Tuesday, July 29, 2014

Your Child’s Behavior Still a Problem after Treatment with One Drug? Try Two

Back in 2010, I wrote about all the strange and bizzaro combinations of psychiatric drugs some of my adult patients had been put on by other psychiatrists who had seen them before me. These combinations, in addition to being excessive, often made no sense from the standpoint of what these drugs did in the central nervous system. 

Uppers and downers and bears, oh my.
In the biz, this is known by some as malignant polypharmacy.
Sometimes polypharmacy is medically necessary because of disorders which co-occur in certain patients (comorbidity), like patients who have both real bipolar disorder and panic disorder. However, a lot of times new drugs from different classes are added merely because the first class of drugs used just did not do the job. And IMO, the most common reason the first class of drugs fails is that the drugs were never indicated for the patient’s underlying condition in the first place.
By now this practice has unfortunately spread to the lucrative field of drugging children, where the use of more than one class of psychiatric drugs is becoming more and more common. I have written about how the use of psych drugs in kids is, in general, often higher in children who have been subjected to a lot of stress and trauma, such as children in foster care (9/20/10, 12/2/11). To me, this fact strongly implies that behavior problems and reactions to stress are being misdiagnosed as mental illnesses.
Higher prescription drug usage also seems to be inflicted more often on poor children, who have much less access to good and more comprehensive psychiatric treatment (read: family therapy), and whose underpaid doctors may give them short shrift.
In the United States, poor children are insured under Medicaid, the U.S. Government’s medical plan for the poor. Medicaid pays psychiatrists quite poorly, so most of them do not accept it. It is especially crappy at covering family therapy.
So, it is hardly a surprise that a recent study of children on Medicaid showed the following results, as reported by the American Psychiatric Association’s newspaper, Psychiatric News, on 6/26/14:
Use of second-generation antipsychotics (SGAs) concurrently with other psychotropic medications in children in the Medicaid program has increased over the last few years, according to a report published online in the Journal of American Academy of Child and Adolescent Psychiatry.

Researchers at Children’s Hospital of Philadelphia used data from the Medicaid program to estimate the probability and duration of concurrent SGA use with different psychotropic medication classes over time and to examine concurrent SGAs in relation to clinical and demographic characteristics. Their analysis showed that while SGA use overall increased by 22%, about 85% of such use occurred concurrently with use of other psychotropic medications. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. The concurrent SGA use occurred for long durations (69%-89% of annual medication days).

The explanations for this phenomenon advanced by the senior author, as reported by the story, were very telling:

David Rubin, M.D., co-director of the Policy Lab at Children's Hospital of Philadelphia. “In all likelihood, the use of the antipsychotics illustrates the great challenge clinicians are having when responding to disruptive and challenging behaviors in youth that don't neatly fit common diagnostic categories. In a society that often doesn't offer other services to respond to these behaviors, we should not be surprised how quickly the use of antipsychotics has grown.”

So, he is almost declaring outright that antipsychotic drugs are being given to children not for mental illnesses, but for disruptive behavior! If stimulants are involved, most of these children are undoubtedly being diagnosed with ADHD. So, if other drugs are being added, it looks as if stimulants may not be working all that well for this problem in a significant number of cases. And yet, doctors and drug companies and even the National Institute on Drug Abuse go on and on waxing eloquently about how impressively effective they are!

And when they are not working, then doctors are apparently adding a drug meant for the almost non-existent condition of pediatric bipolar disorder. I guess these kids have two mental illnesses. Maybe three. Yeah, right.

There is no evidence from clinical trials that the combination of these two drugs is efficacious for anything, nor is there a physiological rationale for combining them. And SGA’s are potentially very toxic, especially in children. And they still do a terrible job of even sedating acting-out kids.


  1. I had problems starting around 1989/90 when I entered Kindergarten, and the military doctors first put me on Mellaril (as my dad was in the army), but thought it didn't really work and switched me to Ritalin.

  2. When I was 12, I took TOVA, and my impulse control was rated below 25, more than 5 standard deviations below the mean. I was on all sorts of stimulants during my childhood years until 8th grade.

    In 8th grade, they took a different approach. I was first put on Prozac and a few months later was put on Zyprexa. I then had my psychotic break, which they weren't sure at the time if it was truly psychosis as I was so quiet and hidden about it, and they jacked up the Zyprexa dose (to 25 mg/day at least, as the doctor later told me) while dropping the Prozac.

    During this period, my challenging behaviors seemed to lessen greatly. I started noticing during this period that I could actually think through the consequences of my actions and could reformulate my patterns of behavior.

    I don't know if that's just maturing (as I was 14 at the time) or if the Zyprexa helped, perhaps by helping my thoughts be more coherent than previously?

  3. Actually, the mindset is why stop at two, especially when you can get three-five times the side effects with a cocktail? Very sad.


  4. My daughter had a diagnosis of ADHD at age 9. Over the years, beginning in middle school, several medications were tried to help with impulse control and concentration, but none were effective. By the time she reached high school, she decided she wouldn't try any more meds, and told us she felt we didn't like her as-is. Fast forward 15 years and now she has a diagnosis of Borderline Personality Disorder. Have you seen other cases where ADHD or ADD was the childhood diagnosis and BPD the adult one? I'm aware that BPD isn't a label applied to those under 18, fwiw.

    1. Hi anonymous,

      Of course I can't say anything about the correctness or incorrectness of any diagnosis your daughter received or what may or may not be going on with her.

      In general, IMO ADHD and borderline personality disorder are behavioral issues that in the majority of cases are due to social and environmental factors, and the symptoms can therefore be very fluid and overlap considerably.

      A diagnosis may be made according to which behaviors the doctor chooses to look at, and which behaviors the doctor chooses to ignore.

      In answer to your question, a lot of my patients with borderline traits were in fact diagnosed with "ADHD" as children, despite the fact that their school performance, though erratic, was often good at times when they were not taking stimulants and vice versa.