Friday, November 10, 2006

Kiddy Shrinks/ Just a Thought


I have to start with a disclaimer: I am not a child psychiatrist.
Also ClinkShrink posted below while I was typing this. Make sure you check it out, and by all means, comment on her post, it makes her day!

So this month's American Journal of Psychiatry arrived in the mail today. I read for a bit about how the suicide rate in children ages 5-14 has was lower in areas where the number of SSRI prescriptions were higher. It's a complex issue, I'm not sure I followed it all (--okay, I read it really quickly and I skipped to the Results and Conclusions sections) but the point was that the Black Box warning on anti-depressants may be inaccurate, or may discourage use of a medication that lowers, rather than raises, suicide rates.

So I came home and ran through my blogroll. Shiny Happy Person and FooFoo are still missing in action. Fat Doctor and Dr. A are both tired and have photos of trains on their blogs. Dr. Crippen across the way on the NHS Blog has a post about children and depression. Poor Dr. Crippen is frustrated; he has a long post--- a really long post-- on how mentally ill children in the UK no longer have access to child psychiatrists, that the system has been dummied down with non-physician, under-qualified mental health care workers.

Over here, at least in major metropolitan areas, mental health centers which treat children all have child psychiatrists on staff. At least on good days. I've already written my thoughts about why psychiatrists should see patients for psychotherapy. As important as that is, it's even more important for child and adolescent psychiatrists to see their patients for psychotherapy, and it's hard to find docs who do both, who do both well, who have time to accept new patients, and it's expensive and really an option only in the private sector.

So why do I think this is so important? And remember, I'm not a child psychiatrist.

Suppose we assume that the FDA is right and that SSRI's cause some children to have suicidal tendencies (-- note that none of the children in the studies of these medications died of suicide). The current thinking is that this may well be right, that a small percentage of children, say 1 to 2 per cent, start thinking about suicide after beginning these medications, and that the thoughts are the result of the medications, not simply a pre-existing symptom as a result of the depression. It seems that the highest risk is in the first few weeks, perhaps even the first few days, of treatment, and as such it is now suggested that children be seen weekly during the initiation of pharmacotherapy. At any rate, warranted or not, the Black Box warning has given parents reason to pause before allowing their children to be medicated, and has given pediatricians reason to refer to specialists.

So a child is seen for depression. Perhaps he sees a psychiatrist who does only medication evaluations, and not psychotherapy. In this setting, the psychiatrist generally does a comprehensive evaluation with the patient and the parents. Based on his/her exam and the reported symptoms, a medication may be started. The problem with "medication evaluations" is that there is some pressure to make a decision about medications fairly quickly. Generally, patients walk away from these first-time visits with a prescription, maybe an appointment to come back in a few weeks for a "med check." It takes the medicines weeks to work, so this makes pharmacologic sense, it just doesn't make patient sense when dealing with a distraught human being. With kids, though, the stakes are higher now, we have that wonderful Black Box warning discouraging the use of anti-depressants. Oh yeah, and there's this other thing with kids: they go through "phases." It can be hard to figure out what's a reaction to circumstances -- think things like parental divorce, moves, new schools, broken hearts-- or what's a normal developmental stage-- think teenage angst, moodiness, irritability, some of which is psychopathology warranting medication and some of which is not. So, if the psychiatrist sees a child for psychotherapy, there isn't a rush a to determine if a medication is needed immediately, he's able to try psychotherapy as a first-line treatment in less severe cases, and he's able to more closely monitor the child's progress, response, and adverse reactions.

Just my thoughts.