It's a trend that should be familiar to anyone in pediatric medicine: More and more children are being diagnosed with anxiety, and they're increasingly being treated with anti-anxiety medications.
Are kids more anxious today, or are doctors more likely to diagnose and treat pediatric anxiety?
Recently, athenahealth researchers examined data from primary care and mental health providers on the athenahealth network who saw pediatric patients between 2013 and 2017. During that time, the percentage of pediatric patients with an anxiety diagnosis more than doubled, from 1.9 percent in 2013 to 4.4 percent five years later. When it came to treatment with medications, the percentage of patients prescribed anti-anxiety drugs over that time increased by a factor of six, from 0.5 percent in 2013 to 2.9 percent in 2017.
“For me," says Josh Gray, athenahealth vice president of research, “it's not just this rise in anxiety diagnoses that's interesting – it's also this enormous relative increase in anti-anxiety prescriptions. Are children really experiencing anxiety at higher rates, or is it that doctors are just more apt to diagnose it? And either way, why are doctors more likely to prescribe [anti-anxiety medication] for anxiety today than they were a few years ago?"
Unfortunately, says Beth Salcedo, the president of the Anxiety and Depression Association of America (ADAA), the answers to such questions “are not yet available to us." Possible explanations, she says, “could include improvement in awareness of anxiety in both parents and kids, and improvement in awareness on the part of caregivers who are now identifying mental health issues earlier."
In the athenahealth study, the researchers analyzed approximately 3.8 to 4.7 million unique visits and 40,000 to 74,000 unique prescriptions in each of the five years from 2013 to 2017. Practice claims with any ICD-9 or ICD-10 code related to anxiety (generalized anxiety disorder, panic disorder, social or other phobia) were counted as anxiety diagnoses, while physician orders of SSRIs, SNRIs, benzodiazepines, tricyclic antidepressants, the antihistamine hydroxyzine (Atarax and Vistaril), or the azapirone buspirone (Buspar) were counted as anxiety prescriptions
Notably, the observed increase in treatment with anti-anxiety medications was overwhelmingly driven by prescriptions for SSRIs: In 2013, 0.4 percent of children were treated with SSRIs, while 2.5 percent received SSRI prescriptions in 2017.
Another interesting finding of the study was the growing “diagnosis gap" between genders. While girls were consistently diagnosed with anxiety more often than boys at the start of the study window, the disparity increased dramatically over the five years: In 2013, the researchers found, 1.7 percent of boys and 2.1 percent of girls received an anxiety diagnosis (a 0.4 percentage-point gap), while in 2017 those figures climbed to 3.6 and 5.1 percent respectively (a 1.5 percentage-point gap).
A two-headed approach to treating anxiety
One physician with insight into the study is Jeff Drasnin, MD, president of ESD Pediatric Group in southwestern Ohio. His two-clinic practice sees numerous children with anxiety-related symptoms, and the diagnoses are increasing every year, Drasnin says. He attributes the rise to external influences in his patients' lives.
“In most of the cases it has to do with stress more than it does any underlying physiologic anxiety, and I think that's just an indication of the kind of world that we live in," he says. “It's more difficult to be a teenager today than it was five or 10 or 20 years ago. The challenges they're facing are more significant. And because often you can't just take the stress away, you end up looking for other ways to deal with it."
Children who, if it were the 1980s, would have been “on the edge from an anxiety perspective and done OK," Drasnin says, today are struggling with all kinds of additional stressors that may just push them past the anxiety threshold.
When appropriate, Drasnin prescribes medication – but he often finds himself encouraging parents to dial back sports and other extracurricular activities and to reassure children they don't have to compete. “Academically it's different now, socially it's different – these kids are under a lot of pressure to succeed."
At ESD, Drasnin says, he and his colleagues keep in mind that “a little bit of anxiety" is perfectly normal in most children. But Drasnin draws the line when that anxiety interferes with a child's happiness, or comes with physical symptoms such as weight loss or panic attacks. “If they get to the point where they're so worried that they're physically ill or they can't do the things they want to do, that's where we'll try to get them to see a therapist, and where we may decide to pharmacologically manage it."
In fact, Drasnin says, his practice is currently in the process of hiring a psychologist to join its staff. The goal is, in part, to reduce their anti-anxiety prescriptions “and to take more of a two-headed approach with direct collaboration between the physician and the counselor." That's an approach that other physicians can follow as they confront the growing challenge of children who are showing signs of debilitating anxiety.
Chris Hayhurst is a writer based in Northampton, MA