Dr. Henry Paul, MD

Psychiatrist, Author and Educator

WHAT ARE THE LONG-TERM EFFECTS OF THE MEDICATIONS MY CHILD IS TAKING?

January 30th, 2014

Naturally, parents worry about long-term negative effects of psychotropic medication on children. We have very little data since most of the psychotropic drug explosion has been relatively recent, and not enough time has passed to see any long-term effects on the brain or development in general, but even for very common psychotropic drugs like Ritalin, which has been used for fifty years, there has been no evidence that there are long-term dangers. At this time, there is no documented reason to worry about psychotropic drugs causing death or long-term damage to our children. While some of the side effects like drowsiness, mood changes, or other symptoms can affect our children, these are easily recognized and treated if the medication is being monitored correctly. Even for drugs that have been used for fifty years there is no evidence of long-term damage to children except for relatively minor issues like a very small height diminution in children who have taken some of the ADHD medications and even in this case it is not known if the decrease lasts into adulthood.

Lastly, there are always the newspaper headlines about famous or not so famous people dying from psychotropic drugs. This is very different from dying from proper prescribing. In these cases, there is usually an overdose of the drug, either intentionally or otherwise, a combination of drugs, or an interaction with illicit drugs or alcohol.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

CAN MY PEDIATRICIAN PRESCRIBE PSYCHIATRIC MEDICATION?

January 28th, 2014

In the United States, doctors without special psychiatric training write the great majority of prescriptions for psychotropic medications. Although it is difficult to quantify, it appears that psychiatrists write only about 20 to 25 percent. It would be preferable to have all of these prescriptions written by a psychiatrist and particularly with children and teenagers it be done by a child and adolescent psychiatrist. Why? Because the practice of prescribing these specialized medications requires specific knowledge of children and teenagers that is only gained by those who have completed special training in child and adolescent psychiatry in approved residency programs.

A general (adult) psychiatrist goes to medical school and then completes postgraduate specialty training of four years of general psychiatry. A child and adolescent psychiatrist goes on for an additional two years receiving additional training in child and adolescent psychiatry.

In a child and adolescent residency, one learns about the details of child/teenage/family development in all areas: biological, neurological, educational, psychological, emotional, and physical realms. One learns about the field of pediatrics and is able to integrate physical illness and its effects into diagnostic and treatment expertise. There is detailed exposure to the diagnosis of all the mental disorders that occur in the formative years, both in outpatient and hospital settings. One studies feelings, behaviors, and thinking patterns. In addition, there is exposure to all the various modes of therapeutic intervention including individual, family, and group talk therapy.

In a child and adolescent psychiatry residency, one scrutinizes the use of psychotropic drugs for the many disorders of childhood and teenagers; not only the helping effects of medications but the side effects, the use of multiple medications, the emotional repercussions of taking medication on the child and family, and the introduction of medication to school personnel when necessary. Most importantly, one learns about the unique metabolism of medication by young people.

Only about eight thousand doctors are trained in child and adolescent psychiatry in the United States. This is a small amount, and the field is considered very understaffed. Because of this, it will not always be possible to see a trained child and adolescent psychiatrist, especially if you live in a rural area. Pediatricians, clinic nurse practitioners, and general psychiatrists are the other major prescribing groups for the child and adolescent psychotropics and, although the great majority has the skill in this area, it is best to find out how much experience in prescribing to young people in particular they have. You can simply ask your doctor directly about their education, continuing education, and of course, direct patient care experience. Additionally you can search the Internet, consult with local mental health associations, and with the referring person (pediatrician) to learn more about the doctor in question.

ANTIDEPRESSANT DRUGS – THE BLACK BOX WARNING

January 23rd, 2014

The use of antidepressants has come under great scrutiny in the past six years due to warnings that were issued by the Federal Drug Administration. A 2003 report and another started in 2005 found that antidepressants possibly lead to increased suicidal thinking and even suicidal behavior in young people. In 2007, the FDA decided to mandate the following black box warning, so called because it is printed in a black box on the medication:

WARNINGS: SUICIDALITY AND ANTIDEPRESSANT DRUGS

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [drug name] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

This was put on all antidepressants although the studies had only been done for some SSRI depressants (Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants). This warning and the accompanying publicity scared parents and led to a marked decrease (up to 50 percent) of antidepressant prescription for young people, Prozac excluded (this was the only antidepressant approved for children). This happened in spite of the fact that it was stated that no one should stop their antidepressant and that there had been no suicides in the group studied.

After the black box warnings had come out, much was written about the fact that it was almost impossible to know if the depression itself caused the suicidal trends and not the medication. The study showed that possibly 4 percent of young people developed these suicidal trends (no actual suicide) compared to 2 percent amongst those who were not treated. Many psychiatrists, including me, appeared on national news shows emphasizing that if, in fact, this was a risk, it was so rare that most of us had never even seen it and that proper monitoring by the prescribing physician would be, in all probability, enough to ward off any tragedy. Despite this, the new prescribing of antidepressants dropped markedly. Tragically, the suicide rate increased in teenagers. No scientific correlation was made, but it seems that this was related to less use of the antidepressants which could have treated the depression and prevented the suicide.

As it stands now, the anxiety about antidepressants has decreased. To my knowledge, there have been no further studies leading to alarm. Prescribing has increased again, and it appears that most prescribers are more vigilant about monitoring for this side effect. If prescribed correctly, under the guidance of an experienced professional, I do not think there is a particularly significant increased risk of suicide. Further studies about particular drugs with proper control groups will clarify the situation. I would not advise any parent to withhold antidepressants based on what we know so far, but be cautious and make sure your child is being monitored for every possible side effect.

HOW MUCH RESEARCH SHOULD I DO WHEN THE DOCTOR PRESCRIBES DRUGS FOR MY CHILD?

January 21st, 2014

It is natural for a parent to worry when a medication is prescribed for their developing child. That’s why it is very important that the prescribing psychiatrist takes time to discuss all aspects of medication at the time of prescribing and on an ongoing basis. Goals of treatment, as well as common side effects, should be explained. Questions should be fielded cooperatively. Informed consent should be routine, but even after that, many parents who live in our information age still have worries and further questions. They often turn to written material they find on the pharmacy drug sheet or the Internet.

In theory, this is a good idea, but, unfortunately, it often leaves parents scared as they read highly technical data and sometimes even plainly wrong information. I often get urgent calls from parents after they have read about a particular side effect that was not discussed. Often the side effect is so rare to the point of clinical insignificance that it was not discussed in our meeting. So many side effects are listed for every drug that if they were all believed to be serious or common many people would take nothing, not even aspirin. The experience and wisdom of the doctor prescribing should help you weigh the benefits and risks of a drug for your child. Many patients call me with these questions, and I usually say that a particular effect is true but rare and should be put aside compared to the benefits of the prescribed drug. Nothing substitutes for clinical experience and the doctor’s ability to understand and evaluate what is meant by the written word.

One caveat I have for parents who use the Internet to research medication is that there is often fallacious material posted by overemotional parents or others who frankly misstate facts. The Internet is full of false claims as to the dangers of medications. Dangers are often made up, reported out of context, exaggerated, distorted, and discussed from a one-sided point of view. The websites that some parents tend to stumble across are often written by nonprofessionals and testimonials are usually filled with generalizations, distorted anecdotes, or even false rumors having little to do with proper prescribing. I spend a great deal of time explaining to concerned parents how to interpret something they have read into a less anxious context, and directing them to more reliable websites or other sources of correct information. This is part of the art of prescribing medication, and doctors must remain patient as these calls are from worried parents who want the best for their children.

DEPRESSION IN CHILDREN AND TEENS

January 16th, 2014

Like adults, children and teenagers have a wide variety of feelings. In fact, young people often seem to have more frequent changes of mood than adults, varying from day-to-day, hour-to-hour, even minute-to-minute. Sadness, joy, excitement, frustration, irritations, exuberance, sulkiness, anger, and the like are all normal and add to the colorful picture that defines us as people, but when a child or teenager becomes depressed it’s a time for parents to be concerned.

Six percent of young people are depressed at any one time and depression is a high risk marker for suicide, especially in teenagers. Thus, childhood and teenage depression is a great health challenge for our country. Depressed children and teenagers often appear as if their personalities have changed. While sadness is normal, it is experienced as more superficial than the more painful and deeper feelings of despair and hopelessness of depression. While a sad child might experience a bit of frustration and disappointment, a depressed one is often angry, irritable, cranky, whiny, and prone to rage at times, even violence. Sleep and appetite patterns change, weight is lost, menstruation and normal bowel function are affected, personal appearance deteriorates, and serious fatigue could ensue, as well.

If you suspect your child is suffering from depression, it is important to take action. Speak with your child’s doctor and then seek out a professional to help. (See my earlier blog on how to choose a professional). Treatment options for depression vary, and often will include treating with medication.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

MEDICATION ALONE IS NEVER WISE

January 15th, 2014

For the treatment of depression, or in fact any psychiatric condition, to be successful it must include some form of the many psycho-therapies available, be it individual, family, and/or group. It can be plain old psychodynamic talk therapy or cognitive-behavioral therapy, social support, self-help groups, supportive counseling, life counseling, or social skills aid. Many studies going back years have shown that treatment for depression combining therapy with medication leads to the best outcome.

Our society more and more looks to quick and painless remedies for nearly all ills. Rapid weight loss, instant body-building and even a magic pill to reverse years of suffering from a psychiatric disorder. In today’s world, especially with limited numbers of child/adolescent psychiatrists and mental health professionals, and with much of the prescribing being done by non-psychiatric physicians, many children are just being given a pill. I implore parents to seek help from a health care provider who uses or recommends verbal therapy to accompany the use of medication.

The gold standard of help in psychiatry still remains, at least to a degree, a human relationship with a professional skilled in the art and practice of some form of talk therapy.

EXAGGERATED PRAISE OF YOUR CHILD AND HOW IT EFFECTS SELF-ESTEEM

January 14th, 2014

A recent NBC News story, “Parents sinking some kids with their puffed-up praise, study finds”, raises some very interesting questions about parents who “bathe kids in exaggerated flattery to boost self-esteem.”

The article hits upon a very important topic: raising children with a good sense of self-esteem. We can most help our child develop decent self-esteem if we, in fact, teach him that his efforts are good and how he approaches something counts more than a result. In other words, we regard the process and show curiosity in the how and why of what he chose to do rather than congratulating a product only. For example, let’s say Susie comes home with a picture she drew. An ideal response would be to ask about why she chose to draw something, how she picked the colors she did, and why she included the particular background that is there. Many parents just praise the product: “Oh how beautiful the horse is!” and this can lead a child to focus on production to the absence of enjoyment and interest in the process.

In a society that puts so much emphasis on products, wealth measures and possessions, without as much on enjoying life we can see that such trends can often begin in childhood. Additionally, when we really value what a child does for us self-esteem also rises. For example, chores, which are really useful, make a child feel useful and necessary and important to his parents. Rewarding these chores with payoff does not feed into self-esteem.

Finally, we should remember we cannot really fool anyone in the long run, especially our children. False or inflated compliments will be perceived as such, and will not only lead to less risk taking as the article points out, but worse it can lead to a distrust of parents’ input — a much worse result.

ARE TOO MANY CHILDREN TAKING PSYCHIATRIC MEDICATIONS OFF-LABEL AND WHAT DOES THAT MEAN?

January 9th, 2014

Using drugs “off-label” for treating all kinds of conditions from cancer to ADHD has become so common that almost every drug at some point is prescribed off-label. “Off-label” means the medication is being used in a manner not specified in the FDA’s approved packaging label, or insert. Off-label prescribing isn’t necessarily bad. It can be beneficial.

In child and adolescent psychiatry, the majority of the drug prescribing is done off-label. Few medications are approved for young people, but making these valuable medications unavailable because drug companies have not tested them for all conditions and populations would cause a lot of prolonged suffering and even deaths. This is the case for hundreds of drugs, not just psychotropics. Studies have been coming out showing the helpfulness of psychotropic medication in young people and hopefully science and research will continue to catch up with clinical reality.

All in all, there are about ninety common psychotropic medications in common use today. The highest rate of approved drugs for use in children is in the area of stimulants used for ADHD. In that category, 100 percent of the drugs are approved for young people. In the antidepressant category, there are about thirty compounds altogether, seven of which are approved for use in children. In the antipsychotic category (most of these drugs are used for behavior control), there are fewer than twenty compounds with seven approved for children. There are no officially approved drugs for the treatment of anxiety in children and teens, and for mood stabilization (bipolar children) six medications are approved, mainly for teenagers only.

So, yes, child and adolescent psychiatrists routinely prescribe off-label, but we know that what we are prescribing works. Although there have been outcries against any off-label drug use because of possible dangers, the other side of the argument is that millions of people would be hurt if medication were withheld. When it comes to children, the outcry is even louder since the vulnerability is assumed to be greater with a younger and more physically and mentally immature population. But despite the many Internet tales of children being harmed by off-label prescribing, there are few reports in professional journals of its particular danger.

Presently about one million antidepressants prescriptions are written yearly in the United States for young people. This number has quadrupled in the last several years. In general, antidepressants are used off-label in treating children except for the following:

Prozac approved for depression in children eight years old and over for depression;
Anafranil approved for children ten years old and older but for Obsessive Compulsive Disorder only;
Lexapro approved for twelve to seventeen year olds for depression;
Luxox approved for eight year olds for Obsessive Compulsive Disorder only;
Sinequan approved for twelve year olds for depression;
Tofranil approved for six years old and over for bedwetting only;
Zoloft approved for six year olds for Obsessive Compulsive Disorder only.

Many people do not realize that the FDA regulates drug approval, not drug prescribing, and doctors are free to prescribe a drug for any reason they think is medically appropriate. For this reason, few patients are aware they are receiving a drug off-label since doctors are not required to tell a patient that a drug is being used that way. If you are concerned about a drug that is being prescribed for your child, by all means, ask the doctor about it.

WHAT YOU’LL NEED TO KNOW BEFORE STARTING YOUR CHILD ON MEDICATION

January 7th, 2014

If you have been told that your child would benefit from taking medication, the following guide will help.

Have your doctor explain your child’s diagnosis in as much detail as possible. Is there a known cause for the difficulty? What course might the disorder take if not treated? For example, if a child with ADHD doesn’t get treatment, the chance of substance abuse increases as the teenage years approach. Teenagers not treated for depression have an increased suicide risk. What positive effects of the medication will the psychiatrist be looking for? How long should it take? What will he do if it doesn’t work? While there is no medication which totally cures everything, your child’s prescription should target specific symptoms.
Make sure your child gets other forms of treatment along with medication. What does your doctor recommend? Individual talk therapy? Special school interventions? Behavioral therapy? Family counseling? Be wary of the practitioner who simply gives you a pill and wishes you good luck.
Make sure your child is physically healthy. If not, then the prescribing psychiatrist needs to be familiar with any medical condition. To this end, the doctor should take a detailed medical history of your child. In addition, I like to see a report of a recent physical examination from the child’s pediatrician. I also suggest a routine blood screening including a complete blood count, a routine metabolic screening, and also a routine twelve lead electrocardiogram in most cases. The blood tests and EKG will not only give signs of present conditions but will serve as baseline readings. Some medications affect blood tests and the EKG, and if we don’t have a baseline it will be difficult to know if future abnormal readings are caused by a medication or were always present.
Have a clear understanding of the medication’s side effects. Most side effects are fleeting and mild and don’t interfere much in your child’s life in any way, but they can be specific depending on the medication. You should know what they are so you don’t get worried. Serious or long lasting side effects for the child and teenage psychotropic drugs are rare, but again, you should be told of the signs. If you read information from the internet, be careful about the websites you choose. Don’t jump to the conclusion that the information you find online is more accurate than your psychiatrist’s years of clinical prescribing experience.
Make sure your child’s doctor, or a covering professional, is available twenty-four hours a day, 365 days a year, for any concerns you have about your child. Anything less is unacceptable.
Understand why the great majority of psychotropic medications given to young people are prescribed off-label, which means they haven’t been specifically approved for use by children. You will want to ask your prescribing psychiatrist what his particular experience is with the medication as well as what studies have shown about its use in children and teenagers.
Find out from your doctor what time of the day and how to give your child the medication. With meals, all pills at once, full or empty stomach? Although, many pharmacies now include a written summary of various aspects of the drug, follow the prescriber’s recommendations over those of the pharmacy. Call the doctor if there is a difference.
Determine what the medication will cost. Are there ways to cut the cost? Your pharmacist is the best source for that information. Cost alone should never force a decision as to choice of medication. Sometimes insurance companies make it difficult to get medication. Be persistent and get help from your psychiatrist to be sure your child gets exactly what the doctor ordered: generic or brand, the correct quantity, and refills, if possible.
Ask if there is a difference between generic and brand name drugs. I have not seen much of a difference between their effectiveness. Generic is usually okay. Some patients demand brand name medications and I go along with it, but with the caveat that these will cost more money with little research showing a beneficial effect.
Tell your child’s doctor about any other medications, supplements, or home remedies your child is receiving to be sure there are no adverse interactions with the prescribed medication. Remember even natural remedies can cause interaction problems.
Never compare dosages in milligrams between medications; they all differ and cannot be compared because of potency differences in the manufacturing process. Thus one milligram of one medication might equal in efficacy ten milligrams of another. For example, I recently had to explain to a patient that the new medication I was giving was measured in one half to two milligrams dosages and was replacing one that measured about thirty milligrams. It was simply another compound whose potency was measured differently.
Be prepared for your child’s doctor to recommend more than one medication. This use of multiple medications has become more common, as it sometimes gives better results. There are, however, risks to this practice which your doctor will need to explain. Risks include medication interaction, increased side effects, as well as decreased compliance because of the difficulty some patients have with multiple prescriptions. Always find out why your doctor is prescribing multiple medications and ask specific questions about the benefits and risks of such prescribing.
Always trust yourself and all the knowledge you have about your child. No one knows your child better than you and thus your observations of side effects, therapeutic effects, and overall well-being are the most valuable. Don’t be intimidated. Call your psychiatrist with any concerns.