Professor Sami Timimi - Common treatments for child and adolescent mental health problems

Common treatments for child and adolescent mental health problems
 
A disproportionate section of this booklet is devoted to examining medication. This is because there has been a rapid increase in the use of psychiatric medication in the young and so careful attention to the evidence base on the effectiveness and safety of this practice is needed.
Medication
Rates of diagnosis of psychiatric disorders in children and prescription of psychiatric medication to children have increased dramatically over recent years, accelerating sharply over the last decade in most Western countries. These changing prescribing habits are being heavily influenced by the pharmaceutical industry’s marketing strategies. By joining in an effort to convince parents, teachers, doctors and other adults with responsibilities for the care of children that the emotional and behavioural problems children suffer with (and how many of us who are parents can seriously say that we have not had times where we were pulling our hair out with frustration or worry at our children’s behaviour?) are caused by ‘chemical imbalances’ in the brain, drug companies are aware that large markets can become accessible to their products. By promoting a line of argument and publicity that creates new diagnoses and talks about them as being ‘under-diagnosed’ and ‘under-treated’ we have reached the age of ‘an ill for every pill’, where marketing has triumphed over science. Nowhere is this problem more obvious than in the prescription of (as I will explain) largely ineffective and potentially dangerous psychiatric drugs to children and adolescents.
The drug industry has grown in profitability and influence in past 20 years and is now second in size only to the arms industry in the US economy. Commercial rather than scientific concerns become the dominant driving force behind ‘innovation’ and new drug treatments. Within a system of capitalist global markets, drug companies have little choice but to do whatever works to increase the sales of their drugs, regardless of the impact on health care. Thus the ‘hard sell’ is an inevitable consequence of the way that drug companies make money. Without strict regulation (and even with it) we should not be surprised to discover that some professionals notice that such a ‘rich’ industry provides many opportunities for greater personal wealth, which is reflected in the proliferation of links between doctors and the industry.
Drug industry money is now everywhere, to the point where career advancement is clearly enhanced by a relationship with a drug company. Research confirms that marketing practices do influence prescribing habits. Links between the pharmaceutical industry and the UK Department of Health have become so intertwined that the “public’s health is being put at risk”, was the conclusion of a recent and highly critical report from a cross-party group of MPs. The report cites multiple failings at the United Kingdom’s drug regulatory body for not scrutinising thoroughly enough data from companies seeking licences for new drugs and for not monitoring side effects adequately. It also blames lax controls at the Department of Health for allowing pharmaceutical companies to have expanded influence over the public and the medical profession, which, they believe, has led to over-prescribing by doctors and an unhealthy reliance on medicines by the public.
In recent years it has become apparent that drug companies are also using consumer lobbying groups to their advantage not only by (often secret) generous donations, but also by sometimes setting up patient groups themselves. For example, the main pro-medication consumer support group for ADHD in North America is CHADD—Children and Adults with Attention Deficit Hyperactivity Disorder. CHADD has long received substantial amounts from drug companies. Some critics believe that CHADD’s basic function has become that of promoting stimulant medications manufactured by its corporate donors (for example, pharmaceutical companies donated a total of $674,000 in the fiscal year 2002–2003). CHADD also produce a monthly magazine called Attention! which drug companies buy in the tens of thousands and then place them in doctors’ offices. In the UK, the main parent support group for ADHD is ADDISS—Attention Deficit Disorder Information and Support
Service. They also receive significant funding from the pharmaceutical industry. For example, a recent educational campaign ‘launched to support parents of children with ADHD’ includes a glossy booklet on ADHD called ‘Family Stress Points’ produced using an educational grant from a drug company. This situation has made it increasingly difficult for professionals, parents and other carers (not to mention children) to obtain impartial advice about the risks and benefits of exposing children to psychiatric drugs.
There are three main classes of psychiatric drugs used in children and adolescents, they are: stimulants, anti-depressants, and anti-psychotics. I will discuss each of them next.
Stimulants
Common brand names include: Ritalin, Equasym, Concerta, Dexedrine, Adderall
The most common medications used in the treatment of ADHD are central nervous system stimulants containing methylphenidate, such as Ritalin. These stimulants are from the same chemical family as the street drugs speed and cocaine; hence all stimulants are potential drugs of abuse and categorised in the legal system as ‘controlled drugs’ (like heroine and methadone). Stimulants’ effects are not limited to those children who are diagnosed with ADHD. Stimulants have the same cognitive and behavioural effects on otherwise normal children and children with other psychiatric diagnoses.
A beneficial effect beyond few weeks or months of treatment in children diagnosed with ADHD has not been demonstrated yet in what is considered ‘the gold standard’ for drug trials—the placebo- controlled double- blind trial. (This means comparing the active pill with an inactive ‘sugar’ pill, where those participating in the study and those studying them don’t know whether they are taking the active or inactive pill). There is no evidence that stimulants result in any long-term improvement in either behaviour or academic achievement, with articles reviewing the literature on treatment with stimulants concluding that a beneficial effect on ADHD symptoms beyond a few weeks of treatment has not been demonstrated.
Stimulants have the potential to cause many side effects, including serious ones. Common side effects include poor appetite, weight loss, growth suppression, disturbed sleep, unhappiness, irritability, mood swings, confusion, obsessive-compulsive behaviours, stomach-aches, headaches, and dizziness. Less common, but serious, side effects include, explosive violent behaviour, a flattening of emotions, and psychosis. Established side effects of long-term administration of stimulants include heart disease, lowered self-esteem, suppression of creativity, learning difficulties, excessive repetition, deterioration in performance on complex tasks, and, occasionally, death due to the toxic effects of stimulants on the heart. In recent years hardly a month goes by without new concerns emerging regarding the safety and/or effectiveness of prescribing psychiatric drugs to the young, forcing the regulatory body the Food and Drug Administration (FDA) in the USA to issue new labelling in 2006 that warns about the danger of stimulants (and the new non-stimulant ADHD drug ‘Strattera’) due to concerns about them causing suicidal ideation, heart attacks, strokes, sudden death and psychosis.
Animal studies have found that giving stimulants to rats can cause a long-lasting change in the brain chemistry. There has been a dramatic increase in the number of children who are receiving stimulants in Western society. The majority of children who are prescribed stimulants will remain on them for many years and increasing numbers are continuing to take stimulants into their adulthood. We do not know the effects on the developing brain, or the long-term effects on the heart, of giving children stimulants for many years, due to a lack of long-term follow-up studies.
Stimulants are powerful amphetamine-like drugs with potentially addictive properties. Children become tolerant to its effect resulting in gradually increasing doses being given to children as years on a stimulant clock up. The potential for tolerance and addiction is further demonstrated by
withdrawal states (known as the rebound effect, which presents as increased excitability, activity, talkativeness, irritability and insomnia) seen when the last dose of the day is wearing off or when the drug is withdrawn suddenly. Stories of adults becoming addicted to prescribed stimulants are becoming common.
Research has focused almost exclusively on short-term outcomes. Why so little long-term studies from the manufacturers? The few long-term studies that have been completed (usually by looking at what is now happening in the lives of adults who were prescribed stimulants when they were young) have shown that stimulants do not appear to result in any long-term improvement in behaviour, relationships, or academic achievement. Despite the lack of evidence for any long -term effectiveness, stimulants are usually prescribed continuously for seven, eight or more years, with children as young as two being prescribed the drug in increasing numbers despite the manufacturer’s licence stating that it should not be prescribed to children under six.
In a world run by those with the power to ‘buy’ media attention, it is not uncommon for single studies to become the basis on which practice develops. One such study was a large multi-centre trial in the United States, testing the efficacy of methylphenidate (Ritalin) for children diagnosed with ADHD. This study is known as the MTA (Multi-modal Treatment of ADHD) study and was first published in 1999. I have heard an eminent professor of child psychiatry in the UK state at a large conference attended by child psychiatrists and paediatricians shortly after the publication of the initial results of this trial, that the implication of this study is that we should be treating children diagnosed with ADHD with stimulant medication as the first line and possibly only treatment. It is notable that in the years since the publication and popularisation of this study there has been a sharp rise in the rates of stimulant prescription in the UK and the practice that professor was recommending has become the norm.
The MTA study was large (with over 400 children) and compared four groups of children who were given either: medication only; intensive behavioural therapy only; combined behavioural therapy and medication; or standard community care. The study lasted 14 months and concluded that the medication only and combined behaviour therapy and medication groups had the best outcome, with the combined group having only a marginally better outcome than the medication only group. A closer look inevitably brings up important questions of methodology as well as the question of a conflict of interest. The principle investigators were well-known advocates of medication with long-established financial ties to the pharmaceutical industry. Methodologically this was not a placebo-controlled double-blind clinical trial (see above) and the parents and teachers who partici-pated in the study were exposed to pro-drug propaganda at the start of the study, thus putting them in a mindset of positive expectation for change in those children receiving medication. Interest-ingly there was one group who rated symptoms through observing children in the classroom, and who were ‘blind’ to the treatment status of the children they were observing (in other words they didn’t know which children were taking medication). These researchers found no difference between any of the treatment groups on the behavioural measures they were using. Not surprisingly this important finding was given no importance in the study conclusions. There are also many question marks with regard the selection and recruiting process, the behavioural interventions used, and the lack of attention to the number of children experiencing side effects. In addition, two-thirds of the ‘standard community care’ group were also receiving the same stimulant medication during the period of the study, yet were placed in the poorest outcome category. Finally, it is important to realise that the ‘behaviour therapy’ group had completed their therapy and had no further face-to-face contact with a doctor or therapist some four to six months before the trial ended, whilst those receiving medication continued to receive regular face-to-face contact with a prescribing doctor right up until the end of the active study period at 14 months. Given that about two-thirds of the ‘standard community care’ group were also taking medication yet placed in the ‘poorest’ outcome group, one likely reason for the finding that participants in the ‘medication-only’ and ‘combined medication and behaviour therapy’ groups had the best outcome, is because they received extra attention and care from doctors compared to the other groups (the placebo effect). If this were the case (rather than the
better outcome being down to the medication) then we should expect that the advantages of the medication groups are lost once the active treatment phase of the study is over. This is exactly what happened.
The participants in the above study were followed up again 10 months after the end of the study – in other words, after a total of 24 months since the start of the study. These results are no longer looking so impressive. While the percentages of children with normalised symptom levels (in other words those who, in the opinion of the researchers, were no longer displaying ADHD symptoms) were essentially unchanged for the behaviour therapy only and community care groups, they had declined substantially for the combined and medication only groups. The medication only group now had a similar percentage to the behaviour therapy only group. Furthermore, there was now no evidence of significant treatment group differences in social skills, reading achievement, and parents’ use of negative/ineffective discipline strategies, and those who were receiving medication were now significantly shorter and lighter than those who were not.
In late 2007 the three-year outcome for the MTA study was published (a further year after the 24-month outcome study). All the advantages with regard to symptoms of ADHD for the medication only and combined medication/behaviour therapy groups had been lost, whilst the improvements in the behaviour therapy only group had remained stable. Since the end of the active intervention phase of the study (at 14 months) participants had been free to pursue whatever treatment they wanted. Some children had started medication and others on medication had stopped. The behaviour therapy group remained (by far) the group with the lowest use of medication. Furthermore when the researchers analysed outcomes for those who had used medication in the previous year they found that they had a worse outcome than those who hadn’t. In addition, those who had higher use of medication also had higher rates of delinquency and substance misuse at three years, and they were significantly shorter (by an average of over 4 cm) and lighter (by an average of over 3 kg) than those who hadn’t used medication. Thus the study that was loudly hailed across the media and within the medical profession, and has been repeatedly quoted including in the Department of Health and National Institute of for Health and Clinical Excellence (NICE) guidelines, as the study that demonstrated that stimulants should be used to treat ADHD, has conclusively discovered: a) that stimulants are not more effective in the longer term than behaviour therapy and may indeed have a worse outcome; b) that stimulants cause significant and enduring side effects, placing question marks on their safety; and c) that psychotherapeutic approaches (in this case behaviour therapy) are safer, just as effective and have beneficial effects that are more likely to be enduring.
Thus the scientific conclusion that we can make from analysing the evidence on treatment of ADHD with stimulants is that despite many studies over many years, the evidence to support the idea that treatment with stimulants produces long-lasting benefits, is absent. Indeed, according to James Swanson who was on the steering committee for the MTA studies “The medication management group [in the MTA study discussed above] functioned better at 14-24 months, but was associated with worse functioning and greater need of additional school services at 36, 48, 72, and 96 months”. Another member of the steering committee for the MTA studies, William Pelham, concluded, “No drug company in its literature mentions the fact that 40 years of research says there is no long-term benefit of medications [for ADHD]. That is something parents need to know.”
More difficult to assess are the possible social and cultural effects such widespread use of stimulants in children may have. Doctors may be unwittingly convincing children to control and manage themselves using medication, a pattern that may carry on into adulthood as the preferred or only way to cope with life’s stresses. Clinically I have come across children on stimulants who have admitted that they were secretly self-medicating at times of stress. Parents, teachers and others may lose interest in understanding the meaning behind an ADHD-labelled child’s behaviour beyond that of an illness internal to the child that needs medication.
Stimulants like Ritalin are also drugs of abuse as they can be crushed and snorted to produce a high. Research has shown that a significant proportion of adolescents in the United States self-report using Ritalin for non-medical purposes. Surveys have shown that between 3 and 16% of college students in the US admit to the use of non-prescribed stimulants. In addition, a significant proportion of those prescribed stimulants for ADHD have also been found to be either taking other stimulants in addition to their own, or to be misusing their prescribed medication.. The chemical effects of Ritalin on the brain are very similar to that of cocaine, which is one of the most addictive drugs, and cocaine users report that the effect of injected Ritalin is almost indistinguishable from that of cocaine.
Studies on the likelihood of substance misuse amongst those with a diagnosis of ADHD treated with a stimulant often conclude that those treated with a stimulant are less likely to abuse substances when compared to those with ADHD who were not treated with stimulants. Whilst it is thankfully rare for children prescribed a stimulant which is taken by mouth to becoming physically ‘addicted’, an unanswered question remains as to whether taking stimulants as a child sensitises the brain toward future substance abuse. The largest community-based study examining this issue, followed up nearly 500 children from the 1970s and right into their late twenties. They found a significant increase in amphetamine, cocaine and tobacco dependence amongst ADHD subjects who had taken stimulants when compared to ‘untreated’ controls. Furthermore they discovered a linear relationship between the amount of stimulant treatment and the likelihood of either tobacco or speed/cocaine dependence (in other words the more stimulant these young people had received over the years, the greater the likelihood of their becoming addicted to tobacco, speed or cocaine by their late twenties)..
Use of stimulants in children therefore remains a controversial issue for reasons that go well beyond its effectiveness and side effects. Yet these important issues that should be important information for all parents and young people who are trying to make the difficult decision as to whether or not to agree for themselves or their child to take a stimulant, is information that is rarely given by prescribers.
Antidepressants
Common brand names: Prozac, Zoloft, Luvox, Paxil
The evidence is now clear with regard the use of antidepressants in childhood – they are no more effective (even in the short term) than a sugar pill (placebo) and have considerable dangers attached to their use, particularly related to them causing an increased risk of developing suicidal thoughts. Despite this, antidepressants remain widely prescribed to children and adolescents.
It is well established that the older tricyclic antidepressants (such as imipramine and amitryptyline) are not effective for childhood depression.. The evidence now clearly indicates that neither are the newer Selective Serotonin Reuptake Inhibitors (SSRIs) antidepressants (such as Prozac and Zoloft). The ‘writing on the wall’ for SSRIs in young people started to take shape following a documentary in 2002 by the world famous BBC Panorama team who reported on several cases of young people who had not previously expressed suicidal ideas, but who committed suicide shortly after being started on antidepressants. The programme makers were then overwhelmed by calls and e-mails from members of the public sharing their own stories of adverse experiences in their children and young people after being started on an antidepressant. In December 2003 the UK government’s Committee for the Safety of Medicines produce the first guidance warning of the potential dangers of prescribing antidepressants to the under 18s and recommending that their use in this age group should be limited and monitored. By early 2004 the academic literature finally began to catch up, with professor Jureidini and his colleagues, writing in the British Medical Journal, reporting that in none of the published studies on SSRI antidepressants for childhood depression have the antidepressants, on measures relying on patient or parent reported outcomes, showed significant advantage over a placebo. No data regarding rates of self-harm, presentations to emergency or mental health services, or school attendance were presented in any of the studies they reviewed leading them to conclude
that investigators exaggerated the benefits and downplayed the dangers of the newer antidepressants for children. A review published in another leading journal, the Lancet, the following week found that the pharmaceutical industry had been ‘sitting on’ many unpublished trials, which showed that the newer antidepressants were even less effective and more harmful for children than suggested by the published trials.
Despite this accumulating evidence about the lack of effectiveness and potential dangers of SSRI antidepressants, the UK National Institute for Health and Clinical Excellence (NICE) guidelines for depression in children and young people published in 2005, concluded that there was still one antidepressant with a favourable balance of benefit over risk – fluoxetine (brand name: Prozac). Given fluoxetine’s similar pharmacological properties to other SSRIs there is no theoretical reason why it should achieve a significantly different profile than them; and indeed it doesn’t.
The Treatment of Adolescents with Depression Study (TADS) is the most influential pro-fluoxetine study and provides a good example of how the publicity (of efficacy and safety in treating childhood depression) for this study does not match the published findings (let alone any undisclosed unpublished ones). Whilst the study was funded by a US government agency, investigators who had received significant industry funding conducted it. The investigators claimed to show an advantage for fluoxetine, especially when combined with Cognitive-Behaviour Therapy (CBT). However there were flaws in the way they reported their data. TADS include a double-blind comparison of fluoxetine against placebo and an un-blinded comparison between CBT alone and fluoxetine with CBT (in other words participants who were in the CBT plus fluoxetine arm knew they were taking an antidepressant and may well have been discussing this in their therapy sessions). TADS didn’t have a group with CBT and placebo. This lack of patient-blinding and placebo-control in these latter two groups is likely to exaggerate the benefit seen in the fluoxetine with CBT group, who received more face-to-face contact and knew (as did their doctors) that they were not receiving a placebo. Furthermore the poor response of the CBT-alone group is a finding inconsistent with the rest of the psychotherapy outcome literature for childhood depression, raising questions about the quality of the psychotherapeutic intervention in this study. Comparing results across all four groups is therefore misleading. The one valid finding from TADS is the lack of a statistical advantage for fluoxetine over placebo on the primary measure the investigators used – in other words, just like other antidepressants in childhood studies, fluoxetine in this study is no more effective than a sugar pill. This is the only scientifically valid finding in this study, yet this finding was not reported in any of the article summaries, either in the journal or the releases to the press. What was reported instead was that fluoxetine is effective in childhood depression when combined with CBT. Despite the exclusion of known suicidal behaviour for anyone participating in the study, TADS found a trend to more suicidal behaviour (six attempts in the fluoxetine groups, versus one in the no-fluoxetine groups), consistent with other trials of SSRIs. Putting together that result with the lack of clinically significant advantage to drug over placebo and similar findings in the previous studies comparing fluoxetine and placebo, the profile for fluoxetine is similar to all other SSRI antidepressants – it has little efficacy and is potentially dangerous.
The dangers of antidepressants are not just from their potential to cause mental agitation (which can lead to impulsiveness, outbursts of violence and suicidal impulses). Once on an antidepressant it can become difficult to withdraw and withdrawal symptoms on stopping are frequent. The literature from studies in adults also shows that those who get better using and antidepressant are much more likely to ‘relapse’ than those who get better using psychological approaches (regardless of initial severity).
One of the likely reasons for the continued and often routine use of antidepressants is the high placebo response found in the studies (in other words a large percentage of the children were getting better, even those just taking a sugar pill). It is thus likely that many doctors see improvements after prescribing an antidepressant for a young person in distress and subsequently attribute improvements to the prescription. This high placebo response may thus reinforce a doctor’s prescribing habits and it has been difficult for many doctors faced with a distressed young person to accept that SSRIs may be
ineffective. On this point Professor Jane Garland, a participant in Sertraline (an SSRI) trials, but who later became sceptical about their methodology and reporting, writes ‘The high placebo response of SSRIs may reinforce physician prescribing, and it has been difficult for many physicians to accept that SSRIs may be ineffective. A complicating factor is that the public at large has now accepted the model of depression as a chemical imbalance for which medication is the treatment of choice, and the physician may experience pressure to prescribe. The disappointing reality is that antidepressant medications have minimal to no effectiveness in childhood depression beyond a placebo effect.’
Interestingly, if we look at the history of the use of antidepressants with children we find that child psychiatry as a profession had already supported the use of SSRI antidepressants long before any of the major studies in children were even published. The scene was thus set for marketing spin to take precedence over scientific accuracy, given that medicalising childhood unhappiness or ‘moodiness’ opens up a potentially large market for the drug manufacturers. As a result it appears that one reason for doing the studies in the first place was to justify already well-established prescribing patterns. It created a trend of ‘because everyone else is doing it’, which has become difficult to reverse despite the evidence. However, the evidence couldn’t be clearer – antidepressants in children are ineffective and can be dangerous.
Antipsychotics
Common brand names: Risperdal, Zyprexia, Seroquel, Abilify.
One of the most concerning trends is that of the increasing use of ‘major tranquilisers’ also called ‘antipsychotics’ for children displaying behaviour problems. These are powerful drugs traditionally used for adults suffering with what are considered ‘severe’ mental illnesses such as schizophrenia (although even here the evidence for the benefit is mixed at best, with much evidence showing that when antipsychotics are used for many years, they can cause subtle forms of brain damage, diabetes and other endocrine problems, and early death). Its use for less severe psychiatric problems and for children is a relatively new and poorly evaluated phenomenon.
According to a report in 2006 in USA Today, outpatient prescriptions of antipsychotics for children ages 2 to 18 in the USA leapt fivefold – from just under half a million to about 2.5 million a year – between 1995 to 2002. This figure doesn’t include prescriptions at psychiatric hospitals or residential treatment centres. The majority of these prescriptions were for behavioural problems in children with diagnoses such as ADHD and ‘bipolar disorder’ (an increasingly popular diagnosis used in the young in the US, but not so commonly used in the UK).
There are few studies on the effectiveness and safety of using antipsychotics in the young, and what evidence we have don’t make encouraging reading. A good example of the type of the misinformation that the medical community routinely receive comes from Susan Morgan and Eric Taylor’s (who is regarded as one of the most eminent child psychiatrists in the UK) editorial in the British Medical Journal (believed to be the medical journal with the highest readership worldwide) in 2007. In their article entitled ‘Antipsychotic drugs in children with autism’ they appear to take a moderate stance suggesting that antipsychotic drugs should not be used indiscriminately in children with autism. However, having stated this they go on to argue that in the right circumstances antipsychotics should be used in children diagnosed with autism who are presenting with behavioural problems. They note that antipsychotics have not been licensed in the UK for this purpose (in other words the authorities who evaluate these drugs have not approved their use for behavioural problems in children with autism), however they state ‘We consider off label use [of antipsychotics] is justified when other approaches fail or are unfeasible’. This effectively leaves the door open for the continued increase in the use of (off-label) antipsychotics, as the reader is left to wonder what other approaches to use and for how long before deciding they have failed. Furthermore, ‘unfeasibility’ of other approaches is becoming a big issue as the increasing popularity of the diagnosis of autism, together with this diagnosis becoming more often than not the
responsibility of busy community paediatricians, means ‘other approaches’ are thin on the ground. They further recommend ‘Diagnosis should distinguish between aggression and other seriously challenging behaviours (which may justify an antipsychotic agent) and lesser levels of irritability (which may not).’ However, they don’t explain how a clinician is supposed to differentiate between what one should consider ‘seriously’ challenging behaviour and irritability. They also talk about autism as if this condition was an already unchallengeable, established fact of medicine, neglecting to mention that the boundaries of this condition has expanded rapidly in recent years. Much of the increase in diagnosis has been amongst non-learning disabled boys in mainstream schools who have a variety of behavioural difficulties. If, as I, and many other critics contend, this is part of a socio-cultural trend of medicalising behaviour problems in response (at least in part) to an increasing sense of moral panic about children in general and boys in particular, then given that their advice is open to such broad interpretation, the outcome is likely to be an increase in the use of antipsychotics for managing challenging behaviour in the young.
But the real problem with this editorial is the lack of scientific support for their position. In support of their recommendation to use antipsychotics for challenging behaviour they refer to two studies only, a far cry from the usual requirement of having several independent studies to compare. Most readers will simply accept at face value what Morgan and Taylor say about these two studies, which is that using an antipsychotic (in this case risperidone – brand name Resperdal) for behaviour problems in children diagnosed with autism appears to be safe and effective. However, a more careful review of these two studies reveals anything but encouraging news for this practice. Firstly both studies were only of eight weeks in duration, far off the many years that drugs’ prescribed to pacify behaviour are usually used for. Secondly, one of the studies reviewed their subjects at six months; this showed a familiar pattern seen with drug treatment for behavioural problems—that of diminishing returns, with less than half of the group that had received risperidone now rated as ‘improved’ (interestingly they do not provide the data for the placebo group outcome at six months). Thirdly, a decrease in challenging behaviour in those receiving an antipsychotic at a sufficient dose is really a foregone conclusion, after all antipsychotics are not classified as ‘major tranquilisers’ for nothing. Whether this is viewed as a therapeutic effect or side effect depends on your perspective. Reflecting this fact, both studies rated high levels of ‘somnolence’ (drowsiness or sleepiness) of around 70%. This leads to the rather peculiar scenario where the same pharmacological effect is simultaneously rated as therapeutic (decrease in aggressive behaviours) and an adverse effect (somnolence).
What is more shocking is the minimising of serious adverse effects, which were prevalent in both studies. To give just one example; both studies found the group receiving risperidone put on more weight than the group with the placebo, in one this was an average of 2.7 versus 0.8 kg, and in the other this was an average of 2.7 versus 1.0 kg. Remember this was after only eight weeks. These drugs are ‘heavy-end’ psychiatric drugs with potentially serious consequences for a person’s physical health including weight gain, diabetes, permanent movement disorders and heart problems. A USA Today study of data collected from 2000 to 2004 shows at least 45 deaths of children in which an antipsychotic was listed in the official Food and Drug Administration (FDA) database as the ‘primary suspect’. Bearing in mind that the FDA’s adverse events reporting system is thought to capture only 1% to 10% of drug-induced side effects and deaths, this should be sufficient to cause considerable alarm about any proposal to recommend the use of these drugs with such meagre evidence.
Thus what the editorial reveals is that Morgan and Taylor are most certainly not the moderates they wish to present themselves as. Indeed they note that Janssen-Cilag (the drug company that makes Risperdal) withdrew their application for risperidone to be licensed in the UK for use in autism, due to fears about its safety. As a result they actually outdo a drug company in their keenness for use of psycho-pharmaceuticals in controlling children’s behaviour and go on to suggest doctors should carry on using it for this (out of licence) indication. Their position only adds to the current social trend of using powerful, risky and largely ineffective medicines to control the behaviour of a group
of citizens (children) who have never had a say in what is being imposed upon them and with scant evidence to back up the validity or utility of such practice. The lesson here is clear. As with many other areas of medicine we should not always trust what ‘opinion leaders’ say.
The above points about psychiatric medication for the young leads to the conclusion that overall, psychiatric drugs are not particularly effective and carry many dangers. This does not necessarily mean that psychiatric drugs should never be used in young people, but it does suggest that they are currently over-used. Young people and their parents should be enabled (through access to information such as the above) to challenge doctors to provide a clear rationale and evidence for using psychiatric medication, particularly if they feel unhappy about it being prescribed.
Psychotherapy
The good news is that unlike medications for children and adolescents, psychotherapeutic approaches have long established themselves as generally both safe and effective. Furthermore, beneficial effects may be more enduring than with medication, given the increased likelihood of ‘relapse’ once the medication is stopped. Although this general statement about the evidence for psychotherapy can be made, caution also needs to be exercised in interpreting the research. That there is a good evidence base that psychotherapy is better than (for example) being on a waiting list is a general level of evidence and doesn’t necessarily mean that everyone who receives psychotherapy will improve, just that you have a better chance of improvement than those who don’t. Psychotherapy can go wrong and individuals can get worse following an intervention. Whilst there is no direct physical dangers (unlike drug treatment) therapists can (and have) abused patients. Just like medication isn’t a ’magic bullet’ neither is psychotherapy. Furthermore, psychotherapy relies crucially on how motivated and engaged patients are in the therapy and with their therapist, so if this doesn’t happen (for whatever reason), the chances of benefiting from it are small.
An important question that has been debated for decades is whether there are any particular advantages for particular techniques with particular problems (or diagnoses) as opposed to common factors with different psychotherapies being more important (in other words, psychotherapy in general being effective for psychiatric disorders in general with little advantage for one particular approach/method over another). This is sometimes referred to as the debate between the ‘medical model’ of psychotherapy (specific techniques have specific ‘ingredients’ that treat specific problems) and the ‘contextual model’ of psychotherapy (the ‘common’ factors to all psychotherapy being more important than specific techniques).
The evidence is now so overwhelming that the debate is pretty much settled. The ‘contextual model’ explains the research findings much better than the ‘medical model’. All recognised formal psychotherapies (in other words where someone has been properly trained to deliver a particular technique) are effective to roughly the same degree, no matter what the psychiatric problem is. Furthermore, decades of increasingly sophisticated research into treatment outcome for psychiatric disorders has found little to support: a) the ability of psychiatric diagnosis in either selecting the course or predicting the outcome of therapy; b) the superiority of any specific therapeutic approach over any other for any particular psychiatric problem; and c) the superiority of pharmacological (medication) over psychotherapeutic treatment for emotional complaints. What is consistently found is that psychotherapy is generally effective, that the most important factors are those inherent to the patient involving his or her resources (such as levels of motivation, social support, and complexity of the problems) and the quality of the relationship between patient and therapist as rated by the patient. Current approaches in most psychiatric services, including Child and Adolescent Mental Health Services (CAMHS), haven’t yet caught up with what the research findings are saying and tend to emphasise emphasises process ‘standardisation’ through following ‘how to do it’ technical approaches to psychiatric problems, with diagnostic-specific treatment approaches (like Parenting classes for conduct disorders and Cognitive Behaviour Therapy for depression). However, specific technique is a factor shown to have as much as seven times less influence on outcome than the
‘common’ (to all psychotherapeutic approaches) factor of the quality of the therapeutic alliance, as rated by the patient.
What this means for a service user is that it is much more important that you strike up a good relationship with a clinician whose approach ‘makes sense’ to you than getting a diagnosis and receiving a specific therapy tailored to that diagnosis. It could be that you prefer and would feel more comfortable with a therapist of a particular gender or ethnic background, or that you prefer to talk about what’s going on emotionally, or that you want someone who gives you tasks to do and is very practical, or perhaps someone who would see all the family to facilitate communication etc. We each have ideas about what it is we might need to improve our situation or help us solve a difficult problem. Good therapy is about being able to match up our beliefs with a therapist who you feel ‘knows where you’re coming from’. That’s what the evidence says and that’s what many years of clinical experience confirms for me.
To help you decide on what sort of approach you might find makes sense for you, below I’ve listed some common therapeutic approaches you may come across in a typical Child and Adolescent Mental Health Service (CAMHS):
Family therapy – Usually involves meeting with various family members in a various combinations to explore family relationships, understand the dynamics of these relationships and make suggestions on how to change these dynamics for the better.
Systemic therapy – Is an extension of family therapy as it involves working with other significant people beyond the family, for example, schools, friends, extended family, employers, social services, other professionals and so on.
Behaviour therapy – Commonly used for behaviour problems and usually involves working with parents to develop strategies based on analysing the problem behaviours and then devising various consequences (rewards and punishments) to reduce unwanted behaviours and increase the desired ones.
Cognitive therapy – Based on looking at a person’s thoughts to help them analyse how their thought processes may be causing emotional and behavioural problems and from this analysis to help them change their thought processes in a more positive direction. Very often cognitive therapy methods are used in combination with behaviour therapy methods, and the term cognitive behaviour therapy (CBT) is widely used to describe this combination of approaches.
Psychodynamic psychotherapy – Based on understanding how emotional conflicts arise, including from traumatic experiences, and thus helping the person process unresolved emotional issues.
Group therapy – Involves a variety of techniques including all the above, but using a format of having people together in a group where they have an opportunity to learn off from each other and provide support for each other.
It is worth mentioning that these approaches are not mutually exclusive and usually involve a lot of crossover, for example, a cognitive therapist doesn’t usually ignore emotional conflicts, nor does a
psychodynamic therapist usually ignore thought processes. The differences are often ones of emphasis and in real life clinical encounters many therapists (often without realising it) ‘mix and match’ bringing in aspects of different models to fit whatever the persons or persons they are working with brings.
Other approaches
There are a whole variety of other approaches including those focusing on diet and nutrition, exercise, lifestyle and so on. Most competent doctors and therapists, will be able to combine a range of therapeutic approaches in a way that makes sense to the patient.
Summary
In this booklet I introduced the reader to common treatments used for child and adolescent mental health problems. I presented the evidence that shows that the three main classes of drugs used—antidepressants, stimulants, and antipsychotics—are not particularly effective (in the long term) nor safe and therefore should not, in my opinion, be used as a first-line treatment or by doctors not familiar with the scientific literature. Psychotherapy in contrast is generally speaking effective and safe, however, there is little evidence to support the idea that particular psychotherapy techniques make a big difference to achieving a positive outcome and much evidence to suggest that the quality of the relationship between therapist/doctor and patient does.