Lexapro in kids?

[Accurate219]

So, I was seeing a 15 yo boy admitted for cellulitis to peds floor, in the consult service who was prescribed Lexapro by his outpatient physician for anxiety. We were consulted for evaluation of his anxiety during day time. Very tiny dose of 10 mg. His mom didn't get it for him yet because they were worried about side effects. I definitely feel he would benefit from the medication but I have not seen it used to much in younger kids. I would rather just go with Prozac for the longer half lives.

His mom does not want something that he has to take on the weekends, only during school time. I was wondering if I should just continue Lexapro per his outpatient psych? If he misses the weekends would he have any signs of discontinuation?

Thanks

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[SmallBird]

So, I was seeing a 15 yo boy admitted for cellulitis to peds floor, in the consult service who was prescribed Lexapro by his outpatient physician for anxiety. We were consulted for evaluation of his anxiety during day time. Very tiny dose of 10 mg. His mom didn't get it for him yet because they were worried about side effects. I definitely feel he would benefit from the medication but I have not seen it used to much in younger kids. I would rather just go with Prozac for the longer half lives.

His mom does not want something that he has to take on the weekends, only during school time. I was wondering if I should just continue Lexapro per his outpatient psych? If he misses the weekends would he have any signs of discontinuation?

Thanks

I really don't mean to be rude, but I think you should get some help with this case (beyond SDN). 10mg is not a tiny dose of lexapro, it's a common dose in adults and an average dose in kids (who often will start at 5mg). Your other questions also imply that there are things you don't yet know about appropriate medication use. This makes me wonder if your are in a good position to be doing this consult. Hope you have a supervisor that can walk you through this one.

 

[hamstergang]

Lexapro is the only SSRI in addition to Prozac FDA approved for the treatment of MDD in non-adults (and from 10mg - 20mg). It is certainly indicated for pediatric anxiety.

His mom does not want something that he has to take on the weekends, only during school time.

We'll that just won't work for treating an anxiety disorder. Mom needs psychoeducation and the kids needs psychotherapy with or without an SSRI.

 

[nexus73]

I'd prescribe a scary clown because exposure to scary things is the best cure for anxiety

 

[LasVagus]

I echo hamstergang: mom needs psychoeducation. I'm wondering if she has another kid who is on Adderall (or some other psychostimulant) and, therefore, thinks that all psych meds start working shortly after administration and are only necessary during school time.

 

[TexasPhysician]

What field are you in? I would advise consulting psychiatry.

 

[Accurate219]

I really don't mean to be rude, but I think you should get some help with this case (beyond SDN). 10mg is not a tiny dose of lexapro, it's a common dose in adults and an average dose in kids (who often will start at 5mg). Your other questions also imply that there are things you don't yet know about appropriate medication use. This makes me wonder if your are in a good position to be doing this consult. Hope you have a supervisor that can walk you through this one.

I do have a supervisor and I am a resident. I just wanted to know how to resolve the mother's concerns. Mom is not completely in agreement with medications due to their busy lifestyle and side effect she has read about. However, we will continue to provide psychoeducation.

 

[Jules A]

If he was on the Lexapro and it was well tolerated I would recommend continuing however since he hasn't started it I liken it to Coke vs Pepsi. You could make a reasonable case to trial Prozac since Mom verbalized concerns about compliance and as mentioned educate her that missing doses is not recommended and therapy is crucial. If the kid is anxious its a fair bet is Mom is anxious also so extra handholding will probably be required. Although 10mg is a reasonable starting dose I tend to think of it as comparable to Celexa 20mg and in kids or elderly usually start at 5mg and increase as indicated.

 

[SmallBird]

I do have a supervisor and I am a resident. I just wanted to know how to resolve the mother's concerns. Mom is not completely in agreement with medications due to their busy lifestyle and side effect she has read about. However, we will continue to provide psychoeducation.

I think that you want to allow yourself to answer all the mothers questions, present an evidenced based plan, and then allow her to make a choice. I'd be interested to hear about other styles, but in my view I try and avoid negotiations with families about medication, as the implicit messaging is all wrong. Maybe there is little risk in stopping lexapro on weekends, but there is likely some risk, and its not how we know this medication to be effective. This mother may have an evolving belief that she has the capacity to understand when a medication is helpful based on her own observations; I would not reinforce this belief as it is very unlikely to be true and could lead to poor decisions down the road. We can't stop patients from having their own heuristics for thinking about medication, but particularly in families we can avoid reinforcing ones that don't make sense.

 

[Blitz2006]

I had a child psych lecture on anti-depressants few days ago.

12-17 year olds: Lexapro is recommended
<12 year: Prozac

Why? Fewer drug interactions with Lexapro (compared to Prozac), and older kids may be on other meds, so this is why Lexapro is preferred in >12 yr old group. But I don't believe there is much difference in efficacy.

We also discussed 2 major studies (I unfortunately forget the names), but basically one showed that SSRI was 61% effective (50% effective in Placebo) and another showed that CBT alone = 81%, SSRI alone = 81% and CBT + SSRI = 84%.

So CBT is crucial for kids!

 

[Blitz2006]

Lexapro is the only SSRI in addition to Prozac FDA approved for the treatment of MDD in non-adults (and from 10mg - 20mg). It is certainly indicated for pediatric anxiety.


We'll that just won't work for treating an anxiety disorder. Mom needs psychoeducation and the kids needs psychotherapy with or without an SSRI.

Yep. And according to my child psychiatrist attending, Cymbalta is the only FDA approved medication for GAD in children...

 

[hamstergang]

Yep. And according to my child psychiatrist attending, Cymbalta is the only FDA approved medication for anxiety in children...

Well that's a little misleading. Cymbalta is the only one FDA approved for GAD, but Prozac, Zoloft, and Luvox are FDA approved for OCD. "Anxiety" is not something that anything is FDA approved for.

 

[Blitz2006]

You are correct. My mistake. I lazily typed anxiety, but I meant GAD.

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[redbandit]

Excuse my ignorance but aren't the therapeutic effects of ssri's in the setting of anxiety not immediate ie. It takes weeks for any appreciable change? How can we prescribe something like that under the context of "not wanting to take it on weekends?"

 

[Shikima]

Excuse my ignorance but aren't the therapeutic effects of ssri's in the setting of anxiety not immediate ie. It takes weeks for any appreciable change? How can we prescribe something like that under the context of "not wanting to take it on weekends?"

Hence the importance of CBT.

Too quickly people want emotions squashed. People need to learn that they're not Vulcan, rather Human. Emotions come in many different contexts and flavors and need skills to manage them effectively.

 

[hamstergang]

This is actually not true:
the combo of amitriptyline/perphenazine, buspirone, librium, chlorazepate, valium, doxepin, vistaril, ativan, oxazepam, chlordiazepoxide are all FDA approved for "anxiety" or some description thereof "apprehension" "symptoms of anxiety", "psychoneurotic anxiety", "tension states" etc.

Interesting. I was so focused on antidepressants I forgot to check these.

 

[Liquid8]

I would suggest discussing the pros and cons of each treatment option (Prozac, Lexapro, therapy) with the mother and the patient to allow them to make an informed decision. As the mother appears to be worried about medication side effects, you could make a case for starting it at a lower dose while in hospital, where it will be easier to monitor and deal with any potential side effects.

There's no point administering antidepressants sporadically like the mother is wanting, so I’d also make it clear that the medication should be taken daily otherwise it will be unclear whether it will be effective or not. If they decide they want to do something different once out of hospital that is up to them but they should obviously discuss this with their outpatient psych.

Excuse my ignorance but aren't the therapeutic effects of ssri's in the setting of anxiety not immediate ie. It takes weeks for any appreciable change? How can we prescribe something like that under the context of "not wanting to take it on weekends?"

Indeed. I will usually tell my patients that SSRI treatment for primarily anxiety issues requires a longer duration and higher dosage to see any effect compared to depression.

 

[Jules A]

Excuse my ignorance but aren't the therapeutic effects of ssri's in the setting of anxiety not immediate ie. It takes weeks for any appreciable change? How can we prescribe something like that under the context of "not wanting to take it on weekends?"

The way I usually approach this which is a bit more palatable for patients to buyin is to educate them that although it can take weeks to achieve the full effect of a dose there can and often are improvements noted sooner. On our end being aware of course additional factors in play including placebo effect, gains of therapy and/or actual efficacy of the med.

 

[singasongofjoy]

I had a child psych lecture on anti-depressants few days ago.

12-17 year olds: Lexapro is recommended
<12 year: Prozac

Why? Fewer drug interactions with Lexapro (compared to Prozac), and older kids may be on other meds, so this is why Lexapro is preferred in >12 yr old group. But I don't believe there is much difference in efficacy.

We also discussed 2 major studies (I unfortunately forget the names), but basically one showed that SSRI was 61% effective (50% effective in Placebo) and another showed that CBT alone = 81%, SSRI alone = 81% and CBT + SSRI = 84%.

So CBT is crucial for kids!

CBT with significant parent involvement. With kids, (except idk, maybe some high-achieving/very motivated teens) CBT is not going to work so well without parents being involved enough to know what strategies were practiced and how they can support their kid in learning/practicing them throughout the week. ALthough then you also have to sometimes help manage that interaction so it's supportive and accepted by the kid, and doesn't turn into a negative interaction between parent and child.

 

[PistolPete]

I like to use Prozac in the adolescent population (>12 years of age) due to the long half life, and often kids are on no meds at all, maybe just birth control. The teenagers often fail to take the Prozac every day, so the long half-life is useful here. Plus, many of my Medicaid patients only have Prozac on formulary, not Lexapro (although Celexa is often available).

 

[Merovinge]

I like to use Prozac in the adolescent population (>12 years of age) due to the long half life, and often kids are on no meds at all, maybe just birth control. The teenagers often fail to take the Prozac every day, so the long half-life is useful here. Plus, many of my Medicaid patients only have Prozac on formulary, not Lexapro (although Celexa is often available).

For depression it's a slam dunk, prozac first SSRI in kids, any other answer is just not right. The black box warning data clearly show Prozac causing the least suicidial ideation and it is the only SSRI with good efficacy studies.

For anxiety, I think any of the SSRIs are more reasonable. Zoloft can be less activating for some folks which is a relative advantage in anxiety. Prozac has the built in slow titration and probably has better efficacy with missed doses but is clearly a more activating drug. Lexapro is a pretty clean drug and now that its a cheap generic we actually have it covered by most public aid plans in my state. 10 is definitely too high a starting dose though, particularly in someone who is anxious. 5 is reasonable as is 2.5 for a few days if someone is particularly expecting adverse side effects.

 

[Blitz2006]

For depression it's a slam dunk, prozac first SSRI in kids, any other answer is just not right. The black box warning data clearly show Prozac causing the least suicidial ideation and it is the only SSRI with good efficacy studies.

For anxiety, I think any of the SSRIs are more reasonable. Zoloft can be less activating for some folks which is a relative advantage in anxiety. Prozac has the built in slow titration and probably has better efficacy with missed doses but is clearly a more activating drug. Lexapro is a pretty clean drug and now that its a cheap generic we actually have it covered by most public aid plans in my state. 10 is definitely too high a starting dose though, particularly in someone who is anxious. 5 is reasonable as is 2.5 for a few days if someone is particularly expecting adverse side effects.

This is good to know about Prozac causing "least suicidal ideation". Is this for children, or applies to adults as well?

 

[hamstergang]

This is good to know about Prozac causing "least suicidal ideation". Is this for children, or applies to adults as well?

I haven't looked at adult literature in a little while, but I didn't think SSRIs caused SI in those 25 and older, and they may decrease it in the geriatric population. I'm sure the real answer is somewhat more nuanced than that, though.

 

[erg923]

due to their busy lifestyle and.

Maybe that's why he is so "anxious?" Although you've never actually discussed what his specific symptoms are or what he states he is anxious about, much less if it's disproportiante to the circumstances...which seems like the most important variable of the case prior to proscribing any form of treatment.

 

[TexasPhysician]

I had a child psych lecture on anti-depressants few days ago.

12-17 year olds: Lexapro is recommended
<12 year: Prozac

Why? Fewer drug interactions with Lexapro (compared to Prozac), and older kids may be on other meds, so this is why Lexapro is preferred in >12 yr old group. But I don't believe there is much difference in efficacy.

We also discussed 2 major studies (I unfortunately forget the names), but basically one showed that SSRI was 61% effective (50% effective in Placebo) and another showed that CBT alone = 81%, SSRI alone = 81% and CBT + SSRI = 84%.

So CBT is crucial for kids!

I would spend some time reading the primary literature this information came from. While some of your individual statements are correct, it is not complete which leads to incorrect conclusions. For instance, those percents are correct, but only at 1 point in the study. Other data points are quite important drawing other conclusions.

 

[Blitz2006]

I would spend some time reading the primary literature this information came from. While some of your individual statements are correct, it is not complete which leads to incorrect conclusions. For instance, those percents are correct, but only at 1 point in the study. Other data points are quite important drawing other conclusions.

Fair enough, I forgot to mention that the point at this study is 36 weeks,

Here is the study: The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. - PubMed - NCBI

 

[TexasPhysician]

Fair enough, I forgot to mention that the point at this study is 36 weeks,

Here is the study: The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. - PubMed - NCBI

Right. It takes 9 months for CBT to reach equal effectiveness as meds. While CBT and SSRI are ideally best together, electing CBT-only means potentially suffering from depression for months longer than needed. This demonstrates the necessity of meds, not CBT

 

[smalltownpsych]

Right. It takes 9 months for CBT to reach equal effectiveness as meds. While CBT and SSRI are ideally best together, electing CBT-only means potentially suffering from depression for months longer than needed. This demonstrates the necessity of meds, not CBT

Also, it is important to note that these were kids rated initially in the moderate to severe category. Not sure how sensitive or valid the Hamilton scale is, but if these are kids that I think of as more severely depressed, I would recommend a consult with their PCP for consideration of an SSRI while I am treating them. To me these kids have already gone past the point of failing classes because they stopped doing schoolwork which is a typical first sign of milder depression. As the depression gets worse, then these kids have stopped engaging in pleasurable activities or engaging with peers.

As for anxiety, my observations are that the SSRIs are minimally effective for these kids and psychotherapy is very effective if you can keep the parent from taking control of that too.

 

[birchswing]

Right. It takes 9 months for CBT to reach equal effectiveness as meds. While CBT and SSRI are ideally best together, electing CBT-only means potentially suffering from depression for months longer than needed. This demonstrates the necessity of meds, not CBT

Practicing CBT or being in CBT therapy for 9 months? I did CBT in high school, and it was only a few sessions. The therapist said I would either get it or not get it. It was kind of like physical therapy with so many sessions allotted from the outset. If it's 9 months that could explain why I didn't get it.

 

[smalltownpsych]

Practicing CBT or being in CBT therapy for 9 months? I did CBT in high school, and it was only a few sessions. The therapist said I would either get it or not get it. It was kind of like physical therapy with so many sessions allotted from the outset. If it's 9 months that could explain why I didn't get it.

Regardless of type of therapy, I don't see much effective change happening in an adolescent in anything shorter than 6 to 9 months for any type of longer standing problem. I have worked with a few kids who don't really have mental health problems, but night be struggling with a current stressor and a few sessions can help with that. A big fault of CBT is the initially promoted 8 session length that has been widely disseminated (probably because of cost considerations) and is not really accurate to the real world application.

 

[PistolPete]

I find that SSRI's have been very helpful for many of my patients with GAD or panic disorder, but at the higher dose range. I find a lot of PCPs put kids and adults on Prozac 20, never go up, then wonder why it hasn't done anything.

 

[erg923]

I find that SSRI's have been very helpful for many of my patients with GAD or panic disorder, but at the higher dose range. I find a lot of PCPs put kids and adults on Prozac 20, never go up, then wonder why it hasn't done anything.

Can we please pause for a minute, folks?

Although I'm very fascinated by the discussion going on here, the case presentation here is weak sauce!

Yes, yes this drug vs. that drug is great for "anxiety." This is boring. Is this really what psychiatry/psychiatric consultation is about these days? Barf!

We don't know why this kid is anxious. We don't know what he is "anxious" about. We don't know if his anxiety is "indicative" or pathological.

I don't know about you guys, but we should not be not be in the business of medicating children in bad circumstances. This is poor psychiatry. No good can come of this without wider Inquiry.

 

[hamstergang]

Can we please pause for a minute, folks. Although I'm very fascinated by the discussion going on here, the case presentation here is weak sauce!

We don't know why this kid is anxious. We don't know what he is "anxious" about. We don't know if his anxiety is "indicative" or pathological.

I don't know about you guys, but we should not be not be in the business of medicating children in bad circumstances. This is poor psychiatry. No good come of this.

We don't really need to pause for this as it wasn't part of the original question. In this scenario that we were given, the outpatient psychiatrist and C/L team both determined that pharmacological management of the anxiety was indicated, and the question assumes that to be the case.

It may certainly be an interesting and educational discussion to delve deeper into the anxiety (and presumably the treating psychiatrists have), but that's certainly not something that needs to be addressed in this thread before moving on. None of us besides the OP are actually prescribing this kid anything, so us not knowing more details of the anxiety isn't poor psychiatry in the least.

 

[erg923]

We don't really need to pause for this as it wasn't part of the original question. In this scenario that we were given, the outpatient psychiatrist and C/L team both determined that pharmacological management of the anxiety was indicated, and the question assumes that to be the case.

It may certainly be an interesting and educational discussion to delve deeper into the anxiety (and presumably the treating psychiatrists have), but that's certainly not something that needs to be addressed in this thread before moving on. None of us besides the OP are actually prescribing this kid anything, so us not knowing more details of the anxiety isn't poor psychiatry in the least.

I think the point of the post was treatment recommendations in the context of, perhaps misinformed parents, and vague circumstances? No?

 

[erg923]

I think the point of the post was treatment recommendations in the context of, perhaps misinformed parents, and vague circumstances? No?

It's somewhat disturbing to me how this jumped so quickly to medication options for everyone on here.

And all but one person, I think, recommended an actual full psychiatric/ psychological evaluation of this individual in order to recommend treatment options.

 

[hamstergang]

It's somewhat disturbing to me how this jumped so quickly to medication options for everyone on here.

And all but one person, I think, recommended an actual full psychiatric/ psychological evaluation of this individual in order to recommend treatment options.

You're implying here that those of us in this thread discussing meds are not advocating for a full and proper psychiatric evaluation of this children and are therefore advocating to just medicate him instead of trying to understand him.

But I doubt that's true for at least most of us. I, personally, am assuming that that's obvious and has already been done by the kid's outpatient psychiatrist and C/Lee psychiatrist. I see the question as, given that it has properly been determined that a medication is indicated, how do you manage the Lexapro here?

We're just starting the question from a different point, not pushing for substandard care. Obviously if the OP didn't do a good evaluation to begin with he should do that.

 

[SmallBird]

It's somewhat disturbing to me how this jumped so quickly to medication options for everyone on here.

And all but one person, I think, recommended an actual full psychiatric/ psychological evaluation of this individual in order to recommend treatment options.

I couldn't agree more! I provide medication consultation to an absolutely phenomenal, psychologist run anxiety disorders clinic. And it's all about having a good assessment, understanding the nature of the anxiety, sustaining factors in the environment and family, teacher and parent accommodation etc. Medication may play an important role, and certainly the data points towards equivalency, but in clinical reality I think many more kids will be helped more by a psychological intervention that is premised on a robust formulation of the kids anxiety than having SSRIs prescribed for threshold criteria.

 

[erg923]

You're implying here that those of us in this thread discussing meds are not advocating for a full and proper psychiatric evaluation of this children and are therefore advocating to just medicate him instead of trying to understand him.

But I doubt that's true for at least most of us. I, personally, am assuming that that's obvious and has already been done by the kid's outpatient psychiatrist and C/Lee psychiatrist. I see the question as, given that it has properly been determined that a medication is indicated, how do you manage the Lexapro here?

We're just starting the question from a different point, not pushing for substandard care. Obviously if the OP didn't do a good evaluation to begin with he should do that.

Then please point me those posts, aside from yourself and one or two other persons?

It also does not seem that the op is a psychiatrist or has consulted psychiatry outside of this board post. Maybe I'm wrong???

 

[Armadillos]

Then please point me those posts, aside from yourself and one or two other persons?

It also does not seem that the op is a psychiatrist or has consulted psychiatry outside of this board post. Maybe I'm wrong???

You probably don't see us discussing hmm maybe we should refer this kid to therapy because atleast for me that's literally the default thing we do for essentially every patient. It's like IM docs starting DVT prophylaxis on inptients or something. Literally every patient I see as an ER consult or inpatient consult is getting a therapy referral. There is nothing to discuss about it.

 

[hamstergang]

It also does not seem that the op is a psychiatrist or has consulted psychiatry outside of this board post. Maybe I'm wrong???

OP is a psychiatry resident, I believe.

 

[Liquid8]

It's somewhat disturbing to me how this jumped so quickly to medication options for everyone on here.

And all but one person, I think, recommended an actual full psychiatric/ psychological evaluation of this individual in order to recommend treatment options.

It also does not seem that the op is a psychiatrist or has consulted psychiatry outside of this board post. Maybe I'm wrong???

The OP’s question is about treatment, not assessment. The OP stated they are part of a consult service, so it would not be unreasonable to assume they are working in consultation liaison psychiatry (who else would be called to evaluate a patient’s anxiety?), where the main job involves doing psychiatric assessments for patients on non-psychiatric wards. By criticising others for not suggesting that a more thorough assessment be undertaken this only demonstrates a limited understanding of the nature of the actual work involved.

Everyone should get a thorough assessment before initiating treatment of any kind, but that goes without saying and isn't helpful advice in this particular context.

 

[birchswing]

Regardless of type of therapy, I don't see much effective change happening in an adolescent in anything shorter than 6 to 9 months for any type of longer standing problem. I have worked with a few kids who don't really have mental health problems, but night be struggling with a current stressor and a few sessions can help with that. A big fault of CBT is the initially promoted 8 session length that has been widely disseminated (probably because of cost considerations) and is not really accurate to the real world application.

Interesting. I think my childhood therapy was way too short and narrow of focus. And my adulthood therapy way too long (8 years) and too broad of focus.

 

[PistolPete]

You're implying here that those of us in this thread discussing meds are not advocating for a full and proper psychiatric evaluation of this children and are therefore advocating to just medicate him instead of trying to understand him.

But I doubt that's true for at least most of us. I, personally, am assuming that that's obvious and has already been done by the kid's outpatient psychiatrist and C/Lee psychiatrist. I see the question as, given that it has properly been determined that a medication is indicated, how do you manage the Lexapro here?

We're just starting the question from a different point, not pushing for substandard care. Obviously if the OP didn't do a good evaluation to begin with he should do that.

This.

 

[singasongofjoy]

I assumed that OP's initial post was a v small snippet of a significantly longer conversation with mom and that, per all the psychiatrists/residents that were on CL during my time on peds CL, therapy was recommended in addition to following through on other recommendations previously made by providers who know the patient better. My experience on CL was that beyond the very brief assessments and very short term, situational interventions/ therapies that can be offered during the duration of the hospital, the bulk of the job was motivational interviewing talking to parents about f/u recommendations when they got home- which at least 50% of the time was getting them to follow through on recommendations they'd already heard from someone else (most often therapy, but sometimes medications or recommended health-related regimes). OP posted a very specific question; I'm sure it was part of a bigger picture unless my peds CL experience was just really out of the norm.