Reprinted from "Medications" issue of Visions Journal, 2007, 4 (2), pp. 25-26
The use of medication for mental health problems in children and youth has skyrocketed in the last 15 years. This is an issue that alarms many people, and not without reason.
Not enough research
There is a significant lack of research on the use of drugs in children and adolescents. One reason for this is the issue of consent. You can’t get informed consent from a child, and not many parents want to subject their children to research. Another reason is that children are not the best reporters of what is happening to them.
Furthermore, the research that has been done on medications used on young people is often quite vague about the benefits of these medications. The lack of a stable pattern of problems over time—since children are constantly changing—makes it hard to describe and evaluate what is happening.
Because there is little research with decisive results supporting the effectiveness of psychiatric medication in this population, there is little government approval for the use of these drugs for children and adolescents. This results in a lot of non-approved or ‘off-label’† prescribing. Most applications of these drugs to this young age group are based on the a drug’s effectiveness in adults, with dosage adjustments made for use in children and youth.
Not “little adults”
Children’s bodies are different than adult bodies; children are not little adults. Their smaller size causes us to think that they just need a smaller dose, when, in fact, a larger dose may be needed.
In newborns and infants a smaller dose is often needed because their immature liver and kidneys process drugs more slowly. Also, the so-called blood-brain barrier is more permeable, so a greater proportion of the drug circulating in the blood enters the brain of a younger person.
After six months of age, on the other hand, a child’s metabolic rate increases and the organ-total body ratios for liver and kidneys is larger. In other words, these organs are larger relative to the child’s body size than an adult’s corresponding organs are relative to the adult body size. This can mean larger doses are necessary for young people, because drugs can be cleared out of their systems much more quickly.
The “quick fix”
There is a lot of pressure from society to medicate. Psychosocial problems can be treated with individual and family therapy and changes in the child’s environment (e.g., home and/or school). Our society, however, wants an instant fix—the ‘pill for every ill,’ ‘mother’s little helper’ thinking.
There are several reasons for the allure of medication. Sometimes its effects are felt sooner than the effects of behavioural methods. Also, because it’s difficult for people to commit the effort and time needed for behavioural methods, these methods sometimes fail. In other cases, the symptoms, or disorder, seem too severe to try and treat with only non-pharmacologic means.
Drugs are also resorted to because there is often a lack of human resources for the first-line non-drug treatment that is recommended in guidelines and protocols. There just aren’t enough professionals and care workers to deal with all the mental health problems in our modern world.
However, a number of factors should lead us to try behavioural changes first:
the demands of making sure children are taking the medication properly
issues of safety and security of drugs around children, both at home and in the community
the high cost of the newer drugs
the risk of potentially serious long-term side effects
Black box warning kickstarts new research
There has been a lot of publicity given recently to so-called black box† warnings. These are warnings about the risks associated with certain medications in certain uses, which are required by government approval agencies to appear on the packaging of pharmaceutical drugs.
The warnings that began to come out in Britain in 2003 and in the USA the following year about the use of antidepressants in children and adolescents are a case in point. According to the media, the warning was that suicidal thinking might increase with the use of these drugs .1
It had been known since antidepressants came into use 50 years ago that suicidal thinking can increase temporarily during the early phase of treatment. What was new was that this phenomenon was being reported for the first time with respect to antidepressant use in minors. The most disturbing part was that pharmaceutical firms bringing out the most recent drugs had this information from their studies, but had not reported it. Indeed, just as had been known to occur among adults before, suicidal thinking did increase in some youths on these drugs. Reassuringly, the overall suicide rate did not increase; however, this important detail was largely obscured by the media.
Some good did come out of this warning. Doctors, especially the psychiatrists, appear to have heeded new recommendations on advising patients of these risks. They have increased the frequency of initial follow-up visits, thus monitoring of their patients has increased.2
More research is being conducted on the use of psychiatric medications in children and adolescents. Parties concerned about the use of these drugs in children and adolescents, such as the Canadian Paediatric Society,3 are urging government regulatory bodies to make changes. They would like to see investigators required to study the use of the drug in young people as well as in adults if their products are to be used in this younger age group. This should result in more appropriate, evidence-based and safer use of medications in our children and youth.
About the author
Lorne is a psychiatrist, recently transplanted from the Prairies, who works with children and adolescents in Richmond.
US Food and Drug Administration, Centre for Drug Evaluation and Research. (2004, October 15)., Suicidality in children and adolescents being treated with antidepressant medications (FDA Public Health Advisory). Rockville, MD: US FDA. www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm.
Lineberry, T.W., Bostwick, J.M., Beebe, T.J et al. (2007). Impact of the FDA black box warning on physician antidepressant prescribing and practice patterns: Opening Pandora’s suicide box. Mayo Clinic Proceedings, 82(4), 518-520.
Drug Therapy and Hazardous Substances Committee, Canadian Paediatric Society. (2003). Drug investigation for Canadian children: The role of the Canadian Paediatric Society. Paediatrics and Child Health, 8(4), 231-234. www.cps.ca/english/statements/DT/dt03-01.htm.