The prescription of psychotropics for children and adolescents includes key safeguards that should be carefully documented. First, the patient should have an appropriate evaluation that encompasses psychiatric and medical areas and that includes basic considerations, such as measures of physical growth, as well as laboratory testing. This evaluation may be performed through a team approach with a pediatrician. Before undertaking treatment, the practitioner should engage the parents and, to the extent possible, the child in an informed consent process that explains the illness, the proposed treatment and the alternatives, and the anticipated outcomes of each. The consent information must include FDA black box warnings.
Beyond the parents’ consent, the youngster should be informed about the basics of the illness and treatment options, and assent should be sought. This assent can be revisited as the young person matures. The treatment approach may require revision if the patient no longer provides assent. In recent years, the rights of the “mature minor” who possesses sufficient cognitive and emotional ability to provide informed consent for mental health and substance abuse treatments have been emphasized.10 Over time, diligent collaboration with the primary care provider and parent for close monitoring of adverse effects and drug interactions is critically important.6
The historical premise of clinical care is to heal, relieve suffering, and aid in the remission of symptoms. As in other specialties of medicine, psychiatrists are now faced with the ethical considerations that accompany the use of psychotropic medications with the intent of enhancement, rather than treatment. So-called cosmetic psychopharmacology has drawn much criticism.11,12 There is less controversy in using psychotropic agents to treat minor depression or subclinical anxiety that may evolve into more severe illness. However, the use of medications to address symptoms such as fatigue or tension in individuals in high-demand roles or to improve cognitive performance in noncognitively impaired individuals is under scrutiny. Across all disciplines of medicine, there is no consensus that this is absolutely unethical, and parallels have been drawn with plastic surgery for physical enhancement.
New ethical standards for enhancement therapies are necessary if the use of psychotropic medications for enhancement is to become accepted practice. These new standards will necessarily entail, at a minimum, a thorough exploration of the patient’s expectations of medication benefits, the known benefits and risks of the proposed treatment, and a clear understanding of available information based on clinical and research experience. The clinician should understand the previous treatments used (including psychotherapy) and should define the overall goals for the intervention. Wherever possible, look for an evidence base to support the use of psychotropics for the condition at hand and mon-itor patients closely for the risks and benefits associated with such approaches.13
Note that the logic behind clinical innovation is not quite met under the circumstance of enhancement therapy because of the first precondition—establishing a true clinical need. Moreover, the risks and burdens that accompany the intervention may be far greater than the baseline state of the individual. For in-stance, stimulant use may unmask latent bipolar disease or disrupt normal physical development in a child or adolescent. Similarly, use of anxiolytics for tension may give rise to addiction and harmful drug interactions. For these reasons, many believe that the mainstream practice of psychiatry has no place for enhancement therapies and that “cosmetic” treatment approaches produce excessive and ineffective polypharmacy and the associated negative sequelae for patients.1
This position is less firmly held with psychosocial interventions, such as cognitive-behavioral therapies to enhance performance in, for example, sports or examinations. Well-informed patient “consumers” are increasingly likely to advocate for the application of these therapies in everyday life. Consequently, the use of psychopharmacological agents beyond historical clinical indications is predictable and efforts should be undertaken to develop appropriate, clinically and ethically sound guidelines for this emerging practice.