G’day all – I hope you’ve all had a cracking weekend just as Troy and I have done.
Had a significant birthday of one of my dearest, long-time friends, which meant we got a night away from the kids (thanks Grandad and Grandma) to head to the beach to celebrate. Happy birthday Rosie!!
You might remember last week, I wrote about ANXIETY in KIDS, and what the general approach is that I take when a child presents with this in clinic (http://www.kids-health.guru/anxiety/)
Today I wanted to write a little about one of the most common types of medications that we use to treat anxiety in children. Many parents are understandably really worried about starting medications in their children and it was my hope that by giving you some information about it, it will help allay that worry, and help you to make an informed decision about what is best for your child. As you will have already read in last week’s blog, psychotherapy is used first line in children… medication has a role to play when the psychotherapy has failed to produce an adequate response, or the child is too anxious to be able to process and take on the strategies taught to them in therapy sessions. In this case, medication is adjunctive therapy – that works to synergistically improve the effect of other therapy.
Generally speaking, the medicines we use for anxiety are called “anxiolytics.” The ones most commonly used in children are from a family called the “SSRI’s” – this stands for “Selective Serotonin Reuptake Inhibitors.” Now, don’t get put off already!! Let me explain what this name means and how they work!
The SSRIs are a family of drugs that modulate a hormone or neurotransmitter in your brain called Serotonin. Serotonin is responsible for HEAPS of different functions across different systems of the body. In this article, we are mainly going to focus on its effects on MOOD and feelings of WELLBEING – and so how it works on nerve cells (or neurons) in the brain.
Just out of interest, other functions that serotonin has in the body include (but are not limited to):
- Regulating bowel movements
- Causing nausea
- Affecting sleep
- Effects on bone health
Generally speaking (because of course things are always more complicated than I can cover in these short articles – especially when we are talking about neurotransmitters and brain function) in the brain, when serotonin is released as it should be, it helps people to feel happier, calmer, more focussed, less anxious and more relaxed. It comes as no surprise then to know that low levels of serotonin are linked to depression, anxiety and poor sleep (insomnia).
So it goes to reason then that the medications that we use to treat anxiety (and also depression) work on pathways that affect serotonin levels in the brain.
Take a look at the diagram I have drawn above… (yes I had fun drawing it and colouring in!! I borrowed my daughter’s colouring in pencils!)
You can see I have drawn 2 nerve cells. The first neuron (the “pre-synaptic neuron”) has an electrical impulse generated down it that causes serotonin to be released from little vesicles (little fluid filled bubbles) in the terminal part of the axon into the “synaptic cleft” (ie the tiny space between the 2 nerve cells). This represents how nerve cells communicate with each other and how an impulse is transmitted from one cell to the next.
The serotonin drifts across the cleft and binds to the receptors on the other side (on the post-synaptic nerve cell). When enough serotonin has bound, a threshold is reached and the nerve cell then sends off an electrical impulse down its axon (ie the message gets through).
So – what happens then in people who have LOW SEROTONIN and are anxious and/or depressed?
Well, there is not enough serotonin in the cleft to bind to the receptors on the second neuron, meaning that the threshold is NOT reached and the message does not get transmitted. This causes feelings of low mood, anxiety, stress etc. ENTER the SSRI’s!!
The SSRI’s are represented by the red shapes in the picture.
Normally, the serotonin that is produced in the nerve cell is reused by being sucked back up into the pre-synaptic neuron in a process called “re-uptake.” The serotonin that has been released into the cleft, bind to the PRE-synaptic receptors (ie on the nerve cell they were just released from), causing the membrane to pinch in and suck the serotonin back up. It then sits in the vesicles in the pre-synaptic neuron waiting for another electrical impulse to cause it to empty into the cleft again.
SSRIs work by BLOCKING the receptors that regulate the reuptake of serotonin. If the serotonin cannot BIND, then it cannot be taken back up. This means that the serotonin released remains in the cleft longer, allowing it to bind to the 2nd neuron and for the threshold to be reached so that the message can get through – thus relieving symptoms of low mood and anxiety. Hooray!!
The SSRI that I like to use in children is one called fluoxetine. There are HEAPS of different drugs in this family that all work in a similar way, but fluoxetine is one that has been around a long time, meaning that it is the one that has the most evidence for effect and safety in children. Other medications in this class are also used, but there is less evidence for their use in children.
Unfortunately ALL medications have side effects, and fluoxetine/SSRIs in general are no exception. If a child experiences intolerable side effects to a medication – then we take them off the medication. Simple. Fortunately however, most of the side effects of the SSRIs are TRANSIENT – meaning that they are most likely to be experienced when first starting the medication (and resurface if the dose is increased) but will wear off over the first week or so. So if you can push past the first week, then generally things get better.
The most common side effects that seem to be experienced by children when taking this medication are (but are not limited to):
- Nausea, stomach ache, diarrhoea
- Headache, dizziness
- Disturbance in sleep pattern (in some children it makes them sleepy, in others it stops them from sleeping well)
- Dry mouth, sweating, blurred vision
- Tremors or shaking
The way I combat these side effects is to “start low and go slow.” So start on a very low dose (that is likely not even therapeutic – with the aim of getting the body used the medication slowly) and move up on the dose every 5-7 days. I also often ask parents to start the medication on a weekend – when they are home with their child to watch them for side effects AND I ask them to give the medication at night.
The reasons for this are multiple:
- If the child experiences nausea with the drug, then they will likely to be asleep during this time making the effect less troublesome
- If the child is made sleepy by the medication, it won’t matter as they will be asleep.
- If the child experiences insomnia then the dose is then easily moved to the morning.
This medication is better given with food/after a meal (ie so after dinner) to make it less likely to cause tummy upset, and to slow the absorption – making side effects like dizziness and headache less likely.
A dose will be calculated for your child depending on their weight, but is more often dictated by their response to the medication as the dose is gently pushed upwards. So if a child experiences a good effect from a medication at a dose LOWER than expected, I would generally STOP and HOLD at that dose.
Fluoxetine cannot be stopped suddenly because it can cause withdrawal symptoms. It needs to be gradually tapered down to stop.
Time to effect
It can take up to 3-4 weeks before a clinical effect is seen with fluoxetine (and other SSRIs). Having said this, time to effect is influenced by a number of things
- How slowly we work up to a therapeutic dose (the slower we work up, the longer the time to effect)
- Individual characteristics that we cannot predict about that child – eg their metabolism, how long it takes for their neurotransmitter system to react to the medication etc
- The psychological effect of having sought help and feeling like there is a plan to move forward.
This having been said, some families will return to see me and report that they noticed a difference in mood/anxiety levels immediately or within a few days.
How long do we use the medication for?
Many parents ask about how long their child needs to stay on a medication for once they have started. There is no one answer to this question. Generally speaking medication is continued for a minimum of 6-12 months. Stopping short of this time increases the chance of relapse of symptoms (both for low mood and anxiety). If the child is doing really well with their psychotherapy (which we always do in parallel with medication) then at the 6-12 month mark we would try to decrease and then cease the medication. If they are doing well but there is something really stressful going on in their life at that time, then we might decide to keep going for a little longer – to give them the best chance of successfully coming off the medication.
Some children stay on the medication longer, or may come off the medication and need to go back on it at another time. This is influenced by lots of things – their inherent resilience ( http://www.kids-health.guru/resilience/ ), their inherited tendency towards anxiety or depression (they are more likely to have further mental health issues if there is a strong family history of mental illness) and what is going on for them in their world at any given time.
If they do need to go back on/take longer to come off, then it is no cause for alarm! We just sit on the medication a little longer, and try off later on down the track. No big deal.
… and my short article on “How medication for anxiety works” has now reached 3 pages (face palm). I really hope you have found this article helpful – please leave me a comment either way so I can continue to improve my articles for parents out there! Now I need to get started on my Uni work for this week!!
Catch you soon!