Black box warnings, suicidal thoughts, sudden cardiac death, and the placebo effect—these are but a few of the concerns that keep me committed to a busy psychotherapy-based career. Before stating my case for more active utilization of psychotherapy in child psychiatry, I want it to be clear that I believe medication is an essential tool and that I use it judiciously in my practice. However, the proverb, "if all you have is a hammer, then everything becomes a nail," could not be more apt than in the field of child psychiatry—indeed, in psychiatry in general—over the past 20 years.
I teach in a multidisciplinary community clinic in which resources are scarce and children often present to us in crisis. The residents here see families in such crises and immediately begin to think, "What can we do?"
Primed in the medical model, the tool that most often comes to their minds is a psychotropic agent, such as an SSRI, because the child seems anxious, or a stimulant because teachers think the child cannot sit still, or maybe even a mood stabilizer because the child seems irritable and swings from one extreme mood to another. Even in a program that is steeped in the tradition of psychodynamic practice, residents' first instincts are often to approach the problem biologically, seeing themselves as "prescribing doctors."
We may give lip service to the biopsychosociocultural model, but its full practice seems wanting at times. What has happened in psychiatry when talking to patients appears to have fallen out of favor and "managing medications" is common practice? Below are 2 case vignettes that illustrate the benefits gained from providing combined treatment to children.
CASE VIGNETTE 1
Allison is 13 years old, with no apparent signs of previous mood problems. Over the past several months, she has been feeling down and, with questioning, has endorsed most of the neurovegetative symptoms of depression. An interview with her family revealed that there is a chronic level of conflict and that Allison largely feels that no one understands her. She was enrolled in a depression study comparing 2 SSRIs and began taking medication and attending weekly one-on-one cognitive-behavioral therapy (CBT) sessions with me. Although I was aware that she was receiving an SSRI, I was blind to the specific medication but was monitoring her for therapeutic changes and side effects.
About 6 weeks into treatment, Allison called me in crisis. She said that she felt suicidal and didn't know what to do. Since I knew she was taking an SSRI (and the concern about paroxetine had just come to the fore) I immediately wondered whether it was playing a role in her suicidal thoughts. I assessed her safety to the degree possible over the phone and together Allison, her mother, and I decided that she would come in the next day for an emergency session; Allison agreed not to harm herself, and her mother agreed to closely monitor her. If I had not been engaged in weekly therapy with Allison, I would have lacked the therapeutic alliance to work out a solution with her over the telephone.
Allison was tearful and upset as the session started. She denied having any current thoughts of suicide and revealed that she had had these thoughts before enrolling in the antidepressant study but had never told anyone about them because she wasn't sure anyone would care. Eventually, Allison revealed that before feeling suicidal, she had agreed to sexual activity with her boyfriend. Afterward, she was quickly "kicked to the curb," literally waiting alone outside his house for an hour until her mother brought her home.
CASE VIGNETTE 2
Carla is a 15-year-old in whom a mood problem has never been diagnosed, but who has—over 2 years—become withdrawn and socially avoidant. During her first interview, I learned that Carla was severely depressed and had developed a particularly avoidant stance toward school, becoming suicidal whenever her parents tried to make her attend. Carla was enrolled in the same depression study as Allison. She started treatment with an SSRI and weekly supportive, psychodynamic therapy because she was resistant to engaging in CBT. To her it seemed like "schoolwork," and she initially only agreed to the therapeutic process because her mother was "forcing" her.
Over the next 6 months, the dosage of the SSRI was gradually increased, per protocol, and she continued to participate in weekly therapy. Slowly, many of her symptoms improved, but Carla continued to feel extremely negative about herself and threatened suicide whenever school was mentioned. One day during therapy, Carla casually mentioned, "Oh, you know I always wanted to be a boy, right?" Mentally, I straightened up but casually replied, "No, I don't ever remember you talking to me about this feeling." Suddenly the missing puzzle piece fell in place, the piece that Carla had felt so secretive about that it took 6 months of patiently waiting for it to be revealed. Now the peer avoidance, extreme dislike of herself, and continual thoughts of suicide had a context.
I believe these case examples highlight the importance, above all else, of the therapeutic alliance. In both cases, I believe that the antidepressant played a synergistic role but that the therapy was truly the transforming event. As therapy progressed for Allison and Carla, they came to better understand their thoughts and the emotions that connected them, not only to their depression, but also to how they related to family and friends. Through therapy, they gained skills for the inevitable life stressors they were facing and would face in the future.
But why see a psychiatrist for therapy—why not split the treatment? My response is why not see a psychiatrist? I realize, of course, that there are several well-known answers to the question, including reimbursement differences, lack of therapy training in residency, and lack of child and adolescent psychiatrists to serve the large population in need. However, in my opinion, there is a larger, hidden, and perhaps unconscious problem: lack of enthusiasm to consider psychotherapy as a tool that is just as efficacious as or, in some cases, more efficacious than a capsule taken daily.
Consider the number of controlled-treatment trials that are completed and then published in child psychiatry's preeminent peer-reviewed journal, the Journal of the American Academy of Child & Adolescent Psychiatry. Over a recent 12-month period, results of 44 controlled trials were reported—32 examined the safety or efficacy of medications and 10 examined the efficacy of psychoeducational and psychotherapeutic interventions, while only 2 trials actually compared medications and psychotherapies.
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