Introduction
Increased usage of psychotropic medication on youth for their behavioral treatment and emotional problems has been very alarming. This has aroused widespread attention in the recent past. However, very few studies have been published concerning socio-demographic behavior of youths under psychotropic medications and even in the management of approaches used in the description of such medication in the community (Goodwin, Gould, Blanco & Olfson, 2001).
Psychotropic medication is often prescribed for mental disorders with the aim of altering behavior and moods. The word is derived from Greek terms; Psycho– implying Mind and Trop– Implying turning or change. The medication is often supplemented by other treatments such as counseling in order to contain the symptoms of mental disorders. However, the medication does not cure mental disorders. It only alters chemical changes in the brain. For example, antidepressants are mainly meant to alter brain moods and the emotion centers. The medication should be prescribed by a qualified medical practitioner. The practitioner should also monitor the effects of their patients because the medication reacts with the pharmacokinetics of the brain to alter behaviors, thoughts and emotions. Just like other medications, psychotropic medication has side effects ranging from aggression, skin rash, weight gain, blurred sight and sometimes decreased libido (Melissa & Kehle, 2011).
There has been an increase in prevalence and substantial morbidity in child and adolescent disorders. Statistics approximate that up to 15% of children and adolescents suffer severely from mental disorder to an extent of functional impairment. Surprisingly, other research findings indicate that only one in five of affected children receive medication from trained mental professional. Prompted by the increase in the efficacy studies in mental illness treatment, research efforts are increasingly focusing on issues concerning safety. It has been noted that since the first use of psychotropic medication in children, seven decades ago, safety concerns have been questioned. For instance, use of stimulants in 1970s and 1980s and use of specific selective serotonin reuptake inhibitors SSRIs when they emerged in the market around 1990s. Recently, safety issues have raised public awareness, especially with regards to the use of psychotropic medications, especially in treatment of depression in children and adolescents. The issues led the 2003 United Kingdom (UK) decision to contraindicate the use of the antidepressants in children; and the scrutiny of safety data from clinical trials in the United States FDA with mandated cautionary on use of such medications (Report of the Working Group, 2006).
Most of the mental illnesses are often identified during childhood or early adulthood. However, researchers have found that psychotropics prescription is being influenced by various myths, including:
- Defining children as young adults
- There are no reasons for children to develop anxiety or become depressed.
- Grouping psychiatric disorders as same across adults and children
- Therefore, children medication is the same drug as adults but in lower doses and.
- That drugs remain the best alternatives in all available therapies.
These theories are identified as baseless facts; arguing that there are child-adult differences in psychotropic medication (Lakhan & Johnson, 2007).
Psychotropics are vital part of treatment interventions for various mental illnesses. There is reduced adult morbidity with successful treatment of psychological disorders in the youth. For instance, stimulants treat deficit hyperactivity disorder whilst SSRIs treat obsessive- Compulsive disorder, anxiety and depression in young adults. Well documented research is available on individual use of drugs for both legal (alcohol and tobacco) and illegal, including amphetamine, cannabis and cocaine and their short-term/ long-term effects on youth’s health. Psychotropic include antidepressant, stimulants, antipsychotics, benzodiazepines and other anxiolytics. What is their long-term effect to the kids? Is the dramatic increase in use and prescriptions of such drugs being of potential harm to the youth? There is very little research into their safety and efficacy in youths and adolescents (Zito et al., 2003).
Although there have been advancement in the field of psychopharmacology, empirical evidence, especially those of regarding safety and efficacy of commonly used medications is inadequate to support the current prescription practices for children and youth. The data supporting efficacy and treatment results and safety of psychotropic conditions is quite small compared to that of the adults, especially with the increase of off-label prescription. They are often referred to as off label because they are approved for adult only. Even though the medication could be safe and efficacious for adults, the difference in physiology makes them vulnerable in the youth system. It is only justifiable for clinicians to prescribe of label because they have to balance their beneficence (use of professional judgment to treat) with non-maleficence (protecting patient from unethical practices. Therefore, the absence of research on psychotropic in youths leaves no other choice other than use of medication proven for adults only. The safety issues and efficacy concerns are evident in psychopharmacology. This paper delineates the most common prescribed psychotropic and their effects on youth (Griffith et al., 2010).
The paper endeavors to explore on the raised concerned on safety issues concerning psychotropic prescription and how they can be circumvented by using alternative medical therapies such as evidence based treatment and psychosocial alternatives. Most common used psychotropic drugs on youths include Methylphenidate (e.g., Ritalin, MPH) and Selective Serotonin reuptake inhibitors (SSRIs such as Prozac & Seroxat) on youth. Most surveys on child and adolescent psychotropic use rank stimulants as the most popular followed by antidepressants. Research also indicates trends on polypharmacy (prescription of two or more medications simultaneously) (Baumann & Spitz, 2007).
Trends in psychotropic medication prevalence
Psychotropics are part of medical interventions for various mental illnesses. There is reduced adult morbidity when pediatric psychology disorders are successfully treated. Most of the mental illnesses are often observed during childhood; especially during the teenage or adolescent stage. Treatment with psychotropics has been very effective. For example, use of stimulants to treat hyperactivity disorder (ADHD). SSRIs are often used to treat Obsessive –compulsive disorder and other psychological problems such as depression, anxiety and such like in children and adults (Mellissa & Kehle, 2011).
Various studies have been conducted on the use of psychotropic drugs on youth. For instance, recent study by National Institute for health and clinical excellence in United Kingdom indicated use of Fluoxetine as the most effective SSRIs in treating depressed youths. FDA also approves Ritalin as the only treatment of ADHD in children above six years. FDA and European Medicines Agency in 2003-2004 reported increased suicide risks of initiated SSRIs with antidepressants in young adults. The report has led to decrease in the number of prescribed psychotropics in the recent past. Researchers relate the increase of suicide rates with the reduction of the medication prescription. Recent study indicated suicidal events at a rate of 4.7% with the use of SSRIs and CBT compared to 9.2% with SSRIs alone; whilst 2.7% for placebo condition (Goodwin, Gould, Blanco & Olfson, 2001).
Prescription of psychotropic medication in US has rapidly risen between 1997 and 2007. Generally, the increase of psychotropic’s drugs had been recorded to have increased by almost six folds. Current data approximates about 4% of children and youth under psychotropic medication at any one given time. Youths in foster care have psychotropic medication at the same or grater rates those insured by Medicaid. More so, the high numbers of youths in foster care under psychotropic’s medication. Most of them are under medications with some being children of very young age sometimes even below six years. Between 45% and 75% of psychotropic medication to youths are usually prescribed off label. Most of them are not even approved by the FDA. Off label prescribing are recognized as standard of care, but the physicians must also be well-informed and be in apposition to of understanding the benefits and risks of off- label use. Despite the increase on prescribed psychotropics on youths, most of the states are lagging behind in taking steps on how to regulate psychotropic’s medications (Maxwell, 2006).
Zito et al. (2003) expounded on the trends in psychotropic medication prevalence. Their study indicated psychotropic prevalence growth of 6% of youths below 20 years. This represented a three-fold increase in the total psychotropic medication prevalence in the decade between 1987 and 1996. However, most of the temporal change was recorded between 1991 and 1996. HMO recorded 5.9% with 6.3% being from MWM and 6.2% among MAM youths. The study showed most of the temporal changes occurred between 1991 and 1996. Youths between 10-14 years were found to be predominantly stimulant treated age group. Large increase of the stimulant medication occurred for females. In the study, antidepressant use indicated an increased growth in boys. More so, identified psychopharmacologic agent’s alpha antagonist (Largely clonidine) increased remarkably from being nonuse in 1987 and 1991 across three sites (Zito et al., 2003).
The Medicaid youth was distinguished by the increased level of the stabilizer and anticonvulsants that were meant to be used in the controlling of the mood to avoid different health problems. Such aspects as neuroleptics and lithium showed a significantly increased level and were observed in the study. Medication with mixed usage was also seen to have variations among HMO and Medicaid populations. Hydroxyzine and benzodiazepines were used by HMO youths and worked as the examples of differentiating some appropriate aspects. Racial disparities also showed varied patterns where substantial narrow rates of African American prevalence ratio for stimulants and for other psychotropic classes (Warthington, 2011).
Other investigations by Zito et al. (2000) on Methylphenidate (Ritalin) and Clonidine (catapres) on youths indicated stimulants as the leading treatment among the two followed by antidepressants Clonodine and neuroleptics. It showed Methylphenidate (Ritalin) prevalence of 90%, With TCA prevalence led in the antidepressant class with HMO assessed being three times more than Clonidine. Methylphenidate was also found to be prominent between 5-14 years. The largest Methylphenidite increase was observed in youths between 15 throughout 19 years having 311%; with the greater proportion of those under medication being girls. However, use of SSRIs antidepressant was found to increase dramatically at Medicaid sites. The antidepressants comprised of small portions by 1995. Their increase in use was found particularly through the off-label (Zito et al., 2000).
Weyandt reported on research carried out on 743 preschool children on psychotropic use. From the results, 165 received psychotropic medication with 48% being under stimulants. He also cites studies done by Safer, Zito and DosReis in 2003 whose investigations showed over 20% of the youth being treated at community health centers with over 40% having inpatient services. Ryen et al, 2002 reported 51% to 94% of individuals in nursing home having psychiatric symptoms. This is a concrete support on the wide use of psychotropic medication by youths (Weyandt, 2006).
Effects of Prescribed Psychotropic’s on Youths
Drugs that are prescribed to treat mental illness are referred to as psychotropic’s medication. They are often used to treat quite a range of disorders, including mood swing disorders, behavioral character, depression and anxiety. The drugs are palliative in nature. This implies that despite their help in improving mental conditions, they do not cure the underlying cause of the condition. Recent research shows an increased use of the drugs to treat kids and adults with a reported of two or three-fold increase of psychotropic use in children and youths from 1987 to 1986. Antidepressants and stimulants being ranked the most prescribed mood stabilizers (Mellisa & Kehle, 2011).
Evidently, there is an increase in use of psychotropic drugs among the youths. However, the exact mode of action among the youths is unknown as Wendayt puts it “at the molecular level an explanation of the action is often possible; at the cellular level, an explanation is sometimes possible; but at the behavioral level, our ignorance is abysmal” (p.52). Some of the reasons behind the lack of understanding the exact effects of the drugs include the unknown factors which influence signaling of neurotransmitters. More so, research shows the insignificant variation among individuals in drug sensitivity, which do correlate with behavioral variation. The field of psychopharmacology requires adequate understanding of neuropharmacology too especially in comprehending a) the genomics of drugs’ response b) Suppression and activation of genes on drugs’ exposure c) structure and function of postsynaptic receptors, auto receptors and heteroreceptors and their response to drugs d) trophic factors and how they contribute to neural regulation and interaction between trophic factors and neural regulation and lastly e) the role of glial cells in neural signaling and the effects of drugs in functioning of glial cell functioning( Weyndat, 2006).
Alternative treatment raised by researchers includes de-stigmatization. According to Sparks and Duncan (2004), mental illness is very stigmatizing and having to carry the label of being mentally ill for the entire’s life. They expound further on how demoralizing and unjust to tell kids they suffer from brain diseases or other mental illness such as biochemical imbalances which they don’t understand. Making the young adults really on medicines and experts to solve their problems marks the beginning of other problems. Sparks and Duncan showed how destructive the diagnosis can be to the youth, especially when they imply that the youth should forget pursuing their dream career because of their mental condition. Such diagnosis and sidekick, medication and therapies create a huge stigma (Sparks & Duncan, 2004).
Benign perspectives on side effects on youth’s psychiatric medications have been identified. Most prescribing psychiatrist discourage their patients from reading the warnings on drugs’ inserts arguing that the warnings can drive one crazy. However, most of the professional organizations urge parents to be informed on the effects of the medication of their children. In reality, the side effects of psychotropic medications for children require serious evaluation. The evaluation should cover the impact on short-term and long-term chemical intervention on the youthful brains. Concrete evidence shows use of neuroleptic and most psychotropic medications to have long-term or even permanent changes on the brain structure (Breggin, 2006). Furthermore, the increased warning signals point toward increased risks on Mania and suicides on with psychotropic medications, especially SSRIs (Breggin, 2000). A Prozac Study on adolescents showed 6% dropouts due to manic reactions. When extrapolated to the population, the study implied that 6, 000 kids drop out for every 100000 children. Clearly, this is a serious and adverse effect to the general population (Mufson, 2004).
Other studies on Paroxetine hydrochloride reported that 21 out of 93 under Paxil medication had maniac like symptoms such as hostility, emotional liability and nervousness. The study reported tremor in 10 while the placebo group had none of such incidence. These are just clinical rates. How adverse are the effects on those under medication for longer periods, the adverse effects tend to be more pronounced. How controversial the scenario is when the psychotropic’s drugs are said to be tolerated and safe; whilst, on the other hand, more children and youths are becoming violent and more depressed due to the medication (Antonuccio et al., 1999).
A case study by Camp (2011) on Foster children under psychotropic treatment showed that after the young girl was treated with depakote, drug used for mood’s stabilization. The side effects recorded included irritability, diarrhea, tremors, dizziness, allergies, stomachs and restlessness. Harmful impact on organs such as bones, liver, pancreas was observed with eventual death of the young girl (Camp, 2011).
Recent study in the UK medicine and healthcare Products Regulatory Agency (MHRA) discourage that Setoxat (Paroxetine also called Paxil in the US) being prescribed for under 18 years (Boseley, 2003). They argue that clinical trials have inadequately demonstrated the efficacy of the compound on children and youth’s depression. More so, the trials had harmful results sometimes up to 3.2 times greater in Paroxetine group as compared to children and Youths under placebo. Most of the effects pointed out include elevated aggression, agitation, self-harm and suicidal cases.
Glaxo pharmaceuticals are the manufacturers of the drug. There were claims on cover-up of studies, which suggest that the drug might have detrimental effects for youths younger than 18 years. However, the company rejected the claims (Sparks and Duncan, 2004). FDA has also issued warnings on the same ground arguing that it has been reviewing reports of the potential increase of risks of suicide thinking and attempts among youth and children under the treatment of Paxil, thereby recommending that the medication should not be used by youths below 18 years. The FDA ruling was from the support evidence on drugs’ trials in pediatric patients with MDD having failed (Food and Drug Administration, 2003). Sparks and Duncan pointed out an investigation done by Keller and associates who concluded that Paxil was generally tolerated and effective for major depression in youths. As they claim the study had been funded by GlaxoSmithKline. As sparks and Duncan points out, it is time to critically examine the rapid encroachment of drug and money and the marketing influences on parents. Drugs are often given to the youths without psychiatrist consent or even without considering the efficacy and safety of the drugs delivered to the youth. The problem is due to the current saturated pharmaceutical environments, raising the myths and belief on the magical powers on drugs. This have become so Ubiquitous such that whenever they are faced with quandaries on how to help their kids, parents and psychiatrist easily rush to psychotropic drugs cabinet (Sparks & Duncan, 2004).
Some of the general warnings retrieved from studies on psycho stimulants include those of Food and drug administration (FDA) in June 28, 2005 concerning the safety issues of methylphenidate (Ritalin, Adderall & Concerta and so forth) drug products. The specific noted drug effects included hallucinations, suicidal ideation, agitation and hallucinations and psychotic behavior. Investigations by The Oregon health and Science University in September 13, 2005 on evidence-based practice centre review findings indicated that virtually almost every study to be conducted by ADHD drugs had no trials that showed the effectiveness of the drugs, and that they lacked concrete evidence that they affected academic performance, risky behaviors and further, no evidence concerning their long-term safety when being used for treating adolescents. In 2006, FDA reported on sudden deaths and medical complications such as strokes, heart attacks and hypertension in kids and adults regarding to the intake of ADHD drugs. This raised questions on drug’s safety and its risks’ management on the advisory committee urging for evaluation on the potential relations of cardiovascular complications with the drugs. Another study conducted by University of Texas published report on cardiovascular problems, especially in children under stimulant’s medications. At the same period, The FDA’S drug and safety management committee issued further warnings on the stimulants, associating them with cardiovascular risks and other complications such as Strokes and sudden deaths (CCHR Internationals, 2009).
There exist multiple FDA warnings regarding use of Strattera drug used to treat ADHD cautioning about the possibility of liver damage in pediatric patients and possibility of development of jaundice having two cases reported from 2 million filled prescriptions. The drug as also associated with increased suicidality, cardiovascular complications, psychotic maniac even to youths who prior had no history of psychotic or maniac illness. The major common effects of these drugs include gastrointestinal discomfort, reduced appetite, weight loss, nausea, headache, lethargy and insomnia (Melissa & Kehle, 2011).
Study by Zito et al (2000) indicated that Clonidine (Catapres) had the most dramatic increase of stimulant use due to the ability to prescribe without the benefit of rigorous data to support it or to portray it as safe or effective treatment for mental disorders. However, they noted cardiovascular effects such as bradycardia, atrioventricular blocking, syncope cases being reported in youths and children under Clonidine treatment in combination with other medications and for treatment of ADHD. Their investigations showed medical complications with abrupt withdrawal from clonidine. The drug used to combat insomnia associated with ADHD itself or used as a supplement in the treatment of ADHD is uncharted. Therefore, its increase in use since 1991 explains the increase in clonidine toxicity in young adults through prescription or those of their siblings (Zito et al., 2000).
The intervention required is a shift and a reconnection of parents and therapist from psychotropic’s drugs and adopt support and encouragement, and such unorthodox routes will definitely bring in change naturally and universally. The core faith in change and the tendency in humans to seek a way out of the darkness should not have children as an exception. It is time to protect children and youth and allow them to be into the equation and allowing them have as a say in their lives (Duncan & Sparks, 2002). As a matter of fact, children trust that grownups know what is best for them. We should not betray this trust. Therefore, parents must demand for high quality and untainted science and accurately balanced information to facilitate their critical decisions. This implies that families should make the decision; they think that they will be most helpful for their young adults. At the same time, it is the professionals’ duty to ferret out good information from the bad and to learn on how to analyze critically claims for the websites, brochures, and press releases and from scientific studies regarding psychotropic medication for children and youths. Therefore, the paper recommends a vigorous critique on what has been established as a daily understanding for what works for kids and youths, and as they navigate the difficult paths to adulthood. Finally, the therapists are also obliged to cease taking the easy road by abandoning tried and true counseling skills in favor of a quick fix. They should as well cease seeking to be up-to-date pediatric psychopharmacology with the expense of strengthening other practices. The therapists should inform the parents widely on the range of nonmedical strategies and the impacts of the psychotropic’s drugs (Sparks & Duncan, 2004).
Areas for future directions on Psychotropic medication
Despite the recent advances in treatment, there are still significant knowledge gaps. For instance, the evidence-based treatment efficacy information is somehow uneven with most of the severe mental health conditions. With some of these conditions such as bipolar disorders and schizophrenia, there is reduced treatment attention by investigators. Most evidence on treatment efficacy is only limited to acute symptomatic improvements; with little attention being paid functional outcomes, long-term effects and safety. Little studies are available on therapeutic advantages of intervention under usual and real-life conditions. Although there is well documentation of numerous single-subject designs for low prevalence disorders and a relative dearth of other controlled and randomized clinical trials with supportive evidence, their interpretation is often limited due to the features of the specific design, inadequate statistical information, and lack intent to treat analytical strategy. With the increase of psychotropic medications among the youths, various loopholes in psychopharmacology should be filled to reduce the high morbidity due to medical related complications or increase of suicidality. Some of these areas include determining the safety of the drugs, their efficacy, other psychosocial alternatives and integrated treatments and sequencing of the treatment (Callaghan, 2004).
Safety of the drugs is very paramount. Children and youths systems are vulnerable and still developing. Their nervous system is bound to be affected by drugs. The shortage of information regarding safety and drugs impact may lead to alteration of the central nervous system. It is important to understand the effects of drugs to know whether the drugs are of advantage or disadvantage. Thus, the need of not only longitudinal but also long-term investigations to establish potential safety issues, which would emerge affecting the development or behavior of the youth. When it comes to polypharmacy, adequate check up and patient monitoring should be carried out. The psychotropic drugs are prone to interaction and could elevate serum levels for one drug causing cytotoxicity thereby increasing the adverse reaction. Therefore, more study should be done to evaluate the short-term and long-term safety and efficacy of polypharmacy (Report of the Working Group, 2006).
Other areas include use of effective psychosocial alternatives to drug’s treatment. Obviously, the risks and safety issues surrounding medical treatments do not cover psychosocial alternatives. Psychosocial treatments are said to be more beneficial than drugs. There is reviewed research on psychosocial treatment of ADHD by Pellham and Fabiano 2008 and non –OCD anxiety disorders by David -Ferdon and Kalsow among many others. However, further research is required. This will facilitate identification of moderators and mediators who will facilitate in dissemination of psychosocial research (Wendayt, 2006).
Other issues which must be put into place are the assessment issues. An assessment must be done to evaluate whether psychopathology is accurately diagnosed in children or adolescents, whether pharmacological interventions are being followed and the outcomes. More so, there are more assumptions in relation to diagnostic precision, intervention fidelity and accuracy of the outcome. As a matter of fact, there has been agreement in distinguishing [psychopathology from normative behaviors; but diverse opinions when assigning specific diagnoses of such disorders such as multiple disorders and primary diagnoses. Therefore, research on assessment should have shown numerous constraints, especially when drawing conclusions on what works, for whom it works and how well it works (Report of the Working Group, 2006).
There are studies at present, which have shown improved efficacy on use of combined drug and psychosocial treatment over singly use of drug or psychosocial treatment. The case has been fruitful, especially on young youths undergoing depression, obsessive- compulsive disorder and with non- OCD- anxiety. However, there are still of loop holes, which require to be intervened.
Lastly, future research should also focus on contextual variables, which could deter the sequencing of the treatment. Such variables could include but not limited to client preferences, ethnic disparities and cultures and beliefs. More so, issues regarding diversity should be put into considerations when doing further research on psychotropics. This could include gender, race/ethnicity, other physical disability, socioeconomic status, culture, sexual orientation. These variables have shown to influence treatment choice and adherence. This area is inadequately explored, and therefore, school psychologists should advance and focus their research in identifying the individual and contextual variables which could affect treatment adherence or acceptability; and those which will reduce treatment’s efficacy (Report of the Working Group, 2006).
Conclusion
Children and adolescents response to medications varies to those of adults. Therefore, systematic and careful investigations are required. More so, all unresolved questions, especially those concerning long-term safety on psychotropic drugs must be put into considerations. More so, it is undeniable that the drugs have the possibility of developing adverse effects in the brain. Such changes could be the cause on changes on personality due to the drugs’ impact on brain neurotransmitters.
Although there have been advancement in the field of psychopharmacology, empirical evidence, especially those of regarding safety and efficacy of commonly used medications is inadequate to support the current prescription practices for children and youth. The data supporting efficacy and treatment results and safety of psychotropic conditions is quite small compared to that of the adults, especially with the increase of off-label prescription. They are often referred to as off label because they are approved for adult only. Even though the medication could be safe and efficacious for adults, the difference in physiology makes them vulnerable in the youth system. It is only justifiable for clinicians to prescribe of label because they have to balance their beneficence (use of professional judgment to treat) with non-maleficence (protecting patient from unethical practices. Therefore, the absence of research on psychotropics in youths leaves no other choice other than use of medication proven for adults only. The current trend of pediatric prescribing practice implies an increased research on this topic. The research should cover on the short-term and the long-term safety as well as efficacy of the psychotropic drugs, the alternatives available, new treatments that can be integrated and sequencing of the treatment. It is up to therapists and their competencies to contribute to the research needs especially to deal with effects of the drugs on youth’s personality. The government should also take an active role to enact legislation, which will curb the abuse of these drugs. Tough legislation against the abuse of psychotropic medication will help to bring back the situation in hand. The public also has to be made aware of the adverse effect of this medication when it is abused.
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