Hawkridge S M, Stein D J
Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa.
Drug Saf. 1998 Oct;19(4):283-97. doi: 10.2165/00002018-199819040-00004.
Few pharmacotherapy trials have been undertaken in young people with anxiety disorders. Of those conducted, few are placebo-controlled or blinded, and often sample size is small, making interpretation of the data difficult. Case report and uncontrolled trial data generally support the efficacy of pharmacotherapy in many of the anxiety disorders seen in young people. However, most attempts to confirm these impressions in controlled trials have not been as encouraging. Further controlled studies in larger, diagnostically homogeneous samples are needed. At present, the decision as to whether or not to use medication in this patient population must be made on clinical grounds. Evidence is accumulating to suggest that anxiety disorders in young people can become chronic and cause at least moderate functional impairment in some individuals. This possibility has to be weighed against the potential for adverse effects of many of the drugs used clinically. Serious adverse effects appear only in a minority of patients; however, there does not seem to be a reliable method of predicting which patients might be at risk. Benzodiazepines are used to treat anxious children, notwithstanding concerns about dependence, behavioural disinhibition, cognitive impairment and mood changes. The tricyclic antidepressants (TCAs) are generally well tolerated, but their effects on cardiac conduction at higher plasma concentrations are well documented and there have been sporadic reports of sudden death associated with their use in children. Toxicity in overdose is an added concern. The use of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in children and adolescents is widespread, but few rigorous supportive trials have been conducted. The occurrence of both potentially serious adverse effects and other less serious, but troublesome, adverse effects and a possible discontinuation syndrome may complicate the use of these agents in younger patients. However, their relative safety in overdose and the apparent reversibility of adverse effects may favour their use over the TCAs. Other drugs used in this setting include buspirone and beta-blockers. No controlled trials are available at this time, but their adverse effect profiles appear to be relatively favourable and further study is warranted, given the promising nature of the uncontrolled data. The reversible monoamine oxidase inhibitors may be useful in younger anxious patients, but controlled data are needed. The decision to use pharmacotherapy should be made after consideration of multiple factors, and firm recommendations for the use of drug therapy in anxiety disorders in children and adolescents await more rigorous data.
针对患有焦虑症的年轻人开展的药物治疗试验很少。在已进行的试验中，很少有采用安慰剂对照或设盲的，而且样本量往往较小，这使得数据解读变得困难。病例报告和非对照试验数据总体上支持药物治疗对年轻人中出现的多种焦虑症有效。然而，大多数在对照试验中证实这些印象的尝试并不那么令人鼓舞。需要在更大的、诊断上同质的样本中进行进一步的对照研究。目前，对于该患者群体是否使用药物的决定必须基于临床依据做出。越来越多的证据表明，年轻人的焦虑症可能会变成慢性疾病，并在一些个体中至少造成中度功能损害。这种可能性必须与临床使用的许多药物的潜在不良反应相权衡。严重不良反应仅出现在少数患者中；然而，似乎没有可靠的方法来预测哪些患者可能有风险。尽管存在对依赖性、行为抑制、认知损害和情绪变化的担忧，苯二氮䓬类药物仍被用于治疗焦虑的儿童。三环类抗抑郁药（TCAs）通常耐受性良好，但它们在较高血浆浓度下对心脏传导的影响已有充分记录，并且有零星报告称儿童使用它们会导致猝死。过量用药时的毒性是另一个令人担忧的问题。选择性5-羟色胺再摄取抑制剂在儿童和青少年中的使用很广泛，但很少有严格的支持性试验。潜在的严重不良反应以及其他不太严重但麻烦的不良反应和可能的停药综合征的发生，可能会使这些药物在年轻患者中的使用变得复杂。然而，它们在过量用药时的相对安全性以及不良反应的明显可逆性可能使其比三环类抗抑郁药更适合使用。在这种情况下使用的其他药物包括丁螺环酮和β受体阻滞剂。目前尚无对照试验，但鉴于非对照数据的前景，它们的不良反应谱似乎相对较好，值得进一步研究。可逆性单胺氧化酶抑制剂可能对年轻的焦虑患者有用，但需要对照数据。使用药物治疗的决定应在考虑多个因素后做出，关于儿童和青少年焦虑症药物治疗的坚定建议有待更严格的数据。
