Suicide Prevention - Alive to Thrive

What About Medication?

There is No One-Size-Fits-All Approach to Prescribing Medications for Mental Health

For your child or teen in mental and emotional distress or crisis, treatment can mean the difference between a normal life and a limited ability to function. In extreme circumstances, it may even be the difference between life and death.

The serious conditions we’ve discussed (major depression, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, and bipolar disorder) all require treatment. For some conditions this might include various forms of psychotherapy or talk therapy.

Still, sometimes talk therapy isn’t enough, and medication may be needed as well.

Medications may be prescribed as a first line of treatment. At other times they’re used simply as a way of helping your child get to a mental or emotional state where he or she can best respond to psychotherapy. Your doctor or mental health professional may recommend talk therapy, medication, or both, tailoring the treatment to the individual needs of your child for the best results.

Who Prescribes Psychiatric Medications?

Primary care physicians such as family doctors and pediatricians often prescribe psychiatric medications. Because they deal with a wide variety of health concerns, they encounter and address mental health problems on a regular basis.

While your primary care physician deals with numerous (mostly physical) health conditions, psychiatrists concentrate specifically on the diagnosis and treatment of mental health problems. Your family doctor may provide a good first line of treatment for some mental health issues, but some conditions, such as bipolar disorder or hard-to-treat depression, are complicated enough to require the specialized care of a psychiatrist.

Children and teens with mental health conditions often have different signs and symptoms than adults with the same conditions, and they may respond differently to certain medications than adults. Child and adolescent psychiatrists have even more specialized training in the psychiatric care of your children.

Besides doctors, a number of other health care professionals are also able to prescribe psychiatric medications for less complicated situations. These professionals include physician assistants, nurse practitioners, and, depending on state law, some other advanced-practice nurses. Additionally, a few states allow psychologists with special training to prescribe a limited number of psychiatric medications.

Selecting the Right Medication

When it comes to prescribing medications for mental health conditions, there is no one-size-fits-all approach. What works well for one child with depression may not work for another. If your child doesn’t respond well to a specific drug, your child’s care provider will try other options to find the right one. Your health care professional may select a medication based on the fact that it worked well in your child or a close family member in the past. In addition to effectiveness, your doctor will also base the decision on possible side effects and safety considerations. While cost might be considered, it will not play a primary role in the decision. After all, a cheaper drug that doesn’t work or is much less safe is no bargain.

Not all psychiatric medications are approved by the FDA for use in children and adolescents; however, your doctor may prescribe such a medication. Some psychiatric medications may be approved for use with adults but not with children. That doesn’t mean the drug is not effective or safe for children, but there may not be enough clinical trial evidence gathered to clearly demonstrate effectiveness and safety, or the drug manufacturer may simply not have sought FDA approval for use in children.

Depending on the medication and the condition it’s prescribed to treat, a drug may take anywhere from a few days to several months to start to have an effect. Talk with your child’s doctor if you’re concerned with how long it’s taking for the medication to start working, and resist the urge to have your child stop taking the drug just because it seems like it hasn’t started working yet.

Medications for Common Conditions

Depression

Cognitive behavioral therapy (CBT) is one form of talk therapy that can be helpful for your child with depression. CBT focuses on changing dysfunctional emotions and ways of thinking by identifying healthier ways to think and behave. Because some cases of depression can be resistant to psychotherapy, your child’s doctor may also recommend an antidepressant.

Depression is associated with certain brain chemicals called neurotransmitters. Antidepressants are helpful because they work by affecting levels of these neurotransmitters, particularly serotonin, norepinephrine, and dopamine.

Anxiety Disorders

There are several types of anxiety disorder, including generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias. Each one can be very debilitating for your child.

Therapy can be helpful in anxiety disorders. While talk therapy alone will be sufficient for many, medication may also be used in the treatment of anxiety disorders. SSRIs are the standard medical treatment, along with SNRIs such as duloxetine (Cymbalta).

Benzodiazepines are another class of drugs that are often prescribed for anxiety disorders. They are beneficial for short-term treatment of anxiety, but they are frequently used for longer periods. Prolonged use is generally not favorable since this can lead to physical dependence and difficult withdrawal.

Post-traumatic Stress Disorder (PTSD)

Medication is typically not a first choice among therapies for PTSD. Counseling using cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), and play therapy for children are often favored as initial treatments. Some SSRIs have been approved for treatment of PTSD in adults, but none are approved yet for treating the disorder in children. Nevertheless, your health care professional may recommend trying an SSRI for certain mood or behavioral challenges caused by PTSD. Likewise, prazosin (Minipress) may be prescribed to help with PTSD-related nightmares and sleep problems.

Obsessive-Compulsive Disorder

Treatment typically involves cognitive behavioral therapy, and medication may be advised as well. Medications include SSRIs and sometimes the tricyclic antidepressant clomipramine (Anafranil).

Bipolar Disorder

Medication is a critical part of treatment and may involve the use of mood stabilizers. Another class of drugs known as “atypical antipsychotics” may be used to treat bipolar disorder.

Categories of Medications

The following categories of medication are used to treat mental health issues:

  • Selective serotonin reuptake inhibitors (SSRIs): Medications in this class work by making serotonin more available to brain cells, which may relieve depression. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa). SSRIs are among the first types of medications a doctor might prescribe.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs): These medications increase the amount of serotonin and norepinephrine available and include the drugs duloxetine (Cymbalta), venlafaxine (Effexor XR), and levomilnacipran (Fetzima).
  • Atypical antidepressants: These medications don’t fit neatly into any of the other categories of antidepressants. They include bupropion (Wellbutrin), vortioxetine (Trintellix), and vilazodone (Viibryd).
  • Tricyclic antidepressants: This is an older class of depression medication. These generally have more side effects than many of the newer drugs and are usually not prescribed unless other antidepressants are ineffective. Tricyclics include imipramine (Tofranil), nortriptyline (Pamelor), clomipramine (Anafranil), amitriptyline (Elavil), and desipramine (Norpramin).
  • Monoamine oxidase inhibitors (MAOIs): Another older category of antidepressants, these can have serious side effects and are therefore recommended only when other medications have not worked. MAOIs include isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine (Parnate). Because MAOIs can cause dangerous effects when combined with certain foods or drugs, individuals using them must adhere to a strict diet and avoid certain medications.
  • Benzodiazepines: These include alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium). Because long-term use of benzodiazepines can lead to dependence, their use should not be stopped abruptly, and withdrawal should occur under the supervision of a physician.
  • Mood stabilizers are used to prevent or reduce mood swings, mainly in individuals with bipolar disorder. The classic medication lithium is included in this category, as are carbamazepine (Tegretol), divalproex (Depakote), and lamotrigine (Lamictal)
  • Atypical antipsychotics: These medications are also known as second-generation antipsychotics. While the side effects of these drugs (which may include weight gain and increased risk of type 2 diabetes) can be troublesome and might discourage some from continuing to take their medications, patients need to strongly consider the benefits of these pharmaceuticals before quitting them. Atypical antipsychotics include aripiprazole (Abilify), lurasidone (Latuda), Olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal).

Safety Concerns with Medications

Anything that has a physiologic effect can also have side effects. That goes for every medication from aspirin to antidepressants. Your child’s doctor will be monitoring potential effects from any medication your child may take, and will ask you to also be on the lookout for any side effects.

For example, some medications may interact with other drugs or with supplements. On occasion they may worsen existing physical or mental health conditions. Some medications can cause physical side effects, such as nausea, diarrhea, and dry mouth. Your doctor can help you and your child weigh the benefits of the medication against the risks.

You can help your child by working with her to take medications as prescribed. Some drugs, if overused or overdosed, can cause great harm. Conversely, it’s critical that your child not abruptly quit a medication, as this may also be harmful. Any withdrawal from a medication must take place under a doctor’s supervision. This is an important concern for teens who find relief from a mental health condition after taking a medication and who may then think the medication is no longer needed.

Finally, it’s crucial to note that while SSRIs are effective antidepressants, research has shown that their use can lead to increased levels of suicidal thinking or behavior in some children and teens. Children and adolescents using SSRIs for depression must be closely monitored— especially in the first several weeks of treatment—for any increase in depression, changes in behaviors, or suicidal thinking or actions.

Talk with your child’s doctor if you have any questions about a drug’s effectiveness or safety.

Alternatives to Medication

While medication has its place in the treatment of mental health conditions, it’s not always the best or preferred option. This is why getting your child into therapy as soon as possible is so important. Psychotherapy can help provide effective skills and problem-solving strategies to help children and adolescents cope with problems in a variety of daily-life situations. Many experts believe that the best approach to treating depression is to use both antidepressants and psychotherapy, especially because the stakes are so high with depression.

Like it or not, for some conditions such as bipolar disorder, medication is usually a first line of treatment, as dangerous mood swings or delusional thinking often don’t respond well to counseling.

Finally, exercise and proper nutrition can play a valuable role in coping with certain mental health conditions. It’s important that your child not rely on medications as a substitute for healthy habits.

Editor’s note: This chapter was written by Ricardo Whyte, MD. © 2018 Ricardo Whyte. All rights reserved. Used under license.

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