After majoring in psychology in college, I entered medical school in 1986 with a strong interest in psychiatry. While in medical school, I was exposed to the subspecialty of child psychiatry, and was very attracted to the idea of making a difference in the lives of vulnerable youth. Child Psychiatrists were experts in understanding normal development through the life cycle. This was particularly fascinating to me and I believed that it would be personally meaningful and fun to work with children. During this time, child psychiatrists often directly provided individual psychotherapy and family therapy to their patients. The use of psychotropic medications in children was not typically a first line treatment.
When I started my general psychiatry residency in 1991, it was common practice for patients admitted to the hospital to be taken off their medications for an observation period so that a clear, thoughtful diagnosis and treatment plan could be established. We were meticulous in documenting symptoms, reviewing old records and spending time thinking about/discussing our patients before starting any psychotropic medications. Social workers met with patients’ families, conducted therapy, and worked hard to develop a meaningful discharge plan for each patient. Many patients were in the hospital for a month or more. This was, obviously, before the concept of managed care invaded the insurance industry.
When I began my child psychiatry training in 1994, most children admitted to our inpatient unit were on no medications or, at most, one medication. There was caution in regards to the prescription of medications to children . . . after all, their brains were still developing! Social workers spent significant time with families conducting family therapy sessions, and children received individual therapy as well. The length of stay was often a month or more.
Now, patients are admitted to inpatient units and the treatment plan generally involves getting them out of the hospital as soon as possible by any means. What this translates to for children is the rapid prescription of multiple medications – usually sedating agents such as an antipsychotic. The biggest risk for polypharmacy appears to come from hospital admissions. Many vulnerable children will be placed on 3+ psychotropics as they are quickly discharged to the outpatient setting.
I have been a practicing child psychiatrist for the past 20 years, working in various treatment settings. I’ve attempted to “influence” the “system” by speaking out against the over diagnosis/overmedication paradigm that currently drives it . . . teaching/training/consulting, caring for individual patients, and through my work for insurance companies. It has been quite a struggle and I have seriously considered leaving the field all together. I continue to care for vulnerable children on a part time basis at a local non-profit in Philadelphia.
I decided to join the Mad In America blog to share my experiences with like-minded others in hopes that such collaborations will help me more effectively advocate for the best interests of my patients and work toward system change. You can see a paper I’ve written, The Overmedication of Vulnerable Youth with Psychiatric Medication: A Call for New Regulations, which explicates my perspective on the current state of the “industry,” and its problems. I look forward to engaging with the readers of Mad in America, as we learn together how to make the changes we need to, in our mutual interests and in the interest of society at large.