Tag Medication

Are Meds Alone Sufficient to Treat My Child’s Psychiatric Symptoms?

teenandmedicationMany parents wonder about the efficacy of using only medication to treat their child’s psychiatric condition. While a full treatment of this question far exceeds the scope of a blog, it’s possible to briefly summarize some important themes and issues.

Clinical work limited to an initial interview and medication therapy risks misdiagnosis.

This is an example of an evidence-based, cost effective and clinically effective, outpatient evaluation for a child’s or teen’s mental health symptoms (assuming medical causes have been ruled out): a family interview, an interview alone with the youth, the collection of parent, teacher and child behavior rating scales and a review of relevant records. This is complex business and I worry about the accuracy of a diagnostic formulation if one or more of these elements is missing. Moreover, it is possible for a child to improve on a given medication without the child actually having the disorder that the medication is supposedly treating (e.g., low doses of stimulant medication will often improve the concentration of any child, regardless of whether or not that child has ADHD. Of course, sometimes it isn’t possible to do more than a brief interview and a medication trial, but if it’s possible to add the other elements that would probably be advisable in most instances.

Treatment with medication alone is rarely indicated.medication

There are some mental health conditions in youth for which medication treatment will almost always be a part of an evidence-based treatment plan (e.g., ADHD, bipolar disorder, schizophrenia). However, the best designed research studies on these conditions almost always indicates that evidence-based talk therapies (usually behavioral treatments) significantly improves the efficacy of the medication treatment (e.g., decreasing the dosage of medication needed, speeding along the management of the symptoms, strengthening the degree of  improvement, reducing the odds of suicidality). Moreover, in the very large majority of instances, children with a psychiatric diagnosis have at least a second diagnosis as well, and many of these co-occurring conditions are either best treated with evidence-based talk therapy alone or are  better treated when evidence-based talk therapy is added to the treatment plan.

Certain diagnoses, while perhaps improved with medication treatment, may not need such if evidence-based talk therapy is tried first.

teenfamilytherapyFor example, for mild to moderate depressive disorders and anxiety disorders, cognitive-behavioral therapy or other evidence-based treatments (e.g., interpersonal therapy for adolescent depression) may sufficiently manage or heal the presenting symptoms without the need to add medication therapy to the treatment plan. While these treatments take more effort than swallowing a pill, they may be preferred by parents who wish to avoid artificially altering their child’s brain chemistry when talking treatments may do the job as well or better.

There are many instances when the science on medication treatments leaves important questions unanswered.

There are many unanswered questions about the pros and cons of providing childmedicationmedication therapy to very young children as there are regarding the long term consequences of being on the same medication and the degree to which medication treatments alter the development of a youth’s brain. If a child needs medication treatment in order to avoid significant here-and-now impairment, most would agree that such questions often need to take a back seat.  But, if a youth’s symptoms can be effectively treated either by not taking a pharmaceutical, or by taking a lower dose, that would appear to be a preferable choice in many instances.

The short-term conveniences affiliated with medication treatments should give us all pause.

I believe the best available evidence would support the position that effectively moneyandpillsdelivered talk therapies for youth spares money, aggravation and pain over the long run. However, in the short run, talk therapies may offer more hassles (e.g., additional costs and inconveniences) than medication treatments. Moreover, considering only short-term costs may create incentives for decision makers (e.g., insurance companies, clinicians with capitated insurance contracts, hectic parents) to gravitate towards treatment plans that only include medication therapy. Such factors should cause us all to pause and reflect on both the available scientific evidence and issues affiliated with longer term consequences.

A take home point is that it is usually a good idea to have a mental health professional on your child’s treatment team who is aware of the relevant science and clinical practicalities and who can help you to effectively navigate your choices. If you’re interested in speaking with a psychologist more about these matters, please click here.

Mom Arrested for Giving Her Daughter Xanax: CBT Can Help to Avoid Such Sad Stories

According to a story this week in the North Platte Telegraph, a mother in Nebraska was arrested for intent to deliver a controlled substance after she gave Xanax to her 15 year-old daughter (the story indicates that daughter later gave it to a friend). I know no more about this story than what is contained in the above link. But I find myself wondering how much each of the following factors contributed to this unfortunate arrest:

√ The pharmaceutical industry markets directly to the public. The marketing budget of this industry far exceeds the public education budget of any mental health association that tries to teach the public about how psychological pain can be understood and relieved.

√ Studies vary but between one in ten and one in four youth suffer from an anxiety disorder (e.g., this graph, from the National Institute of Mental Health, demonstrates the high rates in teenagers).

√ Between 2/3rds and 90% of these kids receive no care. And, even when they do receive care they’ve often been suffering for years first and/or the care is truncated (my blog post discussing some of these issues regarding teens can be found here).

√ Many people, including primary care physicians and teachers, do not know what cognitive behavior therapy (CBT) is or that it is the number one researched talking therapy for relieving anxiety in children and teenagers.

This author knows of not one authoritative association or legitimately published researcher who recommends that anxiety disorders be treated by medication alone, in any human, at least when the afflicted person is able and willing to take part in talking therapy. Moreover, many kids successfully treated with CBT do not need medication to help manage their anxiety-based symptoms.

Cognitive behavioral therapy, which is a time-limited intervention, involves learning a collection of strategies for manipulating emotions and thoughts. Some of these strategies involve recognizing and adjusting thoughts (i.e., the “cognitive” part of the term), while others involve adjusting behaviors (the “behavioral” part of the term). In the case of anxiety treatments there are often two phases. In the first phase the child or teen learns the cognitive and behavioral strategies for defeating anxiety. (In my practice I’ll teach anywhere between five and ten strategies depending on the youth’s problems and situation.) In the second phase the youth then deliberately puts herself or himself into those developmentally appropriate situations that tend to evoke anxiety (e.g., getting on a school bus instead of being transported to school) and uses the techniques to conquer the anxiety. The work is finished once the youth is able to defeat all such fears. Often at termination both the youth and her or his parent(s) cannot believe how far she or he has improved in a relatively short period of time.

These treatments can be delivered to a child by himself or herself (with intermittent parent sessions so that the parent(s) are in a position to coach the strategies once the treatment is over), in groups of youth or together with family members. To identify a mental health professional who might be available to deliver this treatment in your area, click here. Below I have also listed links to three related blog entries.

Affording Mental Health Care

Signs that a Kid Needs Mental Health Services

Seven Common Myths About Counseling

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