I came across a journal article lately that highlights an area of great concern for me and for others in the mental health world. A research paper published in the August edition of the Archives of General Psychiatry (a dense and difficult to read tome), identified a massive increase in the use of antipsychotic mood stabilizers in children and adolescents. In kids below the age of 14, the number of kids seen in medical visits who were on one of these medications went from 2.4/1000 in 2005 to 18.3/1000 in 2009. In adolescents (aged 14 to <18), the rate went from 7.8/1000 to 37.6/1000 in the same time period. There was a similar (although less dramatic) increase in adult usage as well.
Why is this a problem.
This is a problem on several fronts. I am a big proponent of the benefits of medications. They can be WONDERFUL for both the child and for his/her parents. BUT, when used as a substitute for individual and family therapy and when used as a substitute for real change in a child’s life, they are being mis-used. Loyal readers of this blog know my feelings about therapy. If parents and children would follow through on my recommendations for therapy and life changes, the need for the use of medications would clearly go down. If schools were given the resources to think creatively and implement individualized educational programs more readily, there would be less need to medicate our children.
The increase is also concerning because of the lack of good research on the use of these medications in this population. Like other psychiatrists, I use medications like Risperdal, Seroquel and Abilify in an “off label” manner, meaning that safety and efficacy has not been scientifically established and “proven” to the FDA. It falls, rather, under the “standard of care” for the profession. In general, children who have significant behavioral difficulties or severe issues with mood instability DO get better when these medications are used. The medicines have potential long term baggage, however, including the risk of weight gain, somnolence, and increased risk of metabolic diseases such as diabetes and hypercholesterolemia, and the potential risk of muscle movement disorders. We often forgo worrying about those issues in the heat of the moment when a child is aggressive to peers or to family, or when there is a risk of hospitalization or self harm.
But once these risks and difficulties are controlled . . . what then. The Quick Fix that these medicines provide can lull both parents and professionals into maintaining the status quo. It allows us to fit the square-peg of a child into the round-hole of what the family or society wants/needs. Attempts to get the child off the medicine are often delayed by months . . . or years . . . if ever attempted at all. Is that in the best interest of the child?
I’m not so sure. Actually . . . I am sure . . . it is NOT in the best interest of the child.
What this article points out to me is that my patients who are on these medicines need to be reassessed on a regular basis for the need of the medicine. It points out the need to ask the question . . . “what needs to change so that this child does not have to be on this medicine?”. Maybe the answer is that the child NEEDS the medicine. But maybe . . . just maybe . . . a change can be crafted that would allow him or her to get off the medicine.
But change won’t happen if the questions are not asked.
–Dan Hartman, MD
