If you are among the great predominance of families whose children merely drive you mad, rather than suffer from some form of serious mental illness, this commentary need not concern you (directly). But a small percentage of children in this country will suffer, by the time they are 18 (especially in late adolescence), from symptoms of a major mental disorder where thinking, behavior and mood are severely impacted and functioning as a member of the family, a friend and in school is clearly compromised. The conditions I am referring to are the psychotic illnesses of schizophrenia and bipolar disorder as well as some youth with autism (on the severe end of the spectrum), aggressive behaviors, and an uncommon but disruptive tic disorder called Tourette Syndrome. These are conditions for which doctors often prescribe antipsychotic medications such as aripiprazole (Abilify), olanzapine (Zyprexa) quetiapine (Seroquel), and risperidone (Respirdal and other brands).
A recent Journal of the American Medical Association article (October 28, 2009) by Dr. Christoph Correll and colleagues reported on a 12 week trial of these four antipsychotic medications, so called "second generation" drugs because of their more recent development, in children from age four to 19 who had not previously received this class of medication. The children received medication doses decided upon by their doctors; a comparison group of youth was followed and did not receive any of these medications. The research sought to ask if there were significant changes in three important physical measures in this short period of time: weight, lipids (cholesterol and triglycerides), and insulin resistance (a measure of how the body handles sugar that is predictive of obesity and diabetes). Their results were disturbing.
All four of the studied antipsychotic medications were associated with weight gain, ranging from about 10 to 22 pounds, with the comparison group showing no significant changes, in 12 weeks. Significant changes in body lipids were associated with three of the medications but not with aripiprazole or the comparison group. Evidence of changes in glucose and insulin were noted only for olanzapine.
In 2007, New York State Commissioner of Mental Health Mike Hogan (disclosure - my boss) and I wrote an advisory entitled: Bipolar Disorder in Children: Why are the Rates Rising?
Rates of the diagnosis of bipolar disorder in children and adolescents had risen forty (40) times in ten years. What was going on? Genes surely don't mutate that quickly, nor families, and while the environment continues to worsen it is not at that rate. The diagnosis of bipolar disorder was being made liberally, perhaps to better identify those youth in need of treatment, but at a price we are increasingly seeing since the diagnosis is usually accompanied by the prescription of an antipsychotic medication. New additions to what doctors will prescribe are likely now that the FDA Psychopharmacological Drugs Advisory Committee (June 2009) approved quetiapine and olanzapine for the treatment of schizophrenia and bipolar mania (risperidone had already been approved) - though the FDA has yet to act on the Committee's approvals.
I am not crusading against the use of antipsychotic medications in youth. These medications are a proven treatment for youth with psychotic illness and thus critical to their safety, health and recovery. Untreated psychosis, over time, is known to be "neurotoxic", which is to say that in ways we do not yet understand the brain undergoes tissue destruction, at a time of important brain development, with resulting loss of functioning. The dilemma, thus for families and doctors, is that a needed treatment brings with it significant side-effects and health risks. Serious mental illness in a child is a very tough and sometimes heartbreaking journey for a family, all the more unsettling by evidence that treatment can carry its own - and a different - set of problems.
As Commissioner Hogan and I wrote in the Bipolar Advisory, and the same applies to all major mental illnesses, doctors and families need to prudently pursue a thorough diagnostic evaluation to feel confident that a psychotic disorder warranting antipsychotic treatment is what your child is experiencing. Families are entitled to full information about their child and should not be shy about asking questions that are answered in everyday English that explain the basis for the diagnosis offered - and what to expect from treatment, including benefits and risks. A second opinion, when in doubt, or if treatment is complex or not working well enough, should be sought; any doctor who does not welcome a second opinion is probably a doctor worth getting rid of. Youth change, and so does their illness, so
reconsidering the diagnosis from time to time, and the treatment, is fair and should not be dismissed as some form of denial of the reality of a child's illness.
When antipsychotic medications are needed, guidelines for their use have been developed for psychiatric practice. In general, a doctor should seek the minimal effective dose; there is no evidence for using more than one antipsychotic medication, called polypharmacy, though in exceptional instances, with an individual patient, it may prove useful (but ask the doctor to explain why one antipsychotic will not suffice); and medications should be sustained as long as necessary but that does not necessarily mean forever. With the now indisputable evidence of the effects of "second generation" antipsychotics on weight, lipids and likely glucose metabolism (over time), and the consequent risk for heart disease, diabetes, and stroke (to name a few diseases) these health measures need careful monitoring combined with efforts to improve nutrition and exercise, and help youth elude the dangers of tobacco, alcohol and drugs that will add to their problems. Research is underway to determine if there may be medications (now used in diabetes treatment) that may help avert these problems, and the search for better antipsychotic medications, with more benefit and fewer side-effects, continues.
Families need to also understand that medications are only one of the interventions that can be provided your child. Specific psychotherapies complement medications and work to improve thinking, mood and everyday social and educational functioning. Don't settle for just medications when more can be done. And talk to other families who also struggle with the dilemma of how to care for their child while minimizing harm.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Lloyd I Sederer, MD
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