Thursday, January 29, 2009

Psychopharmacology and the Evidence and the Eye of the Beholder

I hadn't run into CounterPunch before- it is an on-line journal of political commentary that prides itself on pulling no punches.  Their article, "Why Hold Up a Drug Just Because It's Dangerous? Fragile: Handle with Risperdal" is worth a read (Get it here.)   She shows how the J& J funding of the "Center of the Study of Pediatric Psychopathology" at MGH was part of a marketing campaign designed to push the limits of acceptable usage for a medication that was initially approved for a very limited set of circumstances, and the dangers of the removal of the barriers that constitute the separation of business and diagnosis.  We've seen this now in so many different medications (e.g. Neurontin, Vioxx) that it really suggests a system problem with the structure of the process of drug development and Federal regulation.  I have faith that this will be dealt with, but the question for us as practitioners and parents is simple:  Given that we live in an imperfect system, where the sources of our information are tainted, how do we know when to medicate and when to refrain from medicating?  I've been mixed up in this business for a while, and have a few ideas for some practical rules that I would like to share.

1)  Always remember that there are no medications that have no side effects.   The only question is whether the side effects are less of a problem than the condition that you are trying to treat.  This should underlie all discussions of medication with children.
2)  Always point out that we know less about the new medications than we do about the older ones.  The phrase, "the devil we know" comes to mind, especially in dealing with methylphenidate and its brothers.  The new stuff always looks better, and we almost always find eventually that it is not quite as good as initially advertised.
3)  We know less about medications in combination than we do about medications alone.  The greater the number of medications we are using on an individual patient, the closer we are moving to experimental medicine.  This doesn't mean we shouldn't do it;  it does mean that we need to watch carefully, and listen to the parents and children about how these combinations are influencing their lives.
4)  Diagnosis in children is fluid.  Parents often tell me that "bipolar was ruled out in the eval" or something like that;  I usually try (gently) to point out that we actually don't know if this is still true 1 or 2 years later.  Kids develop, which is their wonderful strength, but it makes it hard to fit them into neat psychiatric categories.  Makes them hard to study.
I liken the use of psychoactive medications in children to a journey in the woods-  we have a few well-defined trails (like stimulants and ADHD and SSRIs and depression/anxiety), but a lot of what we do is akin to hiking off the trail.  Sometimes you have to do it, especially if you are a family "lost in the woods",  but bush-wacking the psychotropic "road less traveled" can be dangerous, and merits full disclosure.  The danger of marketing campaigns like the one used for risperdal is that they make us forget that we are actually in uncharted territory.

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