Paediatrics: Psychopharmacotherapy

Psychopharmacotherapy

Societal views exist about medication for mental health in general and specifically for children. Not all mental health professionals hold positive views about psychoactive medications or believe them to be safe and effective treatments for mental health disorders. Some non-professional groups are openly antagonistic. Whilst there is some clear evidence to support the use of medications for some children and adolescents with some disorders in some situations, it is also true that more research and stronger evidence is urgently required.

Until recently prescribing for children and adolescents with mental health problems has not benefited from age-specific pharmacokinetic studies, nor had there been extensive work establishing the pharmaco-dynamics of psychoactive medications. As a consequence for almost all psychopharmacological situations, other than ADHD, one usually assumes that the pharmacodynamic effect in children is the same as that in adults. Similarly, there has been relatively little attention paid to pharmacoviga-lence and many questions about drug safety remain unanswered.

Data supporting efficacy and effectiveness also remain relatively sparse and the current evidence-based medicine summaries do not comprise a comprehensive review of child and adolescent mental health prescribing (see Cochrane Library). Many protocols are listed; over time it is hoped there will be more consistent coverage from completed reviews. Despite this lack of evidence, psychotropic medication prescribing has increased exponentially over the past 15yrs. Fortunately, recent changes in legisla-tion in the US and Europe have meant that far more psychiatric drugs are being trialled and licensed for use in children.

For specific prescribing information, indications, contraindications, pre-cautions, side-effects, and dosage regimes the reader should consult an up-to-date formulary and the primary literature. One reference text offers the following useful headings in a section on general principles.¹

·  First do no harm.

·  Know the disorder and use drugs when indicated.

·  Choose the best drug.

·  Understand the drug and its properties.

·  Minimize drug use and dosage.

·  Keep things simple.

·  Avoid polypharmacy.

·  Don’t be a fiddler or follow fads.

·  Take particular care with children.

·  Establish a therapeutic relationship.

·  Compliance (adherence) with treatment.

Whilst some mild mental health presentations may respond to medica-tion alone, in individuals with multiple comorbidities, impairment across domains, or distressed parents, medication is almost invariably adjunctive to or part of a more comprehensive and sophisticated management plan