When medications devalue the opportunity to listen

When I hear debate over the association between SSRIs (selective serotonin re-uptake inhibitors, a class of antidepressant medication) and suicidal behavior in children and adolescents, I am immediately brought back to a night in the early 2000s.  As the covering pediatrician I was called to the emergency room to see a young man, a patient of a pediatrician in a neighboring town, who had attempted suicide by taking a nearly lethal overdose.

That night, as I watched over him in the intensive care unit, I learned that he was a high achieving student and athlete who, struggling under the pressures of the college application process, had been prescribed an SSRI by his pediatrician.  His parents described a transformation in his personality over the months preceding the suicide attempt that was so dramatic that I ordered a CT scan to see if he had a brain tumor. It was normal. When, in the coming years the data emerged about increasing suicidal behavior following use of SSRIs, I recognized in retrospect that his change in behavior was a result of the medication. But at the time I knew nothing of these serious side effects.

At that time, coinciding with pharmaceutical industry’s aggressive marketing campaign directed at the public as well as a professional audience, these drugs were becoming increasingly popular with pediatricians.

As the possible serious side effects of these medications came increasingly in to awareness, the FDA issued the controversial “black box warning” that the drugs carried an increased risk of suicidal behavior. Following the black box warning, pediatricians, myself included, became reluctant to prescribe these medications. We did not have the time or experience to provide the recommended increased monitoring and close follow-up.

Recently the Boston Globe published an article reviewing the data addressing the concern that the warning, by discouraging prescribing, led to increased suicidal behavior. It includes this key finding:

Studies also found no increase in other treatments for depression, such as psychotherapy; leading to what Fritz called “a net decrease in the amount of treatment.”

This finding offers evidence for more insidious and perhaps more dangerous side effect of antidepressant use in children. The fact that we as a society condone use of these medications in children in the absence of relationship based treatments — a CDC report from December 2013 indicated that 50% of adolescents who are on psychiatric medication have not seen a mental health professional — itself changes the landscape of mental health care.

When medications can be used alone, the professions who offer opportunity for listening and human connection are devalued, both culturally and monetarily.

This kind of devaluing sends qualified professionals away. Pediatricians, whose longstanding relationships with children and families makes them ideally suited for preventive interventions, are discouraged from using their time to listen. Social workers, psychologists and others who offer relationship based treatment in which feelings can be recognized and understood, are less likely to accept insurance. They are paid less and less while being required to jump through increasing number of hoops. The drug itself becomes inextricably linked with the shortage of quality mental health care.

A recent study, a survey of close to 2,000 people being prescribed antidepressants, showed a much higher than expected rate of serious psychological side effects. Almost half described, “feeling emotionally numb” and “caring less about others.” These findings occur in the context of a social acceptance of medicating away feelings, and in doing so, devaluing the “being with” that is necessary for growth and healing. The absence of opportunity for meaningful human connection where feelings are recognized and understood, in combination with these psychological side effects, may be what leads to increased risk of suicidal behavior.

I wonder if before we can change what we do, we need to change how we think. Prescribing psychiatric medication to a child without simultaneously offering time and space to listen to him and his family is unacceptable. A change in perspective and attitude is needed before we can to begin to repair our broken mental health care system.

Andrew Solomon, in his sweeping tome about depression, The Noonday Demon, respects the role of medication in treatment. But, recognizing that medication alone it is not sufficient, he writes, “Rebuilding the self in and after depression requires love, insight, work, and most of all, time.”

Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.

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  • DeceasedMD

    Does seem like in just about every aspect of medicine, meds are a substitute for careful evaluation. In this above case, it is more likely a misdiagnosis like bipolar disorder that was aggravated by an antidepressant, or a lack of monitoring closely. Regardless, the point is well taken that quality has gone out the window and a pill has become the answer. Many people expect a pill, such as with antibiotics.

    • iphone12

      Deceased MD, many people who experience adverse reactions to SSRIs are not bipolar but sadly end up on these powerful drugs that cause even worse problems long term. I beg physicians to not automatically make this assumption as peoples lives are being destroyed because of this.

      Regarding antibiotics, ironically, when I investigated having surgery, I was concerned that they were being prescribed unnecessarily post operatively based on research I had done. I would love to see a discussion on Kevin MD about this.

      • Suzi Q 38

        “Regarding antibiotics, ironically, when I investigated having surgery, I was concerned that they were being prescribed unnecessarily post operatively…”
        Do you mean injectable antibiotic use immediately post operatively, or being sent home with an oral antibiotic?

        • compsports

          Hi Suzi Q,

          Because of login procedures that totally drive me crazy with their constantly changing procedures, my id has changed to compsports. Just so people understand I am not trying to deceive folks with multiple identities.

          Anyway to answer your question, I meant being sent home with an antibiotic. I had no problem with the injectable one that would have been used and it seemed according to research which of course, I could have been misinterpreting that this would have covered potential post op infections that had a very minute chance of occurring.

          I do understand where the physician is coming from as they have to cover all bases. But it just seemed I didn’t even have a choice in the manner even though I was willing sign anything to absolve this person of liability if anything bad had occurred.

          • DeceasedMD

            am also not crazy about the new disqus. Don’t need to see each time there is an upvote. Don’t like the format . what do u both think?

          • EmilyAnon

            As long as we’re complaining about disqus: am I the only one who doesn’t receive all their comment updates via e-mail, even though I subscribed to the thread? Very frustrating to discover a response to one of my own comments that never arrived in my inbox. (and yes I check the spam box)

          • Suzi Q 38

            Yes,
            I have had that problem too.
            Maybe let Kevin know and then he or someone else can fix it.

          • Patient Kit

            Sometimes I get email notification of a new response to one of my comments, sometimes I don’t get any notification. It seems pretty random. I know I miss some responses. I try to go back and scan threads I got involved in but I miss some, no doubt. When I’m having a particularly busy day, the notifications are helpful for keeping up with the conversation.

          • EmilyAnon

            Yes, I’ve also started going back into threads that interest me to check for responses I might have missed. Initially I thought it was my free e-mail program just being lazy, but guess the qlitch belongs to disqus.

          • SarahJ89

            It seems weird that anyone would care about upvoting. Almost as weird as the word “upvoting.”

      • DeceasedMD

        It is true that there are a variety of side effects but i mentioned bipolar as SSRI’s commonly makes bipolar people far worse. But clearly I don’t know about this pt and more importantly I hear you have seen or heard about people with bad experiences on these meds. I think the central part of this article is what is key. That it is becoming a substitute for talking. Just feed ‘em meds. And people often expect pills as well whether it is right for them or not.

  • Patrick Kenney

    I was working at a child psych clinic last month that has a pretty good model. No meds are delivered if the child is not in active therapy provided by counselors at the clinic. Now, granted for more severe cases the therapy is not as effective until the meds start to kick in, but the attempt has to be in place. Based on this philosophy, more patients in this clinic are being counseled than are being medicated.

  • Sarah Collett

    As a mother of 2 sons with autism, a mental health pt myself for 20+ yrs, a CMA, and an avid reader of medical literature; I can tell you that I’ve never heard this addressed by numerous medical professionals. And I’ve only read about it once or twice.
    My family has received way too many rx’s over the yrs, just in what I call the “head med” category. I’m fed up with the current “head med roulette” route of picking a med and dose, and then more meds to counteract or add to effects. We have all these “regulations” that are supposed to “protect” us from everything but admitting depression seems to be a license (consent) to be subjected to Rx guessing games. That is unacceptable!
    In my opinion, the current standards of treatment do much more to ensure continued (and often worsening) depression as opposed to actually helping it. The Rx mess (and all that comes with it) is only 1 side of this. The paperwork and insurance hassles, the therapists who are desensitized and incompassionate, the amount of time it takes to get appts with therapists and psychologists, the hassle of getting there and sticking with it…..all while forcing oneself to do these things while feeling beat down, weighed down and overwhelmed – for me, that is more daunting than the depression itself!
    I wish that my youngest son’s psychologist (pill pusher) would’ve considered the great point that you made!!! 1 yr on risperidone (which has been fabulous for his older brother) and my baby is grotesquely obese and dealing with the complications from that, the social stigma and the future health complications. Plus everyone treats him like a fat kid with a food addiction which is so untrue :-(
    PLEASE, those of you who have a pen and a script pad, please realize that sometimes those are more lethal weapons than what we consider true weapons.

  • Sarah Collett

    Time spent actually listening to patients is severely lacking across all areas of the medical field!! And too many pills “replacing” the expertise of the physician. I dont blame doctors for this; anyone that pays attention can see that’s directly attributable to insurance companies. And standards of care that dictate order of procedures with very little room for a doctor to use his expertise to determine the next step of action. Or standards of care that make no sense. The standard of care for autism says that checking vitamin and mineral levels isn’t beneficial. But based upon our personal experiences, I can say that would make more sense and probably provide more insight than the numerous therapists and specialists and med guessing games.
    The whole system needs revamped, based on common sense instead of administrative hassle. Not like we have that option but it would be nice! :-)
    On the listening note…I have given up seeking care for just about anything not accute. I don’t know if that says more about me or the medical field lol but I’ve spent much time and money (of which I have little of either) trying to seek a doctor that will listen to me and help me. It doesn’t seem to matter if I ask for an extended appt when scheduling due to complicated health hx or if I come in with detailed lists of symptoms, hx, etc or if I come in with nothing and play stupid (since most docs I’ve seen seem to be highly offended if I come across as halfway knowledgable). Regardless of my approach the results are usually the same – nothing. Except symptoms that worsen and increase, along with my frustration level and the hopelessness that results from seeking help and getting squat.
    Just 1 of many issues I’m dealing with are some lesions on my face that severely hurt and have been there for 2+ yrs. I’ve been to my pcp, I’ve been to a dermatologist and all I get is antibiotics and fluff. 2 YEARS. I’m HPV 16 positive, have had worsening on/off laryngitis for over a yr amd the 1st lesion that appeared is on my cheek where there is a small bump inside my mouth. Can I get a doctor to LISTEN to this or even look at it??
    Nope just more scripts for more antibiotics :-P
    That’s the biggest problem in medicine today!! Doctors who won’t listen and patients like me, who are so pissed off at the runaround that we give up. I’m 36, a mother of 3, and I don’t expect to live to 45. Because of something treatable, when doctors listen before it’s too late. Preaching prevention and learning new info wont help anyone if doctors don’t relearn how to actively listen.
    If you’re a doctor who’s always in a rush, how would you feel if I was your pt?