Transcript meaning of treatment

The Meaning of Treatment for
Adolescents: Medications,
Therapies, and Other Obstacles
Nancy Rappaport, MD
The Risks and Benefits of
Medication: Presentation Goals
• Informed decision
• Psychiatrist as
consultant
• Review of responses
of an adolescent to a
recommendation to
take a psychotropic
medication
Psychological Autopsies
• Shaffer studied large numbers of
completed suicides at an average age of
16 (170 psychological suicide autopsies)
in an ethnically diverse population in 198486 interviewing multiple informants with
community control subjects.
• More than 90% of subjects who
committed suicide met criteria for at
least one major psychiatric diagnosis
• Half of these subjects had psychiatric
disorder for at least two years
• Link between psychopathology and
suicide
• The most common diagnostic groups
were mood disorders (52% major
depression), disruptive disorders, and
substance abuse
• A child with a mood disorder is four to
five times more likely to attempt
suicide than a child without a mood
disorder
Spirito et al.
• Spirito’s study drop-out data indicated that
35-40% of adolescents in treatment after
suicide attempts dropped out within three
visits
• 58-78% dropped out within nine visits
The Meaning of Medication
• Surprising lack of discussion about the
psychological meanings of medication to
adolescents and parents
• Biological view vs. psychodynamic
formulation
Reservations About Using
Medications
• Controversy and fear that medications can
cause harm
• Ten-week international study randomized,
double-blind, placebo-controlled
• 376 participants from 6 to 17 years old
• Average length of episode of depression
was TWENTY months
• As early as three weeks, patients showed
improvement from medication
• 70 % of patients receiving medication
responded to medication (Wagner, JAMA,
Aug 2003)
Addressing Concerns
• Recent concern with Effexor and Paxil due
to an increase in mood-related symptoms
• Question of increased suicidal ideation
• Highlights monitoring symptom course,
particularly emotional lability
• Adolescents may be skeptical of the
accuracy of the diagnosis/role of biology in
their dysfunction
• Evolving sense of self
“I don’t care.”
“Depression is the mother of
anger”
• Irritability
• Duration of
symptoms
• Vague,
nonspecific
physical
complaints
Controversy and Fear of
Undesireable Side Effects
Possible Side Effects of SSRIs
• Activation
• Bipolar switching
• Celebration
Possible Side Effects of SSRIs
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Dimensional issues or comorbid presence
Evolving psychopathology
Frontal lobe type symptoms (apathy)
Gastrointestinal symptoms
Sex
• Perceived infringement of
autonomy
• “Will I have to take this
medication forever?”
Addressing Concerns
• Predicting with patients that experimenting
with coming off medications is not
uncommon
• Confidentiality and substance abuse
• Non-negotiable decisions
(hospitalizations)
• Even positive results from medication
can be troubling for adolescents
• Improvement can raise important
concerns about whether a patient’s
success should be attributed to a pill
or to themselves
Girls, Sexual Abuse, and
Medication
• Feelings of loss of control
• Perceived blame for traumatic experience
• Regaining control by making informed
choices
• Trap loss of privileges if not taking
medication
Parents
Reprinted with permission
“I don’t want my son to be a
drug addict.”
• Skepticism, fear of
the medical
establishment
• “From the cradle to
the pulpit to the
grave, many blacks
are taught that
suffering on earth
leads to great
rewards in the
afterlife.”
Wait, by Galway Kinnell
Wait, for now.
Distrust everything, if you have to.
But trust the hours.
Haven't they
carried you everywhere, up to now?
Personal events will become interesting again.
Hair will become interesting.
Pain will become interesting.
Buds that open out of season will become lovely again.
Second-hand gloves will become lovely again,
their memories are what give them the need for other hands. And the
desolation of lovers is the same: that enormous emptiness
carved out of such tiny beings as we are
asks to be filled; the need
for the new love is faithfulness to the old.
Wait.
Don't go too early.
You're tired. But everyone's tired.
But no one is tired enough.
Only wait a while and listen.
Music of hair,
Music of pain,
music of looms weaving all our loves again.
Be there to hear it, it will be the only time,
most of all to hear,
the flute of your whole existence,
rehearsed by the sorrows, play itself into total exhaustion