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STRIKE THE RIGHT BALANCE WHILE PRESCRIBING PSYCHOTROPICS TO

CHILDREN IN DEVELOPING ECONOMIES

Devashish Konar MD Consultant Psychiatrist Mental Health Care Centre, Kolkata, IndiaWPA 2014 Madrid, Spain

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DISCLOSURE

I don’t have any financial disclosures to make.

Literature whenever quoted source has been mentioned.

THE CHALLENGE

• Mental health issues are being recognised more and at an earlier age.• Issue is alarming, at the same time recognising them early is good for

the child.• Treating and maintaining them in the society with

trained-manpower- crunch remain the main challenge in developing economies.

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Frellick 2014

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CAN’T DO IT ALONE

• The shortage of clinician with specialised training in assessing and managing the treatment of patients with mental disorder is a major barrier to providing adequate services in low and middle income countries (Saraun & Dua 2009, Saxena 2007 Kakuma et al 2011).• Current models that rely on mental health professionals to deliver

care are unsuitable for low and middle income countries, where number of mental health professional in lacking (Patel 2009).

Raynaud 2014

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TAKE HELP

A shift to collaborative care to emphasise training, supervision, and tertiary care while transferring the bulk of direct service delivery to community health workers or primary care professionals who would receive specific training and supervision in mental health is needed. (Patel 2009)

Raynaud 2014

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ADJUSTING WITH REAL LIFE SITUATION

• Inadequate trained personnel remains the fore concern for developing economies. • So managing the work load with constraint of resources makes the

work difficult. • Clinical work-up has to be brief. • Therapeutic sessions may have to be cut down to counselling. • Medication may become important part of treatment. • Judicious prescribing and never, ever, over-prescribing should be the

mantra.

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PSYCHOTHERAPY VIS-A-VIS PHARMACOTHERAPY

• Targeted psychotherapy by appropriately trained mental health clinicians remains the safest and most efficacious treatment modality for many psychiatric disorders in the pediatric population.• Medication is only one piece of treatment plan.• Relying on it may be the need if other trained personnel are not

available. • And then, if we know that psychotherapy is the safest and most

efficacious treatment, training has to be taken up urgently. Culture specific models need to be tested and popularised without delay.

Szigethy 2014

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FACILITATING EARLIER PSYCHIATRIC CONSULTATION• One of the most important points is facilitation of earlier psychiatric consultation.

• Too often, referral for psychiatric evaluation is only considered in the context of a significant worsening of clinical status, such as onset of suicidal ideation, or when a patient or family is beginning to lose hope and turn to medications “as a last resort.”

• It is important for providers to inform patients and families that waiting for symptoms to become more severe may decrease the probability of response or remission of symptoms.

So, on the one hand they need to be educated to come early for assessment and on the other hand you need to restrict yourself in prescribing medication unnecessarily or at the drop of hat.

Trivedi 2012

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IT IS IMPORTANT TO IDENTIFY EARLY

• Childhood and adolescence is a period of extraordinary biological, psychological and social growth. • However, at such times, individuals are also vulnerable to disruptions of

healthy development. • 50% of all adult psychiatric disorders have manifested by age 14, with 75%

manifesting by age 24. • Two thirds of pediatric-onset psychiatric disorders are moderate or severe,

and most continue into adulthood. • So early identification and appropriate treatment of psychiatric disorders as

early as possible to preserve healthy development and to reduce individual suffering and societal burden is important.

Rapoport 2013

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INVESTIGATION: IF NOT ADEQUATE, BE OPTIMUM

• Adequate investigation may not be feasible due to financial constraints but important ones cannot be omitted and safety concerns may never be downplayed. • So taking hints from clinical presentation regarding adverse effects

may be more important in the context of developing economies.

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SERVICE DELIVERY MODEL HAS TO BE INDIGENOUS

• With limited trained child psychiatrists, training other general psychiatrists and even pediatricians and family physicians may be more important than in developed economies. • Sensitisation about diagnostic clarity, proper drug selection, some

minimal counselling and psycho-education skills and identifying adverse effects are the minimum targets that we need to foray into. • Copying western models may not work across the countries and

cultures. • Chances of being biased in diagnosis and treatment in favour of

multinational pharmaceuticals may be a serious trap. • Culture specific models need to be worked up.

TRANSMITTING INFORMATION IN THIS COLLABORATIVE MODEL HAS TO BE SPECIFICALLY VERY RESTRICTED AND SIMPLE

AntipsychoticsRisperidone Aripiprazole Quetiapine

AntidepressantsFluoxetine

EscitalopramSertralin

Mood-stabilizersLithium

Divalproex

Drug for ADHD Methyphenydate

Atomoxetine

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SOCIAL PRESSURE MAY DECIDE TREATMENT OPTION

• Usually acute crisis brings the child in contact with services. • In these instances, parents and school personnel may demand rapid

results. • Waiting lists for psychosocial treatment and longer periods to initial

symptom control may further diminish the attractiveness of psychotherapy.• Psychopharmacology may be in demand.

Rapaport 2013

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CHILD PSYCHOPHARMACOLOGY BECOMING MORE IMPORTANT• There have been a number of groundbreaking developments in the

management of pediatric psychiatric disorders. • No more exclusive reliance on psychological and behavioral

interventions, psychopharmacologic advances have provided important biological management tools for severe pediatric psychiatric disorders. • The advent of modern psychopharmacology has further informed the

efficacy and tolerability of major psychotropic drug classes in youth.• This progress has been facilitated by regulatory agencies encouraging

and, more recently, requiring adequate studies of pharmacologic agents in pediatric patients.

Rapoport 2013

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NEED TO HAVE ONE’S OWN RESEARCH AGENDA

• Research even though may seem a luxury in developing economies, there is a definite role of it for having country specific, culture specific and need based models of delivery. • Copying western models blindly may neither serve the purpose nor

address the problem adequately.

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