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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.
How did our field come to curb its enthusiasm for psychotherapy? In discussing this complex issue, reimbursement rates are first and foremost on most psychiatrists' minds. Yes, it is true that we are being reimbursed less for a potentially more effective long-term treatment. What is also true, however, is that if treatment is divided between a psychiatrist who is prescribing medication and a nonpsychiatrist who is providing therapy, no third party will reimburse for the time spent communicating between the two. Moreover, preliminary data suggest that treatment may end up being more expensive.1 In addition, in the absence of reimbursement, communication may fall by the wayside to the patient's detriment. Now that doctoral psychologists also are feeling some of the same financial pressures, some are considering gaining prescribing privileges.
Aside from the philosophical issue, what is certain to happen from a financial perspective is that insurance companies will pay psychologists less to see patients for medication management and therapy, shifting important therapeutic work to therapists with less experience and training and potentially diluting the efficacy of psychotherapy. As we seem to go down this slippery path, do we really want to dilute the efficacy of psychotherapy if we have any hope of convincing health care organizations that they should reimburse more for psychotherapeutic treatment?
Efficacy of drugs and psychotherapy
Consider the placebo response rate for children in depression studies. Placebo is often as effective as active medications in the acute treatment of children and adolescents with depression.2-4 Fluoxetine is currently the only SSRI that has consistently shown efficacy for depression in children and adolescents and, therefore, is the only FDA-approved medication for depression in this age group. Instead of being disheartened that the medications do not seem significantly more efficacious than placebo, shouldn't we be asking why placebo works so well?
Furthermore, consider the long-term effects of therapy and medication. Analyses of studies for depression suggest that medication can produce more significant improvement early in treatment. The results of the NIMH-sponsored Treatment for Adolescents With Depression Study confirmed that, with remission rates of 23% (fluoxetine), 16% (CBT), and 17% (placebo). More important, however, was that the superior form of treatment was the combination of CBT-fluoxetine (37% remission). In addition, other study results suggest that in the long term, psychotherapy can surpass medication efficacy.5,6 I am constantly telling patients and residents, "Therapy builds skills that you can keep utilizing, which taking a pill can not duplicate."
There is also an illusion of mastery, at times, in prescribing medication. For residents and psychiatrists, the professional pressure to know what to do and how to "fix" a patient is quite ingrained in our medical training. Residents most often only watch faculty when they are prescribing medication, even if the faculty has an active psychotherapy caseload. Medical training is still an apprenticeship, but the adage "see one, do one, teach one" is difficult to arrange for the practice of teaching psychotherapy.
In addition, prescribing medication can appear to be (and in some cases actually is) easier than psychotherapy. With the well-documented shortage of child and adolescent psychiatrists and long wait lists to see providers compounded with financial concerns, the pressure to do more in less time is enormous for practitioners as well as for health care systems that treat children. Therefore, thinking largely in the biological domain of neurotransmitters, receptors, and brain activity can focus a clinician's thinking to the point that the rich psychosocial aspect of the formulation can be lost.
For example, I recall an instance at the American Academy of Child and Adolescent Psychiatry's national meeting last year in San Diego, when the controversial subject of preschool and prepubertal bipolar disorder was examined during a clinical symposium. What was striking to me (besides the accuracy of the diagnosis of mania in a 4-year-old) was that the researchers were planning on using parent-interactional therapy to treat preschool-aged children with bipolar disorder. Treat a serious brain disorder such as bipolar with therapy? For once I was in agreement-yes, let's consider nonpharmacological management for serious problematic behaviors, especially in children so young.
I don't wish to minimize the obvious distress many families go through with these young children, but to label a child as having bipolar disorder, given our current state of scientific knowledge, leads most psychiatrists firmly down the path of psychotropic medication.
During the same symposium, another researcher discussed the possibility of using medication preemptivelyfor adolescents in whom bipolar disorder has not been diagnosed, if they have subdromal depressive symptoms and a first-degree relative with the disorder. When I asked if any of the researcher's treatment arms included a psychotherapy or psychoeducational component, I was told that perhaps other researchers would conduct such a study. "Where is the majority of the enthusiasm focused in our field today?" I thought. My only answer was "in pharmaceuticals."
Using a comprehensive approach
In conclusion, to clarify why I, a child psychiatrist, use psychotherapy, I would say adamantly that it is because I have this extensive medical training with which I can approach the problem from all directions in a unique manner. Questions about medications and symptoms often lead to fruitful psychotherapeutic moments that we may miss, even when multiple treatment providers are collaborating perfectly. My therapeutic skills and the relationships they engender definitely bring me more professional satisfaction than being seen as "the prescribing doctor."
I struggle, as I believe many clinicians do, with the pressure to help frantic patients and their families, while also doing no harm in the face of limited resources and lacking scientific evidence. In the end, I would rather treat fewer patients, providing the medications and therapy modalities when clinically indicated.
Certainly there will be patients and families for whom perhaps only one modality is necessary, or another treatment provider is necessary, but as specialists, I believe we should treat the most complex cases in the most comprehensive manner available, despite long hours, poor reimbursement rates, and occasional difficult countertransference moments. I know that I would not trade this approach for anything.
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Donnelly CL, Wagner KD, Rynn M, et al. Sertraline in children and adolescents with major depressive disorder.
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Wagner KD, Jonas J, Findling RL et al. A double-blind, randomized, placebo-controlled trial of escitalopram on the treatment of pediatric depression.
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