Psychotropic meds for kids: First do no harm

By GREGORY K. FRITZ
The Providence Journal
Monday, July 23, 2007

One of the guiding principles of medicine that all physicians are taught in medical school is "first do no harm." It reminds us that the goal of medicine is to help patients, but even if that is not possible, we are admonished not to make things worse with our treatment. The adage contains the recognition that sometimes even well-intentioned treatment can cause new and serious problems for the patient, and there is also the unspoken acknowledgment of the limits of medical ability to heal.

Remembering the adage tempers physicians' ambitions, rescue fantasies and scientific curiosity about new treatment.

In child mental health, there is one particular arena where physicians should have "first do no harm" taped to our foreheads: prescribing the new anti-psychotic medications to children and adolescents.

The phenothizines (Thorazine, Stelazine and others) were the original anti-psychotics, introduced to psychiatry in 1952. They proved immensely helpful in treating mania and chronic schizophrenia. The community mental-health movement, in which many chronically psychotic patients in state hospitals were returned to the communities, was made possible in large part by the effectiveness of anti-psychotic mediations.

These drugs were not without serious side effects, however. Sedation, blood-pressure problems and movement disorders were common effects. Among the latter, tardive dyskinesia was the most serious, as the involuntary facial grimacing, wormlike tongue movements and writhing postures emerged later in treatment and were often permanent. Clearly, there was a need for safer medications.

The "second generation" or "atypical" anti-psychotics came into clinical use in the 1990s. Included in this group of medications were clozapine, (brand name Clozaril), risperidone (Risperdal), olanzapine (Zyprexia), quetiapine (Seroquel), ziprasidone (Geodon) and aripiprazole (Abilify). Though chemically different from each other, they have in common a much lower rate of movement disorders and other neurological side effects.

Recent studies have documented a dramatic increase in prescribing rates for all of these medications to children and adolescents. The increases range from 200 percent to over 500 percent and the most common diagnoses for which atypical anti-psychotics are prescribed in the pediatric population include oppositional defiant disorder, conduct disorder, mood disorders and attention-deficit-hyperactivity disorder. Boys are more likely to be prescribed atypical anti-psychotics than girls and white, non-Hispanic youth more likely than minorities.

There are two problems associated with these changes. First, clinical enthusiasm for prescribing the medications clearly exceeds the evidence of their effectiveness; and second, there are serious metabolic side effects of atypical anti-psychotics that may be especially serious in children. Both are cause for concern.

While there is beginning evidence that certain atypical anti-psychotics are useful in treating aggression, irritability and behavior problems associated with pediatric bipolar disorder and other disorders of childhood, the evidence is not sufficient for any of the medications to have Food and Drug Administration approval for use in children and adolescents. Thus all prescriptions are "off label" and evaluation of their efficacy is uneven.

Side effects, including diabetes, increased serum lipids, significant weight gain, sedation and cardiovascular effects, are frequently encountered with atypical anti-psychotics. Children may be more likely to develop these side effects, and once occurring, they may stay with the child for years into adulthood.

Thus the physician is in a difficult position. A child presents significant, worsening behavioral symptoms that impair function and that parents and teachers can't manage. Atypical anti-psychotics have anecdotal appeal and a few studies that suggest efficacy -- and their reported range of effect is broad. But weight gain is likely, a full metabolic syndrome is possible and other side effects are far from rare. What does the responsible physician do? It's a dilemma faced every day across the country.

Hopefully, we first do no harm. We avoid casual prescriptions at all costs, and we seek alternative treatments (even if they are more expensive or time-consuming). When we do prescribe atypical anti-psychotics, we identify a target symptom against which to judge efficacy, we monitor the patient very closely and we discontinue the medication when serious side effects occur. If a child has to live with problems, they shouldn't be ones we provide.

(Gregory K. Fritz, M.D., is editor of the Brown University Child and Adolescent Behavior Letter and medical director of Bradley Hospital.)