Medicating childhood

1. Medicating childhood

2. Trends in prescriptions for stimulants in England

3. Trends in antidepressant prescribing 1992-2010

5. “People with depression may have an imbalance of the brain’s neurotransmitters” Eli Lilly, 2003 “Paxil CR helps balance your brain’s chemistry” PaxilCR.com, 2009

6. Models of drug action

7. Psychoactive drugs • Produce altered mental and physical states • Tolerance and withdrawal effects

8. Pre 1950s: Sedatives Stimulants Post 1950s: Antipsychotics Antidepressants Anxiolytics Mood stabilisers Hypnotics Classification of psychiatric medications

9. No evidence that psychiatric drugs reverse underlying chemical imbalances or other biological abnormalities

10. Disease centred model- assumes benefit Drug centred model- assumes harm Different assumptions- different values

11. Direct effect of psychoactive and physical effects Amplified placebo effects So how do psychiatric drugs work? The drug-centred model

12. Using drugs in a drug-centred manner Need to know full range of: • Mental effects • Physical effects • Short-term effects • Long-term effects • Withdrawal effects

13. and… • Are the effects a drug produces useful in an individuals particular situation? • Do useful effects persist with continued use? • Do they out-weight the adverse effects? • Are there alternatives? • Diagnostic independent practice

15. Effects induced by stimulant drugs (Ritalin, amphetamine, atomoxetine, etc) • Increase attention on repetitive tasks • Suppress exploratory, inquisitive and social behaviour • Stereotypic behaviours or perseveration • May improve attention to simple tasks in short-term • No evidence that they improve performance on complex tasks or over long-term

16. Evidence for stimulants in childhood ADHD – placebo controlled trials(Schachter et al, 2001) • Short-term improvement of attention and reduction of hyperactivity • But trials of poor quality and evidence of publication bias • Longest trials – 6 months- showed no effect

17. MTA study • 14 months: some positive outcomes for children randomised to ‘medication management’ (inattention, parents and teachers, hyperactivity parents only; none for blinded independent rater) • No differences in academic achievment, aggression, parent-child relations and social skills • 3 years no difference between children randomised to ‘medication management’ vs others, or between stimulant-treated children and others • 8 years- no differences

18. Adverse effects of stimulants • Growth restriction (4cm in MTA study at 3 years) • Raise blood pressure, pulse, and associated with sudden cardiac death • Psychological effects: ‘zombie’ effect, psychosis, depression

19. Psychoactive effects of some modern antidepressants (SSRIs and venlafaxine) • Drowsiness, lethargy • Cognitive impairment • Emotional blunting • Reduced libido • Agitation and anxiety • Tension • Insomnia • Anger, Aggression, Emotional instability • Impulses to self harm/suicide • Not pleasant for volunteers

20. Evidence on utility of antidepressants in children • Efficacy of antidepressants in adults not demonstrated because of ignoring of psychoactive effects and amplified placebo effects. • Differences between antidepressants and placebo in children small (mean change 3.51 on a scale from 17-113) (Hetrick et al, 2012 Cochrane review) • Increased suicidal thoughts and behaviour repeatedly demonstrated • May set up lifelong psychological dependence on medicines

21. The antidepressant will help normalise your serotonin levels The antidepressant will improve your depression This drug affects the way people think and feel (not just people with depression), but we are not sure how. It may dampen down your emotions, suppress your libido and make you feel a bit lethargic…. Patient information

22. Community antipsychotic prescriptions 1998-2010 (PCA)

23. National trends in office-based visits by children and adolescents that included antipsychotic treatment, 1993-2002 (Pincus et al, 2006)

24. ‘antipsychotic medicines are believed to work by balancing the chemicals found naturally in the brain’ Eli Lilly, zyprexa.com, 2011

25. Antipsychotics • Physical and mental suppression (similar to Parkinson’s disease for older drugs) • Emotional dampening or indifference • Used as animal tranquillisers

27. Early intervention in psychosis ‘movement’ • Early intervention • Early detection • Prevention of psychosis • Justified by ideas about duration of untreated psychosis and neurodegeneration

30. Castle, 2012 • WHO estimate: 14 new cases of psychosis per 100,000 • Cambridge (England) Early Intervention service 50 per 100,000 • Melbourne (Australia) Early psychosis programme approx 100 per 100,000

31. Trials of early intervention • OPUS study n=547 • Lambeth Early Onset study n=144 • Some benefits while intervention active. Neither showed any specific benefits from starting antipsychotics early, nor any benefits after intervention ceased

32. Prevention of psychosis- high risk mental state • Early estimates: 40% proceed to psychosis • Latest estimates 8-20% (Australian group 13% in latest trial)

33. Prevention of psychosis-drug trials • McGorry et al, 2002: 3X lower risk of developing psychosis • McGlashan et al, 2006- no sigt difference • Ruhrmann et al, unpublished • McGorry et al, 2012- no sigt difference

34. Early intervention and the pharmaceutical industry

35. Bipolar symptoms test

36. The Zyprexa papers • ‘Complex mood disorder’

37. Paediatric bipolar disorder

38. New York Times, 2008