Table II. Treatment algorithm for pediatric anxiety pharmacotherapy In June 2003, the FDA recommended against the use of paroxetine for Major Depressive Disorder in children and adolescents EKG, electrocardiogram, BP, blood pressure, 5-HTa PA, serotonin partial agonist, Rx, prescribe, HTN, hypertension, OCD, obsessive-compulsive disorder, SSRI, selective serotonin reuptake inhibitor, GAD, generalized anxiety disorder.

Treatment algorithm			Select SSRI. Titrate up every 2-4 weeks until symptoms respond, until side effects preclude further dose increases, or when reach max dose. If ineffective or intolerable, use alternate SSRI for 2nd trial.			After 2 failed SSRI trials, reassess or consult, consider clomipramine for OCD; VFX for non-OCD.			If still no response, or familial preference, consider buspirone or mirtazepine, alone or as augmentation.		Consider benzodiazepines for acute relief of severe symptoms or after no response to multiple trials.
Class			SSRI			Tricyclic	SNRI	5-HTa PA	Tetracyclic		Benzodiazepine
Medication	Sertraline	Fluoxetine	Fluvoxamine	Citalopram	Paroxetine*	Clomipramine	Venlafaxine XR (VFX)	Buspirone	Mirtazapine	Clonazepam	Lorazepam
Starting dose	125-25 mg	5-10 mg	12.5-25 mg	5-10 mg	5-10 mg	25 mg	37.5 mg	5 mg tid	7.5-15 mg	0 25-05 mg	0.5-1 mg
Total therapeutic dose range	50-200 mg	10-60 mg	50-200 mg (Rx bid above 50 mg)	10-40 mg	10-40 mg	100-150 mg	75-225 mg (Rx qhs or bid)	1-60 mg (Rx tid)	7.5-30 mg (Rx qhs)	0.25- mg (Rx qd-tid)	0.5-8 mg (Rx qd-qid)
Common side-effect profile	Nausea, Sedation, headache	Activation, nausea, insomnia	Hyperactivity, abdominal discomfort	Somnolence, insomnia, diaphoresis	Sedation, nausea, dry mouth	Dry mouth, constipation, diaphoresis	Nausea, sedation, dizziness	Sedation, disinhibition, headache	Hunger, sedation, dizziness	Sedation, confusion	Sedation, confusion
Special warning/ monitoring			Suicidality, activation (restlessness, impulsivity), Serotonin Syndrome; Develop safety plan and means to assess early side effects, which may resolve in 1-2 weeks; avoid abrupt discontinuation with paroxetine, sertraline, fluvoxamine, and citalopram			Hypotension, rebound HTN, lethal in OD; level ≤400	HTN, tachycardia, suicidalrty	Safe with benzodiazepines	Weight gain	Disinhibition, tolerance. seizure from discontinuation	Disinhibition, tolerance, seizure from discontinuation
Specific indications	GAD	Long haIf-life		No RCTs; little interactions	Social phobia; non-depressed	OCD, EKS, BP Monitoring to minimize overdose risk	GAD; Non-depressed	Augmentation; sexual side effects	Appetite stimulation, insomnia; few interactions	Short-term relief of acute anxiety, longer acting	Short-term relief of acute anxiety, shorter acting; liver impaired
FDA approval	For OCD,≥6	For OCD;≥7	For OCD,≥8	For adults	For adults	For OCD, ≥10	For adults	For adults	For adults	For adults	For adults