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 1984-86 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

• 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 KinnellWait, for now.Distrust everything, if you have to.But trust the hours.Haven't theycarried 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 thedesolation of lovers is the same: that enormous emptinesscarved out of such tiny beings as we areasks to be filled; the needfor 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