Pediatric Anxiety: Initial Pharmacotherapy, Adherence Prediction, and Burden of Events

Anxiety disorders are one of the most common mental illnesses in children. Multiple pharmacotherapies for treating anxiety exist; selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line pharmacotherapy for pediatric anxiety. SSRI adherence is important to consider during care and parent adherence may help predict child SSRI adherence. The burden of serious events following an anxiety diagnosis has not been well characterized in children. In children with anxiety, we aimed to: 1) describe the initial anti-anxiety medication prescribed and psychotherapy utilization, 2) estimate SSRI adherence and determine if parental medication adherence predicts child SSRI adherence, and 3) estimate the incidence of emergency room (ER) visits, mental health related hospitalizations, and treated self-harm events after a new anxiety diagnosis. The research was completed in a large commercial claims database (2004-2014) in children (3-17 years) with diagnosed anxiety (ICD-9-CM code). We estimated the proportion of children initiating each medication class and factors independently associated with non-SSRI initiation. For adherence we measured the 6-month proportion of days covered; parent SSRI, statin, and antihypertensive adherence was evaluated prior to child SSRI initiation. We estimated the cumulative incidence of each event following the new anxiety diagnosis. Among children initiating anti-anxiety medication (n=84,500), 70% initiated an SSRI followed by benzodiazepines (8%) and non-SSRI antidepressants (7%). Anxiety disorder, age, provider type, and co-morbid diagnoses were associated with the initial medication; less than a third had psychotherapy claims before medication initiation. In children initiating an SSRI, parent high adherence (risk ratio=1.16) independently predicted high child adherence compared to parents with low adherence. One-year after a new anxiety diagnosis, 2.0% of children had a mental health related hospitalization, 8 per 10,000 an inpatient, treated self-harm event, and 1.4% an anxiety-related ER visit, with higher incidence in older children with co-morbid depression. SSRIs are the most commonly used first-line medication for pediatric anxiety; yet, a third initiated a medication with limited evidence of effectiveness for pediatric anxiety. Parental adherence may help predict child SSRI adherence. Following a new anxiety diagnosis, a significant proportion of children experience a serious event, adding to understanding the burden of pediatric anxiety disorders.Doctor of Philosoph