requires a prescription, can look at your genetic makeup to help your clinician determine:
- Which medications may have side effects for your child
- Which medications will likely be the most effective for your child
- How your child metabolizes medications for personalized dosing guidance
Pair Medication with Therapy
The right medication at the right dosing in conjunction with therapy provides the best results for treating anxiety and OCD, says Dr. Krunic.
“Learning what to do when you’re anxious is extremely important,” she says. “Medication will allow children not to feel overwhelmed with their anxiety—and calm enough to work with a therapist to develop skills to manage it.”
Does Your Medication Work for You?
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