1 Boring Old Man

^{One feature of living here at the edge of the galaxy is frequent power outage – regular with storms, but sometimes they just happen. So I’ve got an XL battery backup for my computer. But every year or so, the big batteries go kerfunkle and need replacing. The replacements were on the floor next to my chair awaiting installation when the power went poof! this morning while I was in the middle of writing something that evaporated into cyber-wherever. Sitting on the porch watching the sun come up [and waiting for the power to return], I realized that the power outage was fortuitous. It actually addressed the topic I was writing about – a value-added power outage…}

Several of the responses to Cipriani et al’s new meta-analysis of medication in adolescent depression [see antidepressants in kids? a new meta-analysis…] raised the question, "So what is the treatment if it’s not antidepressants?" In the companion comment in the BMJ [Antidepressants fail, but no cause for therapeutic gloom], Jureidini suggests "watchful waiting." And in the The Pharmaceutical Journal article, Bazire points out that CBT might be gone with the wind as well, and seems concerned that we have nothing to offer.

I’m old enough the have done my psychiatric residency BD and BP [before the DSM-III and before Prozac®]. My 6 month 3rd year elective was spent on an adolescent milieu treatment unit. I saw late adolescents in practice, and after retiring, I volunteered in a child and adolescent clinic for four or five years. They had a great group of clinicians, and we did [my version of] collaborative care. I’d see the patients they were either confused about or they thought might need medications, then we’d staff the cases and come up with a treatment plan [only sometimes including medication]. I actually left that clinic because there was an abrupt turnover in staff, and the new crop of clinicians were a different and less talented breed who pressed for medications.

But my point is that there is plenty that needs considering when dealing with troubled depressed adolescent BD and BP. And antidepressants were never the first-line response for me back then or up here. For that matter, the diagnostic formulations pre-DSM-III rarely included a diagnosis of Major Depressive Disorder, even when the kid was depressed. A blog is hardly the place to launch into a discussion of all the forces operating in adolescence or adolescents – things like character formation, identity, dependence vs independence, relating to peers and society, moral development, acting out, sexuality, substance abuse, etc – or all the things that can go awry. But, for me, formulating an approach to a troubled, off-track teen is a much bigger deal that focusing only on how they feel and symptomatic relief.

These days, the primary focus is on evidence-based short-term treatments, case-finding [screening], and cost containment. Those are very important things to consider, but that doesn’t mean that we don’t need to figure out what’s going on with the kid. This is one place where the omnibus category, Major Depressive Disorder, really lets us down. Even back in the day, I could see that the unit I worked on was effective, but way over-kill, often disruptive to the family [and kid], stigmatizing, and expensive to a fault. And I was impressed that in my more recent experience, we could do a good job with far less. Sometimes, just the evaluation process got a confused family back on course, and that’s all that was required.

Back to my main point. Perhaps, right-sizing the use of medication in adolescents is not a power-outage after all – it’s a wake-up call. Adolescence is teeming with shoals, but it’s also a time of life with great promise and possibilities. What could possibly be more cost effective than getting back to focusing broadly in our evaluations and intervening wisely? Pretending that some symptomatic medication is more effective than it is may make some Managed Care actuary feel better, and some PHARMA executive happier, but those are obviously just fantasies that don’t take the long term costs of missed opportunities for change into account.