June 16, 2011

Are Antipsychotics Overprescribed To Kids?

does this make me look like I'm keeping an eye on waste?

10 year study of inpatient kids: 44% got antipsychotics.  Is that a lot?  Yes.  It's a lot.

And most of the time, not even for psychosis.  44% of the PTSD and ADHD kids got antipsychotics.

You can wrack your brain trying to figure this out or blame the usual suspects, but the answer is right there in the article:

Variables associated with antipsychotic use [included] male gender, age 12 years and under, being nonwhite, and a length of stay 13 days or longer.

You'll observe that none of those words is "diagnosis" or "severity."

The cause of these high levels of medications is so simple you'll recoil from the truth of it, but pour yourself a drink and take it like a man: the kids showed up.  That's it.  The kid is in front of you and you have to do something, now, that results in an acute change. Not better grades 4 years out, or less sadness over the teen years; change the sleep tonight, make the kid less hyper now, and when it "stops working" you can up the dose or change the med.

It doesn't matter what the diagnosis is or what the symptoms are, really, whether he ate his dog or got a C on a test he's going to be getting something at qd and hs because that's what you get when you put psychiatry as the cornerstone of a Multidisciplinary Treatment Team.

When a kid is presented to a psychiatrist, the psychiatrist is pressured, obligated, to do something pharmacological.  If a psychiatrist looked a single parent a joint away from a nap right in the eye and said, "nope, he's acting out because of X, Y, Z, and medications aren't going to fix this" that doctor will get his head handed to him by parent or by lawyer.  Justice will be done, you negligent elitist.

And the simple reason why the kids showed up is that the parents and the schools and the cops and the courts were told that's where you go when a kid punches another kid or becomes hispanic.  That's why outside the oakwood offices of the private docs the shingle says "Practice of Psychiatry" in Palatino Linotype, but get within fifty blocks of a black kid and the whole thing is labeled "Behavioral Health" in what I think is Erasermate.

This is why reducing antipsychotic prescription is a Chuck Grassley political diversion, if the kids don't get antipsychotics they won't get nothing.  The problem is the overprescription of prescriptions.

I get that when a 15 year old starts up with cocaine it is a bad thing.  But is it automatically true he has ADHD or BPD and needs medications?  Check the map:

map of psychiatry today.jpg

There's a very large system in place for not doing what's best for people, it is expedient and simple and the law but nevertheless ineffective and counterproductive in the long run.  The trouble is, this system screws it up for people who actually need it.  Just because a 10 minute med check is perfect for the vast majority of patients who don't have any psychiatric illness, doesn't mean it'll work on the kid with prodromal schizophrenia and the crying parents who look at you like, wtf?  Are you kidding me with this?


An Epidemic of Mental Illness


Don't know what the map mea... (Below threshold)

June 16, 2011 6:12 PM | Posted by The Devastator: | Reply

Don't know what the map means, it's going to drive me nuts. Can anyone explain?

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It's a map of the world as ... (Below threshold)

June 16, 2011 6:39 PM | Posted, in reply to The Devastator's comment, by Alex: | Reply

It's a map of the world as portrayed in '1984', which is a novel by George Orwell.

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WHAT is the law? the paradi... (Below threshold)

June 16, 2011 8:12 PM | Posted by noob: | Reply

WHAT is the law? the paradigm of over-prescription? who has the power to affect that paradigm, if not psychiatrists?! I think psychiatry has more implicit political power than most people realize. They say, "the personal is political", and making that decision for ONCE to give real advice and not some tranquilizer is a way of instantiating that political power, personally. Maybe people should re-define what they expect from psychiatrists, but it goes both ways.

It's like with cops: there's a cultural expectation that cops act like assholes. But then they actually do, on a personal level...under the similar auspice of LAW. But who's really in control of those expectations? In my mind psychiatry as an institution abuses its political power by not acknowledging it, but also, by not using it. I guess the DSM is the dark-side of that institutional power, but what would YOU do, doc, with an eleven year old who keeps punching kids on the playground and says he hears voices in his head?

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Okay, I see the legend now.... (Below threshold)

June 16, 2011 10:08 PM | Posted, in reply to Alex's comment, by The Devastator: | Reply

Okay, I see the legend now. But why "yes" and "no?"

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is it automatically true he... (Below threshold)

June 16, 2011 10:26 PM | Posted, in reply to The Devastator's comment, by tanj: | Reply

is it automatically true he has ADHD or BPD and needs medications?

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Hmm, okay. I guess I'm most... (Below threshold)

June 16, 2011 11:58 PM | Posted, in reply to tanj's comment, by The Devastator: | Reply

Hmm, okay. I guess I'm mostly wondering why the arrows point where they do. Quote says nonwhites get antipsychotics -- so why is there a "No" arrow pointing to what I believe is Paraguay? And to the middle of the ocean?

But I don't want to belabor this too much. No one can be told what the Matrix is, etc.

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The point is that it's diff... (Below threshold)

June 17, 2011 3:11 AM | Posted, in reply to The Devastator's comment, by tanj: | Reply

The point is that it's different.

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"who has the power to affec... (Below threshold)

June 17, 2011 5:11 AM | Posted, in reply to noob's comment, by Sfon: | Reply

"who has the power to affect that paradigm, if not psychiatrists?!" Whoever is paying the psychiatrists.

What is the difference between a psych who cuts corners to maintain his standard of income, and a corporation that does the same for the same reason?

A psych in such a position has just as much of an ethical responsibility not to risk harming people as a corporation dealing with chemical storage, even if that means bagging groceries under med school debts because he cannot get honest work in the field. That is not a realistic thing to expect of people, however.

Psychiatrists are not going to properly treat people if we put barriers in the way and pay them to do something else, ethics be damned. Furthermore the profession will fill up with the sorts of people who have no problem with this.

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The "YES" arrows point to U... (Below threshold)

June 17, 2011 7:44 AM | Posted, in reply to The Devastator's comment, by DirkAnger: | Reply

The "YES" arrows point to USA, Europe, Australia, the Asian Southeast and Russia.

The "NO" point at Bolivia, the Maldives (sort of), Greenland, and a place that doesn't exist but is filler because the cartographer didn't want to repeat that tip of Alaska in both places.

Not sure what to make of it, other than it's automatically true in rich places, I'm guessing for the reasons usually mentioned in this blog

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The real problem is that th... (Below threshold)

June 17, 2011 1:34 PM | Posted by Anonymous: | Reply

The real problem is that these meds work so damn well and if you only get 3 days IP to fix a kid, Well there you go.

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I am about to start a job i... (Below threshold)

June 17, 2011 2:50 PM | Posted by Anonymous: | Reply

I am about to start a job in a community mental health center and am scared to death of myself. I have always emphasized good evaluations and good diagnostics no matter what pressures came down in the academic environment I was in previously, but have been told at this new gig "We have a psychopharmacologic model here" after describing my interest in behavioral strategies. It sounds like 15 min per patient, meds expected...my strategy going in is to provide education to the staff and to always give patients info re: treatment options. If I become a Seroquel pusher, please find me and shoot me.

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Chuck Grassley (R-Ethanol) ... (Below threshold)

June 17, 2011 7:54 PM | Posted by Jack Coupal: | Reply

Chuck Grassley (R-Ethanol) looks cranky because Congress just voted to somewhat stop federal subsidies paid to corn farmers.

A kid can have PTSD? When did that start?

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since forever? since as lon... (Below threshold)

June 18, 2011 12:49 AM | Posted, in reply to Jack Coupal's comment, by Anonymous: | Reply

since forever? since as long as PTSD has existed (or been named, take your pick)?

kids go through trauma too... abuse, rape, assault, and so on. blissful childhoods =/= universal.

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" says "Practice of Psyc... (Below threshold)

June 18, 2011 4:14 AM | Posted by Termm: | Reply

" says "Practice of Psychiatry" in Palatino Linotype"

could someone explain this? I don't undderstand the significance of why he referenced Palatino Linotype. as far as I know, it's just a pretty font.

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Of course there is over pre... (Below threshold)

June 18, 2011 11:39 AM | Posted by KILL DR. PILL: | Reply

Of course there is over prescription of drugs to kids. To adults. To animals.
There more the "industry" dupes, the better. Lucky you, you will not last to long to see men, woman and children become cattle. Aw, that is already the case.

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By God's holy trousers, don... (Below threshold)

June 18, 2011 12:01 PM | Posted, in reply to Termm's comment, by Guy Fox: | Reply

By God's holy trousers, don't take things so literally. There's nothing inherent about Palatino Linotype. It's a symbol, and it only has meaning in context. Contrast PL, as you say 'a nice font', with Erasermate, i.e. a hand-scrawled sign.

Ditto the map. Rich countries with well-developed (i.e. oppressive) institutions are the places where ADHD/BPD automatically implies a need for medication (i.e. 'YES'); poor countries, Middle Earth, and Xana-frickin'-du deal with this problem otherwise. By Mill's Method of Difference, you should be able to work out the relevant variable and infer the argument.

You're in a forest of complex ideas, dry humour and slippery words. You'll never find your bearings by examining individual xylem cells. No, I'm not just referring to the content of this blog.

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The adult analogue of the p... (Below threshold)

June 18, 2011 1:22 PM | Posted by SteveM: | Reply

The adult analogue of the pediatric in-patient is the captive nursing home resident. That population was aggressively "pharmed" by Eli Lilly with it's "5 at 5" marketing spiel for it's toxic anti-psychotic Zyprexa.


Anti-psychotics are used as psychotropic sledge hammers. Given that psychiatry has devolved into chucking brain grenades at patients using a script pad, the best the oily American Psychiatric Association can do is look the other way.

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Alone, I think you're delud... (Below threshold)

June 18, 2011 5:24 PM | Posted by Anonymous: | Reply

Alone, I think you're deluding yourself. You've described a system that gives the psychiatrist the perfect excuse for failing miserably. The vast majority never gets better because you can't change their environment. You don't have enough time to help the ones who actually need you. You get to be part of a system where you never have to confront the reality that the meds don't work all that well, even for their intended purpose. Even under ideal circumstances, a huge number of your patients will never get better. It's just another narcissistic "if only".

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Well, helloooo:The... (Below threshold)

June 18, 2011 6:40 PM | Posted by EdithNPP: | Reply

Well, helloooo:

The FDA can approve the use of as you describe them *antipsychotics* for non psychotic states: such as irritability/agitation in children with autism spectrum disorders. As far as I know, the only FDA approval of a drug for a symptom NOT for a disorder, not even A psychotic disorder for quite young children.

Of COURSE every peds psychdoc did it, does it but in any event: major neuroleptic with major side effects including metabolic syndrome, potential of motor side effects and hormonal side effects and does every *prescriber* who prescribes it monitor those? Or titrate slowly to the very lowest dose possible?

not in my experience: how do we as prescribers know that risperdal motor side effects are reversible, or that elevated prolactin levels are without consequence? OK, maybe kids have had elevated triglycerides forever because nobody ever bothered to check them before but that does that mean we're going to continue to blithely prescribe meds we know can elevate glucose and trigyceride levels?

Love to see the seven year olds waltzing into my office polishing off the last of their Big Gulps that came along with their SuperSized Meal....then try some parent education about nutrtiion and exercise with the parents who are themselves either obese(usually) or eating disordered...sheesh.

And these same parents are offended when I tell the kiddos to clean up the corner of my office that has cool toys...no wonder they're in to see me.

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I am a therapist at a commu... (Below threshold)

June 19, 2011 6:47 PM | Posted, in reply to Anonymous's comment, by Denise LCMHC: | Reply

I am a therapist at a community mental health center. The psychiatrists/nurse practitioners have the last word on what happens with every client, and refusing to take medication is not generally allowed. I think this emphasis on medication may account for why I have a hard time convincing people they need to make changes for any progress to be made. My clients prefer the quick fix of having their medications adjusted if they are not feeling well. I'm fighting an uphill battle much of the time.

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As a RN who works with deme... (Below threshold)

June 20, 2011 1:12 AM | Posted, in reply to SteveM's comment, by Anonymous: | Reply

As a RN who works with dementia patients, I assure you zyprexa is by no means the choice med for dementia.

A few considerations.

1) Dementia absolutely causes severely impaired cognition, aggression, and hallucinations. This requires treatment to manage. It is for the safety and well being of the patient HIMSELF that he is not agitated, staying up all day and all night, no appetite, trying to tear up the environment to go see his brother who died 20 years ago. Unless, of course, you are some kind of crazy person who believes in unlimited freedoms regardless of the long term impact, then it is OBVIOUS that nursing homes and medications are very necessary.

2) Seeing as the overwhelming majority of alzheimers patients/nursing home facilities are funded on government money (medicare), there is NO WAY IN HELL our doctors are going to be prescribing zyprexa over .25 of risperidone. See zyprexa is a brand name drug, and all alzheimers patients are coded the same (meaning you get just as much money for the patient whether or not he is on fancy zyprexa, or bland generic risperidone). To maximize profit for the facility and cover expenses, you make sure the doctor uses risperdone not zyprexa.

When doctors do use brand name antipsychotics, for dementia their choice med is seroquel, and they NEVER approach the antipsychotic dosing range. Like, if a resident is on 75 mg that is a TON. Most stay

The reason psychiatrists prefer seroquel rather than zyprexa in the elderly is because at 25mg seroquel has zero antipsychotic properties and functions more like a really strong benadryl. The major problems in alzheimers disease is a loss of circadian rhythm (this is due to the brain disease itself, as well as abnormal nursing home environments where there is no light/dark pattern). The second major problem in dementias and other old age illness is loss of appetite.
25mg of seroquel will put you to sleep at night, AND increase your appetite, but it does not hit and block your dopamine and serotonin receptors like a starting dose of zyprexa will.

There is also a LOT of room to tinker with the dose of seroquel for a dementia patient. You can do 25 at hs, 12.5 in the am... you can increase it to 25 in the am if he is still combative and out of control for AM care and breakfast. You can do 25 at lunch if theres a mid day problem too. You can do 50 at night if he sundowns badly.

With zyprexa, you've got 5, 10, 15, 20 and the dose isn't as flexible, and it is WAAAY more sedating than seroquel because right away it is a serotonin/dopamine blocker, right away it is working more like an antipsychotic than seroquel is at a low dose.


Oh man, I wish you could shadow me at work for like, 1 week.
You would totally change your tune and by the end of that stint you would be like "SEROQUEL FOR ALZHEIMERS, WOOT WOOOOOT".

But yea, you don't work in health care.

However I'm sure you have that cure for irreversible brain rot called alzheimers, and you're just waiting for the right opportunity to SURPRIIIISE!!! the world and claim your nobel peace prize.

'Till then, it's very low doses of antipsychotics to keep these people sleeping, calmer, and getting along. Making the best of an imperfect old age.

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Another med commonly used i... (Below threshold)

June 20, 2011 1:19 AM | Posted by Anonymous: | Reply

Another med commonly used in dementia is mirtazipine and this is chosen for similar reasons as seroquel.

It makes you sleep, it makes you eat, and that's the major problem for alzheimers disease.

Remeron is not used for agitated dementia because its a daily med and not as flexible as seroquel. Seroquel is awesome for dementia, thank baby jesus for seroquel.

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1) Elevated prolactin cause... (Below threshold)

June 20, 2011 1:28 AM | Posted, in reply to EdithNPP's comment, by Anonymous: | Reply

1) Elevated prolactin causes breast development, lactation, and infertility, so it has an obvious well known consequences. It may have other less well described consequences, but it definitely has known consequences.

2) If you practice properly and run baseline lipids you will know if the patient had elevated triglycerides "forever" or if this is a new change from induction of antipsychotic medication.
If you practice by starting meds without running labs you are silly.

3) All people eat like crap - the poor and mentally ill generally eat worse because in being poor and mentally ill they lack either the opportunity or ability to learn information/make long term plans/delay immediate gratification.

Lecturing them about it and looking upon them in disgust for failing and remaining fat only highlights you as a rich educated person who was not raped as a child, does not have schizophrenia, was not beaten by their crazy drug addicted mother, did not have the money and opportunity to go to school to be a RNPP and they resent you for it. Education is one thing... lectures and disgust is totally unnecessary. I'm a nurse. Patient education is very important. Lectures and sneers and feeling contaminated by someone's presence is useless and unproductive.

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That sucks.... (Below threshold)

June 20, 2011 1:33 AM | Posted, in reply to Denise LCMHC's comment, by Anonymous: | Reply

That sucks.

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that's where you go when... (Below threshold)

June 20, 2011 1:50 PM | Posted by harpy: | Reply

that's where you go when a kid punches another kid or becomes hispanic

damn you, I almost choked on my lifesaver

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"The real problem is that t... (Below threshold)

June 23, 2011 9:58 AM | Posted by medsvstherapy: | Reply

"The real problem is that these meds work so damn well and if you only get 3 days IP to fix a kid, Well there you go."

No, I don't think so.

I worked, as a 'psych tech,' or what the child-and-adol patietns call 'staff,' in a couple different treatment centers before it became de rigeur to Rx everyone. Most of the kids that came into the long-term place I worked, and the medium-term place I worked, were not on meds. Yes, this was quite a long time ago. BC: Before Clozaril.

We staff made the kids straighten up. How? Go watch SuperNanny. We were much more strict. At the first sign of anything, you got a 'consequence.' You cleaned up after yourself or the whole group would not leave the cafeteria/meal table for the next 'activity,' or for free time.

If you acted out of line, the world stopped until you got on board.

Etc. Very strict.

Also, obviously, we were trained to not be abusive, and never were. We never called anyone by any derogatory names, beyond lazy or foolish. We never hit, shoved, spanked, or threw things at the kids in the treatment center.

And we kept our word. Scrupulously. If we said you would stand in a corner for one minute if you failed to follow some instruction, like put your plate in the sink, you WOULD stand in the corner - if it took three of us to get you there. And we would keep you there until you stood there under your own power for one minute - AND once that minute was up, you were DONE! - But you had to THEN go and clear your plate.

So, you figure out pretty darn quick if 'staff' asks you to clear your plate, or apologize for name-calling, or whatever, you ought to fall in line because you will eventually perform anyway.

As staff, we learn to commit 100% to anything we say. So, we learn to not make idle threats - because we know we will be tested, adn will have to back up our words.

Unlike the parnts of these kids, we did not have a steady stream of unfulfilled threats coming out our mouths.

Do you ever wonder how some parents control kids with just a look?

How uncle so-and-so, or the one day care worker, gets kids to behave simply by seeming scary? those ppl mean what they say.

In those first 3 days, the kids got in line. Really, the worst it ever was was maybe close to 2 weeks to get a kid in line. It took only a couple or a few of these episodes for kids to shape up. These were the worst kids from their schools, and they were not from nice schools.

All definitely looked "improved" at 3 days. Because of the social / parenting context. Thy did not look doped up because we did not have them on drugs.

Here is what is odd: no one ever asked us 'staff' what we did to achieve results. Not one parent. We had a system. If you talk to anyone who has done this type of work, we ALL have the same standard operating procedure. No one asks us.

At the day treatment place, we were the ones who received the kids in the morn, and from whom the parents picked up the kiddo in the evening. Any parent at any time could have said, 'hey, what is it that you do to get my kid to resemble a human?'

At the long-term "residential" place, the parents would get their kid for weekend passes, and were supposed to be there weekly for a 'parenting group.'

Did the parents ever ask us staff how we changed the kid from "adhd," or 'conduct disorder," to behaving human?

Did the parents ever ask the MSW who led the parenting group, "hey, the house parents have my kid making his bed, doing homework, talking respectfully, doing laundry, cooking meals for groups, etc -- can the house parents come into this 'parent group' and tell us how they do it?"

Honestly, I would have been happy to answer. See, we spent time with the kids, and grew to love and appreciate them. We never cut them slack, but we did care abt them. It's only human to care for kids you are caring for. It would have been awesome to tell a parent, you have to have rules, you have to be strict, and mean what you say, and punish early and with a big punishment, don't repeat yourself more than twice, and also spent quality time, and have fun and laugh. And don't use food, sleep, abuse, or lack of caring be used as punishments. evar.

Nope. Why not?

My guess, now that I have become one of the people with diplomas on the wall, and a state license number-

1. We all somehow believe the doctor is orchestrating everything , and is responsible for results. If we docs are not, then the whole charade starts to fall apart, and we with diplomas would have to admit that you would be btter off with the supernanny visiting your home for a week, than our remeron.

2. the parents always had a sheepish, embarrased style - they knew how we achieved behavior change: by acting like parental authorities - our success was proof that the problem was their parentin