Opinion | Psychiatric Meds for Kids: How Young Is Old Enough?

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Jessi Gold, MD, MS, an assistant professor in the department of psychiatry at Washington University School of Medicine in St. Louis, and Amanda Calhoun, MD, MPH, a psychiatry resident at the Yale Child Study Center in New Haven, Connecticut, to discuss the nuances of prescribing psychiatric medications to children.

Click here to view part 1 and part 2 of this conversation about the state of child and adolescent mental health.

The following is a transcript of their remarks:

Faust: I think people want to know about medications — and I feel like Dr. Gold, you could help us with this a little bit. My sense is that there are stigmas on seeking out mental health, if there’s access. That’s the key.

But as you mentioned, there’s always a debate on how early to start medications, especially for teens and adolescents. Has the pendulum moved at all, both with respect to what the average person coming in is seeking, and also with respect to what the field is saying is the best standard of care?

Gold: It’s complicated. I think it went one way and then it went the other way and then we’re always backtracking because they think we overprescribe, so I think as a field we’re seen as a group of people who just want to drug you. I don’t practice that way. I know Amanda doesn’t. I know a lot of people in our generation don’t, and so our generation tends to really evaluate and we’ll send you to therapy; we believe in therapy. If therapy doesn’t work, we’ll add on meds, but I think it is really hard to know sometimes. The evidence on medication is that we’ve seen it work, it does work, but it’s imperfect and it takes a really long time to work and it works best with therapy.

So it’s very complicated to say one or the other or when you need what. And I do think that if you put it head to head with therapy, people are much more comfortable – I mean, I’m much more comfortable talking about having gone to a therapist than the fact that I take Wellbutrin and have since college, right? We as a society are not as comfortable with medication because it means some degree of severity that feels really hard for people.

But not everyone needs meds their whole life. If they have meds for a moment in time, we have to be better about taking people off of them or trialing to take them off of them — not for things like bipolar [disorder], sorry guys that want to be manic because I get it, it’s fun — but I think ultimately we just have to have more nuance in it and how we evaluate it and have really good patient-centered, family-centered conversations around it, because I have a lot of patients who say ‘I’ve had these side effects on this medication for forever. My doctors just kept telling me I need the medicine and I have no choice.’ That’s not how we can approach this. If they’re not feeling well on [the medication] and they’re either going to stop them or they feel ill, we have to find another answer, and maybe the answer is imperfect, but you have to meet them somewhere.

I think that’s an important part of being a psychiatrist, an important part of having the power to prescribe medication — particularly in kids, which Amanda probably knows a lot more than me because I haven’t prescribed a kid since residency.

Calhoun: Yeah. I work with very young kids and I saw someone in the comments saying the youngest they’ve seen is [age 5 years]. I think the youngest I’ve prescribed has been [age] 4 at this point. I do have very young kids that are on medicines and do really well on medicines and I have a lot of parents who are very grateful for the medicines.

I’d say one big bucket where medicines can be very instantly helpful in some instances is ADHD [attention deficit/hyperactivity disorder]. There’s been this pendulum swinging again about the overdiagnosis of ADHD. It’s like, okay, if you’re a child psychiatrist and you’ve seen severe ADHD, it is not just your typical…and any parent or caretaker or someone who knows someone with severe ADHD, you cannot ignore it. It’s to the point where the child will not sit down, they’re potentially hurting themselves, they’re jumping from one thing to another. Parents are exhausted, they can’t sleep, all of this. We can prescribe medications and get the child to sleep within the day. I’ve had that happen recently and parents are like ‘Oh my gosh, I need this medication.’

So it depends. It just depends on what’s going on. I try to be very honest and I let them know I don’t have an agenda. My agenda is to make you feel better. I would love for you to — if you want to get better on just therapy — that’s great, let’s try it. But if I do really think that medicines will be helpful, and that’s usually with my more severe cases, I will say ‘In my clinical judgment, I would recommend medicines; try them.’

But yeah, checking in is really important.

Gold: Now that [Amanda] mentioned ADHD, I just want to tell the government that those medicines need to come back because we haven’t had them in so long. I’ve never had a shortage this long in anything I’ve ever prescribed, and it is horrible for people.

Calhoun: Yes.