Medicating childhood
Trends in prescriptions for stimulants in England
Trends in antidepressant prescribing 19922010
45
40
35
30
25
20
15
antidepressant
prescriptions
(millions)
10
5
0
1992
1996
2000
2004
2008
• “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
Models of drug action
Disease centred model
Drug centred model
Drugs correct an abnormal
brain state
Drugs create an abnormal brain
state
Drugs as disease treatments
Psychiatric drugs as
psychoactive drugs
Therapeutic effects derived
from effects on (presumed)
disease pathology
Useful effects are a consequence
of the drug induced state
Paradigm: insulin for diabetes
Paradigm: alcohol for social
anxiety
Psychoactive drugs
• Produce altered mental and physical states
• Tolerance and withdrawal effects
Classification of psychiatric medications
Pre 1950s:
• Sedatives
• Stimulants
Post 1950s:
• Antipsychotics
• Antidepressants
• Anxiolytics
• Mood stabilisers
• Hypnotics
• No evidence that psychiatric drugs reverse
underlying chemical imbalances or other
biological abnormalities
Different assumptions- different values
Disease centred modelassumes benefit
Drug centred modelassumes harm
So how do psychiatric drugs work? The
drug-centred model
• Direct effect of
psychoactive and
physical effects
• Amplified placebo
effects
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
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
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 shortterm
• No evidence that they improve performance on
complex tasks or over long-term
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
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, parentchild relations and social skills
• 3 years no difference between children randomised to
‘medication management’ vs others, or between stimulanttreated children and others
• 8 years- no differences
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
•
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
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
Patient information
• 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….
Community antipsychotic prescriptions 19982010 (PCA)
8
7
6
5
antipsychotic
prescriptions
(millions)
4
3
2
1
0
1998 2000 2002 2004 2006 2008 2010
National trends in office-based visits by children and adolescents that included
antipsychotic treatment, 1993-2002 (Pincus et al, 2006)
• ‘antipsychotic
medicines are believed
to work by balancing
the chemicals found
naturally in the brain’
Eli Lilly, zyprexa.com, 2011
Antipsychotics
• Physical and mental suppression (similar to
Parkinson’s disease for older drugs)
• Emotional dampening or indifference
• Used as animal tranquillisers
Early intervention in psychosis
‘movement’
• Early intervention
• Early detection
• Prevention of psychosis
• Justified by ideas about duration of untreated
psychosis and neurodegeneration
Symptom
Social withdrawal
Functional decline
Behavior changes
Concentration
difficulty
Examples

Spending more time alone

Avoiding friends and family

Avoiding groups

Dropping grades

Missing classes, school, or work

Not responding to friends

Collecting objects or hoarding

Developing a new and unusual interest

Developing an odd habit or gesture

Taking risks

Having trouble focusing or paying attention

Losing abilities in athletics or hobbies

Losing track of conversations

Forgetting

Getting lost

Developing difficulty with homework, reading, and understanding long sentences
Loss of motivation or 
energy
Quitting sports, groups or clubs

Declining interest in previously enjoyable activities

Sleeping more

Spending more time inactive

Staying home from school
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
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
Prevention of psychosis- high risk
mental state
• Early estimates: 40% proceed to psychosis
• Latest estimates 8-20% (Australian group 13%
in latest trial)
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
Early intervention and the
pharmaceutical industry
Bipolar symptoms test
The Zyprexa papers
• ‘Complex mood
disorder’
Paediatric bipolar disorder
New York Times, 2008