The Question of Medication

The question of whether or not to try medication with a teenager can be a difficult one for parents. Many parents are adamantly opposed from the outset, and for understandable reasons. Placing trust in a prescriber when it comes to psychoactive medication for their children is probably the biggest concern, but it is compounded by worries about side effects, horror stories in the media, “bad experiences” reported by friends of the family, and the seemingly boundless conflicting information coming from every direction.

For parents wrestling with this decision, I offer the following counsel:

The use of medication in any clinical situation comes down to weighing the potential risks of a medication trial versus the potential benefits.

Note that I say the risk of a medication trial. We shouldn’t be talking about a commitment to medication for life, or even the long term. We should be considering whether or not it is a good idea to try medication out for a short time and see what happens. The decision about whether to stay on medication or not is a separate question, one that is often easier than the trial itself, because after the trial we are in a position to say if things have changed for the better, the worse, or not at all.

There is really only one potential benefit of a medication trial:

1. Correction of a biological imbalance that is getting in the way of a person’s functioning. (Note I didn’t mention a person’s “feeling better” – see this post for details.)

This could range from relieving excessive anxiety or depression to reducing or eliminating the symptoms of a more serious psychiatric condition, such as bipolar disorder or schizophrenia.

Biological imbalances don’t respond nearly as well to “psychological” interventions (e.g. therapy) and often appear to have a life of their own. They may get better or worse on their own over time, often unpredictably. Just as treating “developmental” or “psychological problems” with medication is generally an act of futility, so can be treating more severe biological ones with therapy. The best therapist in the universe is not going to make the voices go away for someone with schizophrenia, or talk someone out of a manic episode.

The results of correcting biological imbalances can be dramatic, and sometimes life-saving. The direct benefits are often followed by a host of indirect ones. To the degree that a person’s symptoms were interfering with social relationships, family life, work, or school, these aspects may all improve. To the degree these imbalances were a driving factor in self-medication through substance abuse, achieving sobriety may become much easier.

So what are the risks of a medication trial?

1. Side Effects.

Side effects may range from serious allergic reaction (which is possible with any medication) to mild general effects that resolve over time, like headaches or sleepiness. Specific medications have more specific risks, such as the possibility of weight gain or tremor. Some require regular bloodwork to monitor things like kidney and liver function, but these types of medication are the exception rather than the rule.

One side effect that is more common with antidepressants in particular is feeling more anxious or experiencing a worsening of mood. Of course, for a person with a mood problem to begin with, we don’t want this to happen! This is why we call it a medication trial, though, and the medication can (and should) be stopped. I tell my patients if they feel a medication is making them feel worse in any way, they should stop it right away and contact me. This particular side effect appears to be more common in adolescents, and is the cause for the so-called “Black Box Warning” on antidepressants and now other psychiatric medications as well. Unfortunately, the effect of this labeling change and the way it was implemented has led to a lot of folks being scared away from treatment that might really benefit them.

I’ve been doing this a long time, and following some common sense precautions (e.g. using antidepressants judiciously in folks who are already anxious or have mood instability, and always instructing patients to stop a medication if they feel worse), I’ve never had a serious problem with this. On the other hand, I have heard of patients having bad experiences when these precautions aren’t followed (for example, if a provider insists that a patient “push through” mood-related side effects during a medication trial).

2. Physical Dependence.

Fortunately, most psychiatric meds are not habit forming. The major exception is benzodiazepines (think Ativan, Klonopin, Xanax, Valium) which can be addicting. This is the reason I very rarely use them. Stimulants like Ritalin can be abused and have some street value, so I pay particular attention to whom I writing the script for when I write them.

Although not “habit-forming,” some meds (particularly certain antidepressants) can cause some unpleasant withdrawal effects that aren’t dangerous but are uncomfortable, which is why I try to taper them if possible instead of stopping them abruptly.

A lot of parents have concerns about “permanently” altering brain chemistry in a negative way with a medication trial, but this idea isn’t supported by evidence. Actually, it appears to be the opposite for some of the more significant psychiatric illnesses: there is evidence that early intervention in both mood and thought disorders can modify the course of the illnesses to make them less severe over time.

3. Psychological Dependence

This is an interesting one: the idea that a medication may become an “unhealthy crutch” for kids that enables them to avoid working on solving their own problems.

For some kids, I think this is true, although I see meds less as a crutch and more a distraction from real work that needs to be done. I see many kids who have been put on medication in an effort to treat a developmental problem, i.e. a problem of immaturity or bad habits. Developmental problems don’t respond much to medication (which is why the medication aren’t really effective as “crutches” anyway). Moreover, excessive attention focused on “getting the right medication” can distract kids, their parents, and treatment providers from the real problem, which is one of practicing healthier habits and becoming more mature.

4. Fear that Medication Won’t Work

Some trials just don’t do the trick. The good news is that – to the degree that an imbalance is biological -- it’s quite likely there’s a medication out there that will help. It might just take another trial.

5. Fear that the Medication Will Work

Parents who started the trial with negative preconceptions about “altering brain chemistry” now find themselves faced with a potentially more difficult question. The medication trial was successful. How do they now feel about a child’s staying on medicine?

Decisions, decisions!

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