Antipsychotic Drugs

 

The world changed when Prozac came out in 1989.  A few years later, in 1993, Risperdal was FDA approved for schizophrenia, heralding the “second generation” antipsychotic medication family which includes drugs such as Zyprexa, Geodon, Seroquel, Abilify, Latuda, Saphris and Fanapt. As with all new drugs, there is tremendous hope that the disease sufferers will have relief, and yet, as the story unfolds, the patients may experience greater relief, but they also suffer new side effects which the “first generation” drugs did not have. In other words, like so many things in life, it was a trade-off, as opposed to a transformational treatment. Whereas first generation antipsychotics gave patients a “Parkinson’s look,” second generation antipsychotics cause metabolic symptoms, meaning they are at significantly higher risk for cardiovascular disease and hence a shortened lifespan. Since the metabolic syndrome evolves over time, patients on second generation drugs appear “normal” whereas patients on first generation drugs look “diseased” and hence there is a greater tolerance of these second generation drugs by the general public. As a result, these second-generation antipsychotics are overprescribed to populations in which behaviors may be difficult to manage, such as in foster care and nursing homes. So, coincident with Prozac bringing in a generation of people who are medicated with psychotropic drugs, Risperdal was introduced adding on to the explosion in psychopharmacology. Further, in 2006, Risperdal was approved for the treatment of irritability associated with autism, opening the door to children being placed on antipsychotic medications in shocking numbers. This is disturbing because metabolic side effects are cumulative, and as such, the longer a patient is on these medications, the greater the risk of both morbidity and mortality. The antipsychotics, since they appear easy to tolerate, have become the go-to drug for all behaviors which are scary, which includes severe anxiety and severe anger. As such, there is less of a curiosity about why the patient is anxious and/or angry, and a quick trigger to give medications which immediately calms, but with long-term risks, many people do not want to consider. This issue of short-term relief, in exchange for long-term problems, is a particular problem given that outcome measures are often for short-term issues, and so the data can appear positive, if the measurements are done fairly quickly after symptom presentation.

 

Arlie, a twelve-year old girl, comes to mind. She is bright, has an intact family, has four older and academically successful siblings, and she goes to a high-pressured private school. As the semester nears to an end, she refuses to go to school. No one knows why and she won’t say. Her parents take her to two psychiatrists. One says she should go on Abilify, an antipsychotic, to soothe her presumed anxiety about going to school. The second psychiatrist, many decades older than the first psychiatrist, suggests that she baby-step her way back to school, with incentives after each step, and with a peer assigned to helping her through her day. The parents, not wanting to “trouble the school” opt for medication. Arlie is placed on Abilify and she still refuses to go to school. Her Abilify is increased and then she reluctantly agrees to go. She stays on Abilify and the parents feel they made the right decision. Arlie, when asked, states she is “crazy” and so she is on medication. She feels she “gave up” because the medication dulled her brain, but it is also true, she would say, that it is easier for her to be in school. Arlie illustrates the complexity of these antipsychotic medications. The fact that they produce symptom relief is not necessarily a reason to prescribe them. Behavioral techniques to get her back to school would be more time-consuming and would require heavy lifting by both the school and the family. On the other hand, Arlie would not carry the emotional weight of being on a psychotropic medication. She would also not risk long-term side effects and perhaps most importantly, she would not have the cognitive dulling associated with this class of medication. This case illustrates the tremendous generational divide in treatment approaches. It also illustrates the cultural shift which has taken place over my lifetime. When I trained in child psychiatry 1989-1991, most parents were frightened of medicating their children. Today, I see that , like Arlie’s parents, there is an eagerness to medicate and have the problems be resolved relatively quickly. The fact that antipsychotics no longer make patients look like they have a terrible neurological disease has opened up use of these medications to populations, such as children, who benefit from their calming effects. This benefit comes at a scary price. And so, the class discussion will begin.

 

 

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2006/ucm108759.htm

Childhood Medications: Time To Wake Up

 

http://online.wsj.com/article/SB10001424127887323477604578654130865747470.html

 

Now we have data to support my long-running rant that many child psychiatrists, working in community settings, are prescribing antipsychotics to children, not because they are psychotic, but because they are angry, traumatized and very difficult to manage. This is an “off-label” use of medications as these medications are not indicated to control difficult behavior, but as a side effect, they do help kids and adults calm down. The disparity among the privately insured versus the publicly funded children could be explained by the fact that these two populations have very different mental health issues. Generally speaking, publicly funded children have more social stressors, and hence they have more traumatic experiences in which they have to deal with, often with a limited environment that does not give them the opportunity to discover the language of feelings and hardship. Plus, many of the children in foster care need to stay in foster care, so there is a strong push to use all available tools to prevent a child from yet, another traumatic transition. Still, to get these medications, there is a doctor prescribing them, and this is where I want to focus. Child psychiatrists are often hired out of training, where they have been primed to think about how psychotropic medications impact children. They need jobs out of training and community jobs both provide employment, but also an opportunity to serve the under-served. Yet, when these young physicians land in their first job, they are confronted with an ethical dilemma. The staff at these agencies want these kids to calm down. Atypical antipsychotics can do this. For a short time, an atypical could calm down a tough situation, and so that might make sense. The problem is that this “short time” becomes year after year, and placement after placement, leaving these children in a compromised mental space. These atypicals dull thinking, and cause the metabolic syndrome, meaning truncal weight gain, and a high likelihood of type II diabetes. So, do we deal with the short-term crisis of aggressive behavior, or do we think more long-term about the exposure to detrimental side-effects? I think we need to understand these children, as most of them falling under the umbrella of trauma, and as such, they need to cope with their trauma through understanding and modeling. Psychotropics present short-term gain, for long-term pain. It is not worth it. Child Psychiatrists should use this data as a point of advocacy. We have to be part of the solution, not the problem.