Overprescribing Medication for Children

I’ve written on this subject before, and others are catching on.  John Grohol of PsychCentral writes:

Eight medications for a single child? Heck, I wouldn’t want to see an adult taking that many medications for a psychiatric disorder, much less a child of 10.⁽¹⁾

Yes, he talked about a report of a child being on 2 antipsychotics, 2 mood stabilizers, 2 stimulants, 1 antidepressant, and another med just for ADHD.  You’ve got to be kidding me.

I wish this surprised me.  It doesn’t.  Dr. Grohol thinks things might be better if the diagnoses were rendered by psychiatrists….maybe…maybe…

…general practitioners and physicians should never be diagnosing a child’s psychiatric condition unless they are a psychiatrist, plain and simple. They might offer a preliminary diagnosis, but then the rule should be that they refer on to a qualified mental health professional (a psychiatrist is fine, but psychologists and other mental health professionals are also well-qualified to properly diagnose and recommend a comprehensive treatment plan).

I’ve evaluated numerous children diagnosed by psychiatrists who were on 4 different classes of medication for ADHD (antipsychotic, mood stablizer, antidepressant, and another med to combat side effects).  As Dr. Grohol notes:

Compared to adults, few studies have been done to ensure the safety and efficacy of many of these psychiatric medications (except for childhood concerns like ADHD). Medications for children are sometimes necessary, absolutely. But it should be done only under the oversight of a specialist in mental health concerns (a psychiatrist) and treatment should, ideally, be conducted through a treatment of team of mixed mental health professionals.

I would urge even more caution that Dr. Grohol.  A psychiatrist will typically spend 15-30 minutes evaluating the issue.  Usually (not always), their only tool is medication.  In my practice, if it is at all feasible, I work with the patient in every way I can think of to avoid medication.  Occasionally, it’s not possible.  But very often it is.  If a psychiatrist wants to put your child on meds, ask if it has been approved for use in children.  There are not many meds that have been, but they are used all the time.

(1). http://psychcentral.com/blog/archives/2008/12/15/overprescribing-medications-in-children/

Antipsychotic Medication for Everything

CLPsych has an interesting post on a study that found that among patients with Medicaid in Oregon who were prescribed antipsychotic medication, only a minority actually had a diagnosis of a psychotic disorder or bipolar disorder (15% vs 27%).  The rest had diagnoses of depression, anxiety, or PTSD.  I think I’d like to add to this the fact disorders are often diagnosed for the medication as I’ve written about before (On Diagnosis, Symptoms, and Medication; Diagnosing for the Medication).  In other words, there are times when the diagnosis is given in order to justify the medication that is prescribed.  This doesn’t happen all the time, but it does happen.

http://clinpsyc.blogspot.com/2008/09/atypical-antipsychotics-for-all-oregon.html

Diagnosing for the Medication

When I worked at a mental health center, I often found myself scratching my head as to the diagnosis that was given to a patient by a psychiatrist.  I had diagnosed one individual with an Adustment Disorder, which is anxiety and depressed mood related to a difficult situation in life.  The psychiatrist diagnosed, schizoprenia, paranoid type.  I was left utterly scratching my head as to why the psychiatrist had diagnosed schizophrenia, whereas I diagnosed an adjustment disorder.   After looking at the medications that were prescribed, I found the reason, Abilify….an antipsychotic medication.  Even though this patient did not meet the diagnostic criteria for Major Depression, let alone schizophrenia, the psychiatrist wanted to try Abilify; therefore diagnosed schizophrenia.  That was the only conclusion I could come to.  I saw this on numerous occasions.  The diagnosis didn’t fit, and the medication was an antipsychotic.  So, the diagnosis would be Bipolar Disorder, or a psychotic disorder. 

As the Last Psychiatrist noted:

“You might argue the diagnosis leads us to the treatment, but in most cases, meds are used across all diagnoses, and more often than not a diagnosis is created to justify the medication.”

I had one patient, who for 14 years, was diagnosed with depressive disorder, NOS and personality disorder, NOS, until the psychiatrist wanted to try an antipsychotic.  Suddenly, the diagnosis became schizoaffective disorder. 

You may think that the diagnosis doesn’t have implications for treatment, but it does.  If you are psychotic, you are not responsible for your behavior.  The patient diagnosed as schizoaffective, was seen as psychotic by his wife and his psychiatrist.  Therefore, he was not responsible for his Borderline, manipulative, aggressive and passive aggressive behaviors.  This was the way the psychiatrist and his wife saw his behavior.  I did not see the behavior this way because I was his psychologist.  So, this puts me in a difficult position.  I see him as responsible for the choices he makes, but the psychiatrist and wife see him as “mentally ill” when he engages in unsual behavior.  I have to set limits and tell him that I would “find him a therapist who expects less” of him when the psychiatrist and husband justifies his behavior. 

You see, I also do evaluations related to “sanity” and “fitness to stand trial.”  This particular individual would likely be seen as incompetent and insane for his inappropriate behavior by the psychiatrist, but would be seen as perfectly sane by me who sees him as having a different diagnosis.  You can say the diagnosis has no implications, but it really does in terms of personal responsibility and therapeutic issues with respect to psychotherapy. 

So, this is one reason that I see diagnostic accuracy as being an important issue for treatment.  My personality testing, interviews, and observations yield a diagnosis of a primary personality disorder, whereas, the psychiatrist’s desire to prescribe an antipsychotic yields a diagnosis of a psychotic disorder.  So, it comes down to a situation where the patient has to decide to believe a professional who believes that they have control over their decisions versus a professional who believes they have no control or responsibility for their decisions.  So far, when faced with this decision, my patients go with me, who believes that they have control and responsibility for their decisions.  When they are legitimately psychotic, that’s one thing, when they are not, that is another.  The diagnosis has real world implications in terms of personal responsibility and psychological treatment.  Fortunately for most patients, when push comes to shove, they would rather believe that they are responsible for their behavior and have a desire to make efforts towards changing their maladaptive behavior.  Unless they truly are psychotic….then the issue of personal responsibility has less meaning to them, because their reality contact is impaired.

So generally, when one of my patients is seeing a psychiatrist, the diagnosis has real world implications.  And when they are not, the diagnosis has less meaning.  Only the individual factors that contribute to the person’s difficulties are relevant.  When the psychiatrist renders a diagnosis, then there are real world implications that affect the patient and their family.