Health and Pills

The physician should choose the one most appropriate medication.

Current indications for the use of psychotropic medications in children and adolescents can be summarized briefly (Table l). The listing in Table 1 is by no means an exhaustive review of this rapidly emerging field. In two situations, autism and obsessive-compulsive disorders, there is only recent evidence of the possible usefulness of psychotropic medication.

Certain psychotropic medications, such as lithium salts for manic-depressive disorders in children and adolescents, are best left in the hands of psychopharmacological specialists. The use of antihistamines, such as diphenhydramine, and benzodiazepines in treating anxiety disorders of children has not been clearly substantiated. These medications should be used in consultation with a child psychiatrist. They are, however, relatively safe in comparison to the major tranquilizers.

The physician should therefore become thoroughly familiar with a small number of psychotropic drugs in order to respond to parental questions. Three drugs, which are commonly used in pediatric psychiatry, are methylphenidate, imipramine, and thioridazine. The physician should have a certain range of knowledge about these drugs in order to provide appropriate care, although one may choose to use other drugs. One should know the indications, proper assessment procedures, optimum dosage, price, side-effects, drug interactions, contraintfications, common withdrawal effects, alternative therapy, and concurrent treatment recommended for the drug (Tables 2-4).

Freeman recommends that the physician should be prepared for a potential barrage of questions by the enlightened parent consumer. Such questions may include any or all of the following:
• How do drugs change behaviour?
• My child has brain damage. Will he react differently?
• Should something else be tried first?
• Which behaviour should be treated first?
• How quickly will the drug take effect?
• Are drugs abused by teachers? Institutions?
• What are the different kinds of drugs?
• What changes can I expect at adolescence?
• Are all brands the same?
• How long will she have to take the drug?
• How many drugs can he take at the same time?
• How many times a day does she need to take it?
• How do the drug doses differ from adults’?
• What time does he take them in relation to meals?
• Are drug samples ok?
• Should parents adjust dosage?
• Should drugs be discontinued suddenly?
• Why do stimulants slow down hyperactivity?
• Will she become addicted to this or other drugs?
• What side-effects can I expect?
• Do other drugs interact with this one?
• What side-effects mean that we should stop giving the drug?
• What examinations or blood tests will he have to take? How often?
• Will she become dazed or “out of it”?
• Will it slow down his learning?
• When will you want to change dosage?
• Will it affect her nutrition?

A simple time-saving technique that may anticipate most questions is to provide the family with a drug information pamphlet. The parents should be advised to read the pamphlet and then to ask questions.

Psychotropic drugs should be neither the first choice nor the last choice in treatment for the behavioural and emotional disorders in children. The physician needs to keep in mind that the child is a developing individual, whose subjective symptoms may not indicate mental illness as clearly as adults’ symptoms may. As a result, the physician’s decisions about treatment are usually based on the assessment of the ecological system of the child (home, school, neighbourhood).

Taking the History

Behaviour data, either in narrative form or using numerically validated scales (e.g., Conner’s scales), can be obtained from parents, guardians, siblings, peers, and teachers. The physician must be wary that medication may be sought as a simple solution for complex problems, such as family stress or parental emotional illness, inappropriate teaching situations, or inadequate child care. The physician must therefore explore the psychosocial history and educational background adequately and should also determine the availability of psychotherapy, behavioural therapy, family therapy, and remedial education.

Before initiating treatment the physician needs to determine any history of physical problems, especially drug hypersensitivity; previous history of seizures (which is not necessarily a contra-indication); and liver, kidney, or visual dysfunction. Any gross neurological abnormalities, especially incoordination, gait disturbance, tremors, or tics, should be noted.

Certain drugs may require additional tests. A complete blood cell and differential count is required before prescribing methylphenidate or thioridazine; a platelet count is also necessary before prescribing methylphenidate. Patients treated with imipramine should have dexamethasone testing, an electrocardiogram before and during treatment, frequent blood samples to assess the serum level of imipramine, and reassessment after a two-week withdrawal period when treatment is discontinued. Thioridazine therapy requires liver function tests at least once every month.

Attitude Toward Drugs

The attitude of the child, family, or guardians to medication should also be carefully assessed. Do they regard the child as unco-operative or manipulative and the medication as a means of control? Does the child or guardian expect the medication to cure the disorder? Is there undue pressure or resistance to the use of medication? The physician must also be aware of his or her own desire to offer a “quick fix,” for the sake of time or lack of awareness of other therapeutic interventions.

Klaus Minde has encapsulated, in two doctor-patient exchanges, the major communication required about the role of psychotropic medications in a child’s ecological system:

Doctor A. (to the parents):

I would like John to stay with these pills and take them twice daily, seven days a week at exactly 8 a.m. and 12 noon. Don’t let him forget them. Watch that he really takes them and don’t leave it up to him to remember. He is obviously doing much better and we want to keep it that way.

Doctor B. (to the child):

Paul, don’t forget that these tablets are simply some kind of crutch-like a crutch you need when you break a leg. Always remember, however, that a crutch can only help you with your walking, but can never do the walking for you, because that you have to do yourself.

Dr. B. has avoided enhancing powerlessness in the child and has stressed the importance of Paul’s effecting change. Minde stresses the “demedicalization” of this transaction. Although it is tempting to use the placebo effect of any medication, particularly in suggestible children or parents, Minde cautions against the resulting loss of autonomy and responsibility for the patient’s own actions.

Physicians have been using psychotropic drugs in children increasingly, probably because of the successful results of methylphenidate (Ritalin®) with hyperactive children who have an associated attention deficit disorder.

Parents and child advocates have been simultaneously concerned, however, about accuracy of diagnosis, over-labelling of the child, long-term side-effects, and providing a quick “fix” while neglecting other therapies that require long-term commitment. Consumer complaints in Ontario resulted in unique legislation, the Child and Family Services Act (CFSA) of 1985, which defines psychotropic drugs; formally states the physician’s responsibility to obtain informed consent; defines informed consent to include drug dosage and risks; requires caretakers other than the parents to be informed about the medication; and sets limitations on the emergency use of psychotropic drugs with adolescents older than 16.

This article will address common questions from parents and guardians about the use of psychotropic drugs, will provide a brief guide to use of three common psychotropic drugs used with children, and will list the common conditions in children and adolescents for which psychotropic drugs might be considered.

Legal and Ethical Issues

Although the CFSA applies only to children and adolescents in programs of the Ontario Ministry of Community and Social Services, the principles of obtaining informed consent have been endorsed by the Ontario College of Physicians and Surgeons and the Canadian Medical Protective Association. There have been myriad articles aimed at physicians following the 1980 Supreme Court of Canada “Reibl versus Hughes” case, which established the precedent of a physician’s obtaining informed consent.

Assessment of the case’s impact, however, has shown that it has been ignored for the most part by physicians, much to the dismay of the Ontario Hospital Association (and likely the Canadian Medical Protective Association). All that is legally required now, even under the Ontario CFSA, is a note in the doctor’s record that he or she has discussed the purpose of drug treatment and the risks associated with this treatment. The Ministry of Community and Social Services has, however, recently considered requiring formal, written consent forms signed by children receiving their services. The Ontario Medical Association will be asked to participate in developing potential regulations.

The Biomedical Ethics Committee of the Royal College of Physicians and Surgeons of Canada has urged a higher standard of informed consent than the law requires and has recommended the concept of shared responsibility. This recommendation entails good communication with the patient or surrogate, provision of reasonable data, noting and discussing any indecision on the part of the patient or surrogate, consulting legal authority if the physician believes that serious harm may befall the patient without treatment, and finally, avoiding delegation of this important medical act to others.

Now finally, let us grant that all the claims made for a new drug are true, that with it we can do this or that, as alleged. There still remains the question: do we want to do all these things? Shall we tranquilize the patient merely because the means are at hand, or alert and stimulate him, willy-nilly, when he is deluded or obsessed? Do we really want to lose control of all our mild elderly diabetics through a fistful of pills? Are we to go on creating more resistant infections through giving each new antibiotic a whirl? Shall we blindly accept the asseveration that two drugs with opposing types of action invariably give a nice blended effect when used together in fixed proportions ? Do we need to risk orthostatic hypotension, ileus, visual disturbances, palpitation, paresthesias, etc., merely to obtain blood pressure reduction in a mildly hypertensive patient? How frequently is intravenous iron administration advisable? Do we want often to replace thyroid substance with a quicker-acting compound whose omission may cause distressing withdrawal symptoms? And so on and on.

Do we really need all the time all the things that all the new drugs will give us? With full realization of the probable absurdity of the comparison, I am nevertheless going to liken political man’s possession of his new military weaponry with medical man’s acquisition of his new pharmaceutical arsenal. The time is not yet here when the decision will have to be made whether to drop the hydrogen bomb or not to drop it, but all the world is quivering with fear that such a moment is imminent, and men of good will everywhere are agitating for restriction of the use of this dreadful new power to those activities only of mankind wherein his best survival interests can be selectively aided. To use or not to use the new drugs for all they can do, that too is a question, our peculiar and particular medical question, and ours the solemn responsibility to answer it. For progress in this field will not be halted, and we are only now crossing the threshold into the vast drug sales room of the near future, whose walls and floors and counters and chests and racks and shelves will be loaded with bottles crying out “Use me! Or me! Or me! Or all of us together!” Shall we do it, always in all cases, all of it? Money in immense amounts is invested in the effort to tell us that this is our duty; the symptom is there, the drug is or soon will be available; the two must meet head-on invariably. “Treat your patient with these new drugs, Doctor, treat him, each one of him, or else a new kind of physician will be created who will do it.” In such exaggeration there is truth. Investigations now under way, may bestow power through drugs over metabolic processes as will make nuclear fission seem puny in potentiality for control of the world.

We doctors, while we can, must make the decision whether to give up and merely hand out the pills, or not. No individual can dictate that decision, but remember: all drugs, even the very best, are psychologically or physically potentially toxic agents — and none should be used unless unavoidable.

Publish date: 1959

Progress has been made with such giant strides in recent decades that one is tempted at times to bemoan the smallness of the territories still to be conquered. But for the pharmacologist at least, whatever the feeling may be in other circles, there exists a sufficient and powerful antidote for his ego in the large list of areas in which drugs are still badly needed. The things we might expect from these drugs, drugs that are not yet found or devised, are shown in Tables 3 and 4.

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This is a wonderful list, is it not? All this still left for the pharmacologist to do. And of course he will eventually do most of it, but there is something between him and the practitioner — a great vested interest which must sell to live. This vast pharmaceutical industry has become a familiar and essential ingredient of medical practice, and we should all generously and gladly attempt to be useful to it in recognition of a mutual interest and a shared desire. But this must not be done through yielding independence or sacrificing the intelligent approach!

Do not, I implore you, gain all the accretions to your pharmacologic knowledge from the paid sales representative, whose training is necessarily not comparable with yours, or accept the receipt of his sample as a mandate to use it. And do not believe the bromide that no one can keep up with medical advances today, for there are numerous existing abstract, year book, review and other services which make it quite possible to do so sufficiently well for practical and satisfying purposes. The expenditure of only a minimal amount of time is required too, if one’s time slices are adequately cut with this in mind. Most of you are keeping up better than you are told that you are.

And then there are the advertisements, the gorgeously colored spreads that make it difficult to find the reading matter in many of our journals. Please, if you must study the more gaudy of them at all, do so with a sour skepticism and a jaundiced and cynical eye. Be advised and aware that in some instances the journal references embodied in these advertisements are to preliminary findings that do not apply at all directly to the clinical claims that are made, and that in other instances the references are to publications that have actually been written by the pharmaceutical house staff itself for the inexperienced investigators who have made the clinical trials. The fact is that there are not enough existing facilities, and fully qualified clinical research workers, to perform the kind of studies that every new drug should have before it is made available for uncontrolled use in practice.

Publish date: 1959

During each of the past ten years the pharmaceutical industry has produced an average of approximately 400 new products. In the most recent year of record, 1957, the number is said to have been precisely 400, and 51 of these were single new chemicals. Many of the agents are produced in refined form in amounts that are absurdly small in relation to the bulk of the crude materials from which they are processed. Some typical yields of useful and familiar materials of different sorts are shown in Table 1. Add to the comparisons afforded in this table the fact that many entirely synthetic compounds are obtained through even more exhausting and expensive manipulations than are required in refining crude materials; and consider in addition the huge sums expended in research and promotion in order to make available, and to bring into the physician’s awareness, the packaged drugs awaiting his prescription — think of these things and it will easily be realized that the pharmaceutical manufacturers are obliged to interest themselves vitally in what it is that makes a new product acceptable to the doctor. To supply one observer’s version of what the requirements are, is the purpose of this presentation.

Source Of The Drug

I should say that if the new drug proposed for your use is, or is derived from, an old folk remedy the chances are good that it is worth paying attention to — not trying at once, willy-nilly, but at least watching to the extent of asking to see the records of its unbiased and controlled trials in specialized clinics. For the record of such agents is impressive, as is shown in the listing in Table 2 of valuable drugs obtained from folk medicine.

If a drug is offered because it has been discovered by search among the chemically close relatives of an active drug for another one of the same sort, you will be well advised to be hesitant in accepting it until full trials have been made by others better placed for such trials than yourself. Good drugs have often been developed through such approaches admittedly, but since these searches are usually begun merely to turn up for competitive reasons another drug as good as the one of established value, there is no obligation to believe a priori that the new agent is better than the old. It may be just as good and no more toxic, and this in itself may sometimes assure it a place in the armamentarium since there are instances in which there is advantage in having two strings to one’s bow — but let the qualified investigators determine the facts of the case while you continue to use the agent whose worth you know. Now, if the new drug has been evolved in attempting to improve an original compound through chemical modification, I should advise again to delay transferring patients to it until its clinical status has been proved by investigators qualified to make the controlled trials. There is a tendency among sales representatives of some pharmaceutical houses to maintain that certain chemical configurations reliably confer specific pharmacologic attributes upon compounds in which they are incorporated. But the actual fact is that invariability and predictability have not yet been achieved in this field of structure-activity relationships. One wants to know in each instance, first, whether the chemical configuration in question has really been shown by disinterested investigators to possess the attributes claimed for it; second, whether the structure to which it has been attached is one that is likely thereby to have the desired pharmacologic action conferred upon it or strengthened in it; and, third, whether the attachment has been made at a point that will potentiate or may actually weaken and possibly even pervert the action of the basic structure. These things the individual practitioner surely will not know.

Publish date: 1959

Research geared to meet women’s special needs.

A total of almost 400 drugs are now in various stages of development to meet the special needs of women. The drugs, many of which offer innovative therapeutic approaches, are intended to treat diseases that either disproportionately affect women or are among the leading causes of death. The top causes of death in women are heart disease, cancer, cerebrovascular disease, chronic obstructive pulmonary disease, pneumonia, diabetes, adverse drug reactions, Alzheimer’s disease, nephritis and septicemia.

Drug Research

Cancer drugs are far in the research lead. Between the early 1970s and the early 1990s, the incidence rate for lung cancer more than doubled and the death rate rose 182% in women. Of the 94 drugs being developed for cancer in women, 44% are targeted for breast cancer, 30% are for lung cancer and 20% for ovarian cancer. Uterine cancer, including endometrial cancer, is the most common malignancy of the female genital system, followed by ovarian cancer. The second largest number of investigational drugs are for obstetric/gynecologic disorders.

Cardiovascular Issues

Much attention has been paid to cancers in women, but cardiovascular disease is the leading cause of death. Heart attacks alone claim 250,000 lives annually and of those women who suffer a heart attack, 44% die within a year, compared to 27% of men. Cur-rently, 48 drugs are in development for cardiovascular disease.

Musculoskeletal disorders

Women suffer high incidences of musculoskeletal disorders. Osteoporosis, for example, affects one in every four women past age 50. And about 23 million women, including half of women over 65 years of age, suffer from arthritis. A total of 55 drugs are being developed to treat musculoskeletal disorders.

Antipsychotic drugs

Women are 60% more likely than men to experience major depression. Most of the antipsychotic drugs in research are for treatment of depression.

James McCormack, Glen Brown, Marc Levine, Robert Rangno, John Ruedy
W.B. Saunders Company, 55 Horner Ave, Toronto, ON M8Z 4X6
1996/550

Strengths

Evidence-based approach for making drug therapy decisions

Weaknesses

Missing key information

Audience

Any clinician who prescribes drug therapy, particularly useful for teaching practices

This book is not just another multi-authored reference book. It is designed to wean clinicians away from “habitual or intuitive solutions” and to encourage decisions based on explicit factors. To achieve these goals, the book has a section on drug therapy for disease states to help readers make therapeutic choices that are reasonable if not optimal and to provide information on initiating, altering, or terminating a drug.

For each clinical condition a set of questions is asked. For example, in treating depression, before choosing a therapeutic agent you are asked to consider treatment goals, evidence to support drug therapy, when to consider drug therapy, initial treatment, dosage, the length of the initial treatment regimen, the efficacy parameters and patient assessment interval, when to add an additional drug if initial therapy fails, and the length of drug therapy.

This is good medicine. The process reinforces a framework for making therapeutic decisions and subsequently managing patients appropriately. The text also has sections on common drug-induced adverse reactions and drug monographs. Both these sections use questions to develop rational therapeutic decisions.

No text is perfect. Inevitably some key information is missing. I could not find a specific therapeutic approach to necrotizing fasciitis. Also, the book does not provide advice on how to switch from one group of antidepressants to another. Nevertheless, once I got used to the directed format, I found it is easy to use and helpful in making reasonable if not optimal drug therapy decisions.