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Ask Your Peers

In this section, experts in social work, counseling, psychology, and psychiatry answer some of your questions about working with clients on psychotropic medications.

Click on the question you are interested in, and you will be linked to the expert responses.

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Questions

  1. I have an adult client who is socially withdrawn and sometimes makes bizarre statements. He is currently receiving a high dose of an atypical antipsychotic and appears overly-sedated. How do I discuss a dosage reduction with the client? With the prescribing physician? Are there ways I can deal with his withdrawn and unusual behavior other than with medication?

  2. My agency receives most of its program funding from Medicaid, which requires A DSM-IV-TR diagnosis and medication treatment before approving psychotherapy services. How do I circumvent these requirements if my client would prefer not to take medications?

  3. A child under my care has been doing poorly in school, often by being disruptive in class and not obeying his teachers. He received a diagnosis of ADHD about 8 months ago, and is now prescribed multiple medications, including a stimulant and what seems to be a low dose of an atypical antipsychotic. How do I raise my concerns about this medication regimen with the child’s parents? With the prescribing physician? Is there anything that I, his teachers, and his parents can do to help improve his school performance?

  4. I am providing therapy for a young teen who is exhibiting occasional behavioral outbursts and who is refusing to take medication his parents and doctor recommend. How can I best serve this child’s needs and advocate for his rights? How would being forced to take medication against his will affect the psychosocial intervention we are undertaking and his social/interpersonal development? Are there any psychosocial approaches to resolving his outbursts that we could explore?

  5. I am concerned about a client who has a history of alcohol abuse and appears to have developed a dependence on benzodiazepines prescribed for anxiety. She comes from a family with multiple problems including domestic violence, unemployment and substance abuse. How do I raise concerns with the client, and the physician, about the prescription of addictive substances to someone with a history of addiction?

  6. A young woman who is pregnant has been prescribed an SSRI antidepressant and told it will not harm the fetus. I believe the risks have not been fully explained, and besides, the medication seems to be causing her to be more agitated and anxious. Can I legally recommend to this client that she consider (using an appropriate discontinuation protocol) discontinuing use of this medication while she is pregnant and/or breastfeeding? What recommendations can I give to the client for managing her depression while she is off medications?

  7. A child under 12 has complained about the side effects of her medication, but the physician has dismissed both her concerns and my efforts to advocate on her behalf. How can I gain credibility and make sure my voice is heard when I do not have medical training?

  8. I am concerned about the effects of polypharmacy on an adolescent client, but both the client and his parents have a preference for medication treatment. The client appears unmotivated and prefers to watch TV or stay in his room all day. What are my options?

  9. After attempting to discontinue use of an SSRI, a client of mine became severely agitated and unable to concentrate. She also experienced severe digestive distress. The prescribing psychiatrist explained to her that she is still suffering from depression and should continue to take the medication. I believe she is experiencing withdrawal symptoms. How can we sort through conflicting information and help her obtain appropriate counsel so she can successfully discontinue treatment?

  10. In the treatment of schizophrenia, are there acceptable alternatives to medication treatment?

  11. My new client, a 7-year-old boy, has been diagnosed with Bipolar Disorder, because he has been getting into fights with his peers, has screamed at a teacher and cried a few times in school, and his mom says he’s often “out of control” at home. He has been prescribed Depakote and Seroquel. The psychiatrist has told the mother that Bipolar Disorder is a serious brain disease and that if it isn’t treated appropriately now, my client is likely to be very disturbed for many years. He seems disturbed now and I think his living conditions are chaotic, but I’m confused about how one can be so sure about this diagnosis in such a young boy and what treatment alternatives would be acceptable to propose where I work, as most people here would never think of questioning these psychiatric diagnoses and treatments.

Answers to Question 1

Grace E. Jackson, M.D.

The first priority for any mental health professional should be the identification of biological causes for these phenomena.   Psychiatrists are trained to consider and screen for the following conditions: infection (e.g., pneumonia, urinary tract infection, syphilis, hepatitis, HIV, Lyme), intracranial structural defects (brain tumor, brain abscess, arterial-venous malformation, acute or resolving stroke), endocrinopathies (dysregulated glucose, prolactin, cortisol, thyroid hormone), hypoxia-ischemia (cardiovascular or pulmonary disease), demyelinating disease (multiple sclerosis), autoimmune disease (systemic lupus, arthritides), metabolic abnormalities (e.g., anemia),  dietary abnormalities (e.g., thiamine, pyridoxine, folate, cobalamin, zinc, magnesium, calcium, phosphorus, sodium, chloride ) and/or exposure to neurotoxicants (i.e., street drugs, prescription drugs, heavy metals, organophosphates, solvents).

The so-called “atypical” antipsychotics are neither “atypical” nor “antipsychotic.”
Not infrequently, these chemicals induce or enhance bizarre statements (disorganized speech or delusions), social withdrawal (depression), and sedation (encephalopathy), regardless of dose. The processes through which these medications exert destabilizing effects include receptor blockade (D2, ACH, histamine), electrophysiological (depolarization) blockade; direct toxicity (cell death); and induction of other disease processes (pneumonia, diabetes, hypothyroidism, PE).

Prescribing clinicians are largely unaware of these problems. Non-prescribers may be able to assist clients by providing pertinent information to prescribers (an extensive set of peer reviewed journal articles can be downloaded for free from the website of The Law Project for Psychiatric Rights), and by advocating for their clients with family members, schools, employers, and the courts.  Dose reductions may or may not improve troublesome symptoms, but they are often a good place to start. Dose reductions should be conducted gradually and with careful monitoring, unless an immediate health emergency (such as neuroleptic malignant syndrome) demands abrupt cessation.

As for dealing with clients who exhibit withdrawn or bizarre thought processes, language, and/or behaviors, the Pre-Therapy Network (see work of Garry Prouty, PsyD) is a group of international therapists and laypersons who have learned to apply client-centered ideas and techniques in such scenarios. The entire goal of Pre-Therapy is to “make contact” with individuals who are unresponsive to usual forms of communication. Also, the mere act of “being with” a person who is experiencing profound emotional distress can provide great solace.

[See Dan Dorman’s book, Dante’s Cure, for a real-life story of a woman who made a complete recovery from psychosis, and how that journey occurred.]

Stephen Wong, Ph.D.

There are proven psychosocial techniques for modifying psychotic behavior including bizarre verbalizations.  Contrary to common belief, bizarre speech is much like rational behavior in that it is influenced by its environmental consequences.  Bizarre speech that gives a person sought-after attention or that allows him to avoid difficult or tedious tasks will be reinforced by these consequences and will increase in frequency.  Conversely, bizarre speech that prevents a person from obtaining something that he wants or that is consistently ignored will decrease in frequency.  Thus, the general strategy should be to not reward psychotic behavior with extra attention or special consideration, but rather to reserve such favorable treatment for making steps towards or performing normative role expectations.

Another strategy for modifying bizarre speech is to try to uncover the meaning of the speech (i.e., what the person is “asking for”), and to prompt the person to express his needs in a more appropriate manner.  When the client then states his needs in a more acceptable manner it is important to respect the client’s wishes and respond to these more suitably worded requests.  For an example, if a client refuses to get out of bed in the morning and claims that “the poison in my blood is dissolving my bones.”  The caretaker in this situation might discourage the bizarre speech and encourage sensible speech by saying to the client, “It sounds like you are too tired to get up right now.  If you will say, ‘I am too tired to get up now,’ I will give you another 15 minutes to sleep.”  If the client presents the request appropriately, the caretaker would allow the client the additional time in bed, and would return in 15 minutes with more vigorous prompts to get up.

Anthony Martignetti, Ph.D., DAC

Ask how s/he is feeling (e.g., how do you feel as compared with before taking the medication?).  If feeling better, ask if there has been any sacrifice or detriment noticed for the sake of the improvement.  If not feeling better, or feeling worse, inquire further.  Share with the client your honest reaction to what you're noticing. Ask permission to speak with the prescribing physician, and if that's approved, get a signed release to do so (this signed release requirement is a given and so I may not always mention it specifically going forward) and then share your observations with the physician. 

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Answers to Question 2

Grace E. Jackson, M.D.

The decision to accept or decline medication falls within the process of informed consent. No agency or institution has the legal right to impose pharmacotherapy upon a client as a precondition for psychotherapy or any other benefit. In the absence of a life-threatening emergency, involuntary treatment with any medical intervention constitutes assault. If necessary, a situation of this type could and should be litigated. A good source of information on this issue is Jim Gottstein, Esq., the founder of The Law Project for Psychiatric Rights. See  http://psychrights.org/Articles/jgehppv9no2.pdf 

Anthony Martignetti, Ph.D., DAC

Cite the client's preference in your notes and to supervisors. As well, cite the wide world of research comparing and contrasting psychotherapy to psychopharmacological treatment, which, despite strongly opposing forces, demonstrates as very effective (in many studies more so than drugs without the potentially troublesome and dangerous side effects).  Let the agency, and the insurance company, rest assured that if medication becomes required as an important and clinically necessary adjunct or supplement to treatment, and if the client changes stance with respect to medication, then it would be, of course, assessed and considered as a potential addition to the treatment regimen.  In my view, nobody should HAVE to take psychiatric medication as a requirement to treatment. 

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Answers to Question 3

Grace E. Jackson, M.D.

American children who step aboard the “merry go round” of psychopharmacology commonly progress through several stages of treatment:

ADHD >>>  Stimulant
ADHD + dysphoria >>>  stimulant + SSRI
ADHD + bipolar >>>  stimulant + SSRI + Depakote
ADHD + psychotic + bipolar >>>  stimulant + SSRI + Depakote + antipsychotic

Tragically, most physicians have not been trained or encouraged to think rationally about the hazards of monotherapy (let alone polypharmacy) in children. Mental health professionals have an ethical duty to inform parents about the potential lethality of drug combinations. In the scenario described in this question (stimulant plus atypical antipsychotic), the risks include sudden death due to stroke or dysrhythmia; neuroleptic malignant syndrome; tardive phenomena (irreversible movement abnormalities of face, tongue, neck, limbs, trunk); diabetes; and impaired growth.  

The prescribing clinician should be reminded about the irrationality of this particular drug combination. Stimulants are designed to enhance dopamine transmission.  Atypical antipsychotics are intended to block it.   In one sense, the pharmacodynamic effects of stimulants plus antipsychotics would be expected to oppose each other. In another sense, the brain’s adaptations to each class of medication might be synergistic (enhancing the risks of movement abnormalities, dysphoria, and psychosis).  Most importantly, the parents of any child should receive information about the neurotoxic effects of these medications.  In the case of stimulants and antipsychotics, the dangers include the inhibition of neurogenesis and the induction of neurodegenerative changes.

Stephen Wong, Ph.D.

Several things can be done to improve a child’s conduct in school, whether or not he has been diagnosed with ADHD. Teachers and parents can examine the course curriculum to see if it matches the child’s abilities (is neither too hard nor too easy) and ways to make it more interesting for him (e.g., include math problems about favorite players’ statistics and season scores).  The possibility that classmates are teasing the child or encouraging him to act out also should be explored. If the latter situation applies, different seating arrangements or a class reassignment may be required.

Classroom conduct can also be improved by making the child more successful in the classroom. This can be facilitated by home tutoring and by sincere and consistent parental support of the child’s academic pursuits. Finally, token or point systems can be set up to provide positive reinforcement (tokens and points exchangeable for privileges, special activities, and monetary rewards) for attendance and improved performance at school.

Anthony Martignetti, Ph.D., DAC

Ask if the parents are concerned about the effects of the drugs (e.g., long-term effects, any side effects noticed, the impact upon the child’s sense of self, etc.). If they are concerned (or perhaps even if they don't seem to be), it would be a good idea to refer them to literature which discusses potential short and long-term problems (especially the recent studies and analyses of stimulants and anti-psychotics on kids) and alternative remedies. Discuss the diagnostic criteria for ADHD with the parents, and ask if their child is substantially different from other children (especially other boys, since it is still most often boys who receive this diagnosis). Ask if the parents' lives are easier (if so, how), if the child's life is easier (if so, how), if there has been a price they've been paying for their child taking these multiple (and system-shocking drugs), and if they have considered non-medical alternatives (e.g. mind/body connecting/focusing activities such as meditation/yoga for kids, martial arts (especially, for example, Aikido, which is usually quite enjoyable for young boys and girls, and which has no kicks, punches or attack moves yet is incredibly effective as a defense). 

Doctors are tough on this issue, but not all of them. You should already have a physician, whom you know to work with as a referral. Doctors generally have a regimen, with one or two tools, and they stick close to the protocol, often to be safe (on paper). The atypical antipsychotics are, I believe, an attempt at an end run around the antidepressants which have gotten bad press and had some lethal results with the young. Refer to PBS Frontline show “The Medicated Child” for more info (see Module 2 page on this website).

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Answers to Question 4

Grace E. Jackson, M.D.

In one sense, advocating for the rights of a teenager should be no different than advocating for the rights of an adult. Under the U.S. Constitution, all patients have the right to freedom from medical intrusion (freedom of privacy). When medical interventions are delivered without proper, informed consent, they constitute bodily assault. 

Unfortunately, minors lack the legal “right” of self-determination or autonomy.  Children – like adults who lack capacity (competence) for medical decision making – are technically at the mercy of those who act on their behalf. This means that the safety and well being of any child or teen depends upon the ethics and insights of their guardians or the State (courts).

A concerned but respectable minority of health care professionals, educators, and attorneys believe that the “right to decline” mental health screening and treatments —including electroshock, medication, neurosurgery, and/or magnetic stimulation—should be protected for all age groups. A teenager who opposes psychiatric treatment may need to seek the appointment of a new guardian and/or legal representation, in order to be able to assert this right.

As for the management of behavioral outbursts, it would be appropriate to consider the biological, psychological, and socio-cultural determinants and contexts of these events. Particularly in teenagers, it is essential to rule out the potential role of illicit drugs, alcohol, or prescription medications (e.g., anabolic steroids); and the potential toxicity of past exposures (such as heavy metals, food additives, and/or autoimmune changes from multiple vaccines).

Provided that a teenager desires and consents to them, there are many psychosocial approaches to dealing with “outbursts.” These begin with identifying the psychological and sociocultural causes of the events (what does an outburst mean or signal), followed by the fostering of self-control (mind over brain). Approaches might include chi gong, yoga, or time in nature; neurofeedback or biofeedback; nutrition; expressive therapies (art, music, psychodrama); and/or psychotherapies (family systems, group, or individual).

Stephen Wong, Ph.D.

A good way to begin dealing with any behavioral disorder is by examining whether there are adverse or disturbing events that might be precipitating the problem.  Therapists and helpers should explore whether there is turmoil within family, financial difficulties, conflict with peers, physical illness or other conditions troubling the child that can be ameliorated.  Next, therapists and helpers should assess the specific situations in which disruptive outbursts typically occur.  Do they usually involve parental demands that the child views as excessive, unfair, or particularly unpleasant?  If so, it may be possible to negotiate revised demands that are not so objectionable to the child and that will reduce conflict.

Parents should try not to react to emotional outbursts of youth with their own emotional outbursts or punishment.  Parents should view their child’s behavior as an expression of his anger or unhappiness, which needs to be shaped into more mature and constructive forms of communication.  At a later time, when the youth is calm, parents should discuss the issues that trouble the youth and brainstorm solutions.  The youth should be encouraged to suggest acceptable, alternative courses of action and in the future voice those suggestions before an argument or outburst occurs.  When the youth later makes these suggestions it is essential that the parents listen, if they wish to see more mature and controlled behavior from their child.

Anthony Martignetti, Ph.D., DAC

Forcing anyone to take medication for behavioral reasons (especially for “occasional outbursts”) is, to me, a violation of human rights.  As an agent involved in forcing a person to take medications, you undermine any chance of making a deep and trustworthy connection.  In doing so, one becomes part of the huge machine controlling and running the client against his or her will.  It is a way to (re)traumatize the individual.  If the matter is taken out of your hands, as the therapist of record, and medication continues to be a pushed or forced part of the treatment and the parents/doctors win out, I recommend staying with the client (not abandoning him/her in frustration or as a statement to anyone), and being with the client in a compassionate and understanding way, acknowledging that those in bondage seek liberation, and the road to freedom from forced treatment can be worked on, and perhaps worked out together.  Forced psychotherapy or medication should be seen from the point of view of “therapy as punishment” and that is never appropriate. 

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Answers to Question 5

Grace E. Jackson, M.D.

Almost all of the drugs that are prescribed by psychiatrists either sensitize the brain to other addictions (benzos cross-sensitizing to alcohol, stimulants cross-sensitizing to cocaine) or become addictive substances on their own.

For most patients, the use of psychiatric medications ultimately fulfills four of the seven DSM criteria for drug dependence: 1) tolerance; 2) withdrawal; 3) larger amounts consumed, or longer use than intended; and 4) continued substance use despite knowledge of having a persistent problem which is due to that substance.

First, the use of all psychiatric medications is commonly accompanied by habituation or “tolerance.” As the brain adapts to the presence of drug treatment, the efficacy of the initial dosing dissipates. It is for this reason that almost all patients return to their doctors, only to have their doses increased over time. Second, the interruption or cessation of psychoactive drugs almost always results in withdrawal or rebound symptoms (such as: insomnia, headache, irritability, diarrhea, tingling, tiredness). Third, many patients find that they are unable to tolerate these withdrawal symptoms. This results in chronic or maintenance therapy which lasts much longer than originally intended. Fourth, medicated patients find themselves continuing psychiatric drugs despite the fact that these treatments are the cause of significant suffering and disability (impaired judgment when driving, insomnia, sexual dysfunction, impulsivity).

What about benzodiazepine use by patients who have histories of alcohol abuse?  Textbooks of pharmacology and drug labels specifically warn physicians about the importance of avoiding benzodiazepines in previous alcoholics, for two reasons:
1) to avoid re-kindling the previous compulsion to drink alcohol; 2) to avoid “hooking” the patient on the alcohol-substitute.

Ultimately, a client must be given an accurate or “authentically” informed consent to care. This requires truthful information about the potential for prescription medications (no less than street drugs) to induce long term chemical dependency and degenerative changes in the brain.

Anthony Martignetti, Ph.D., DAC

A distinction must be made with respect to the “drug of choice.”  There are individuals who use and abuse alcohol, but are not inclined to do the same with benzodiazepines or other drugs. You must also define and determine what is meant by “dependence.” If 0.5mg of Ativan becomes a “habit” for sleep, that may not be so bad even though the individual is “dependent” on it for sleep. If you notice escalation of use, and habituation to greater doses for the same effect, then concerns should be raised with the client and with the prescribing physician (always with permission, of course). Along with the prescribed (and perhaps temporarily necessary) use of tranquilizers, alternatives should be investigated by the client (meditation, yoga, aerobic exercise, possible chemical alternatives such as melatonin, valerian root, Kava-Kava). These alternatives are often outside of the realm of the therapist’s area of knowledge, but complementary therapists—such as chiropractors, acupuncturists, Naturopaths, herbalists, etc.—are often good resources for both the client and therapist to learn about what's available and the risks/rewards related to use of these alternatives.  Some physicians are, of course, knowledgeable in the use of these alternatives as well. Dr. Andrew Weil's website (www.DrWeil.com) is a good source, as are his numerous books.

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Answers to Question 6

Grace E. Jackson, M.D.

If a young woman has been informed that an SSRI will not harm the fetus, then she has been misinformed. Research in non-human animal species and epidemiological human studies suggest that SSRIs pose direct and indirect risks to the embryo and fetus—especially to the formation of the brain, heart, and craniofacial skeleton. Because SSRIs pass through the placenta, they may exert toxic effects directly by inhibiting or accelerating the process of apoptosis (programmed cell death). Alternatively, SSRIs may exert toxic effects indirectly by disrupting maternal levels of serotonin and other hormones (including prolactin, thyroid hormone, and glucose), all of which participate in the development of the unborn child.

For humans, the long-term risks of prenatal or neonatal exposure to SSRIs remain uncharacterized. However, it should concern medical professionals that research in rodents has repeatedly and consistently revealed a link between early exposure to serotonin reuptake inhibitors and the emergence of potentially long-lasting decrements in learning, memory, and emotion (e.g., abnormal responses to fear-producing stimuli, diminished capacity for nurturance and attachment, and depression). According to the “precautionary principle,” it is entirely appropriate to advise clients that SSRIs should be avoided before, during, and after pregnancy in order to avoid known and presumptive risks of structural and functional deficits.

Stephen Wong, Ph.D.

Although many young mothers-to-be are ecstatic about their pregnancy, other women may be overwhelmed with anxieties about their new responsibilities, the loss of personal freedom and adventure, financial burdens, changes in the mother’s relationship with her partner, and other issues.  The young mother-to-be may benefit from discussing these challenges with other people, such as young and older mothers who have successfully dealt with these matters.  Establishing a network of family and friends who can give advice, occasionally assist with childcare and domestic duties, and offer other forms of support can raise the morale of young mothers.

For a young mother who is already experiencing depression, the above support should be provided while therapists and helpers assist the young woman to re-establish her functional routines. Women who are depressed can be helped to overcome their low affect and inertia by encouraging them to gradually resume their rewarding and stimulating activities (e.g., socializing with friends, shopping, cleaning house). Small steps towards assuming former responsibilities should be enthusiastically recognized and praised. As the women become re-involved in their former socialization, recreation, and work patterns they should be urged to paying close attention to their mood and affect, which will usually improve as their activity increases in quantity and variety.

Anthony Martignetti, Ph.D., DAC

You are, in my view, ethically obliged to make your thoughts and concerns known about her seeming anxious and agitated, and to urge her to investigate alternatives for her sake and the sake of the unborn child.  Recommend she speak with the prescriber and offer to do so as well. However, as far as I know, if you do not have prescriptive privileges, you cannot put someone on, nor take someone off, medication. 

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Answers to Question 7

Grace E. Jackson, M.D.

All mental health professionals can serve as client advocates by recognizing, recording, and reporting medication side effects. They can also encourage their clients, and/or clients’ guardians, to maintain a diary or daily log of adverse drug effects. (This is especially important in the era of the 15-minute “med check.”) Particularly for young children who lack the language skills and insights of adults, the observations of non-prescribing members of the treatment team may provide potentially lifesaving information that would otherwise be overlooked or ignored.

Anthony Martignetti, Ph.D., DAC

You are trained to listen to the experience of others.  Trust that.  You are trained to believe (and sometimes disbelieve) what is communicated by those you treat.  Listen deeply.  Kids are usually not going to lie about those kinds of experiences.  Adults are not as trustworthy for lots of reasons.  Kids tell you what they feel (especially bodily) and you can let the child know that you are definitely listening, plan to make her/his feelings known, and then insist, insist, insist that, as a trusted advocate, and perhaps the only voice for this kid, that the medication therapy be investigated and reevaluated.  The only people you'll scare away with your insistence are bad treaters. Also, refer to the Rebecca Riley case from Hull, Massachusetts (a four-year-old girl who was given a diagnosis of Bipolar Diosrder and who died from an overdose of psychiatric medications).

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Answers to Question 8

Grace E. Jackson, M.D.

In the present era of medicine, most psychiatric drugs are dispensed to patients by a changing panel of primary care clinicians. Even when patients are referred to psychiatric specialists, however, the care which they receive is typically limited to short “med checks” delivered at infrequent intervals (e.g., every three to six months). It is within this climate of medical care that the use of drug combinations—otherwise known as “polypharmacy”—has become the exception, rather than the rule.

Polypharmacy arises for many reasons. In some cases, prescribers may be following medication algorithms or “clinical pathways” which specifically promote the use of
drug cocktails. For example, when addressing the drug treatment of manic-depression or bipolar disorder, textbooks of psychopharmacology recommend the concomitant use of a benzodiazepine, an anticonvulsant, and an antipsychotic drug. In other cases, prescribers add new chemicals in an attempt to alleviate the side effects caused by previous treatments.

Children, teenagers, and their guardians should be educated about the difference between rational and irrational polypharmacy. In the former case, the prescribing clinician carefully considers the pharmacodynamic, pharmacokinetic, and unique biological factors which arise from the use of multiple agents. In the latter case, the prescriber piles on drugs in response to diagnostic labels—generally, without regard for pharmacological and physiological effects. Because of the fact that irrational polypharmacy is often ineffective and sometimes lethal, a client should always be encouraged to seek treatment from a professional who is capable of considering: 1) pharmacodynamic features; 2) pharmacokinetic features (including cytochrome P450 and UGT effects); and 3) unique biological factors (e.g., age, diet, habits, body size, renal/hepatic function) in his or her own case.

Stephen Wong, Ph.D.

An adolescent receiving multiple medications with a pattern of inactivity and reclusiveness should be referred to his physician for possible over sedation or adverse drug interactions.  While these medical questions are being investigated it would be worthwhile to examine the youth’s interests and motivation to see what might draw the client out of his room.  What sorts of things does the adolescent like to do or liked doing in the past?  How can these activities be made available to the client and how can he be encouraged to become involved with them?  Are there new activities that the youth might become interested in if he is introduced to them?  What are the adolescent’s expected responsibilities within the home (e.g., household chores, homework, eating meals with family)?  Is the youth fulfilling these responsibilities before he is allowed to retreat to his room to watch TV?  Is the amount of time allowed for watching TV excessive and should his parents simply restrict use of the TV to a couple of hours per day?  Answers to these questions may suggest helpful options.

Anthony Martignetti, Ph.D., DAC

If the client and parents prefer medication treatment, you need to be sure about whose bias is being supported and whose needs are being met.  You don't want to assert your own either.  Many adolescents (obviously not all, otherwise they wouldn't have their well-earned reputation as rebellious pains-in-the-neck) take on the belief systems of their parents (such is the case with religious beliefs, world views, thoughts about gender roles, races of people, other cultures, etc.).  You can ask how informed the parents are about side effects and alternatives to medication treatment.  You can supply them with, or direct them to, such information all the while monitoring your own countertranference (as always) with the help of supervisors and trusted co-workers. 

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Answers to Question 9

Grace E. Jackson, M.D.

Because of the fact that the continued use of all SSRIs leads to adaptations within the brain, the discontinuation of these drugs also results in compensatory brain changes.  Some writers distinguish between “drug rebound” – referring to the return or worsening of initial symptoms; and “drug withdrawal”—referring to the emergence of brand new signs or symptoms. For example, when patients stop taking SSRIs, common symptoms include headache, insomnia, nervousness, dizziness, diarrhea, numbness, and dysphoria (low mood).

In my own clinical work and research experience, I believe that it may be useful to conceptualize “drug discontinuation phenomena” in terms of three phases.  First, there is an acute period involving the elimination of the drug from the bloodstream and brain. Most doctors fail to appreciate something which is known as the “brain:plasma” dissociation for pharmacokinetics. What this means is that many psychiatric drugs depart the brain more slowly than they clear the bloodstream. This fact leads many physicians to under-estimate the duration of acute drug withdrawal or drug rebound.

Next, there is a period of recalibration within the brain. During this time, the central nervous system undergoes changes in receptor sensitivity, receptor availability, and intracellular signaling cascades. This process may also last for many weeks.

Finally, there is a chronic period of neuro-rehabilitation. If successful, this final interval (hopefully) involves changes in cell-cell connections, protein synthesis, membrane composition, myelination, and mitochondrial function. These changes can only occur in the sustained absence of the previous neurotoxicant(s).

Textbooks of pharmacology, residency programs, and CME materials do not train physicians to appreciate the fact that these three phases may persist for months. The result is that patients who experience discontinuation symptoms are often misdiagnosed with relapsing or recurring “illnesses” for which lifelong drug therapy is prematurely and wrongly recommended.

Non-prescribers can advocate for their clients by educating them about the complex and highly variable nature of these changes; and by assisting other professionals in properly identifying withdrawal or rebound symptoms when they occur. In some cases, it may be necessary to briefly resume trials of pharmacotherapy before pursuing a gradual and carefully monitored drug taper.

Anthony Martignetti, Ph.D., DAC

We don't know what is going on.  Yet.  But the rapid (unmonitored) discontinuation of those types of medications can lead to a kind of rebound effect often regarded by treaters (and patients) as the resurgence of symptoms.  She and you should go to her doctor and discuss the possibility of a rebound, and advocate for her to wean off the medication with the doctor’s supervised conservative regimen. If symptoms emerge and persist after that, then other choices should be made.  Also, digestive distress can have a number of etiologies.  We need to take all those kinds of symptoms seriously.  We don't know what's going on yet, remember? 

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Answers to Question 10

Grace E. Jackson, M.D.

There are many alternatives to medication for psychotic symptoms. The website of the Law Project for Psychiatric Rights contains many articles which describe the benefits and success rates of drug-free approaches. Also, Dr. Dan Dorman’s book – Dante’s Cure –is a compelling, real-life story about a woman who made a complete recovery from the symptoms of schizophrenia. See also:
http://psychrights.org/States/Alaska/CaseXX/3AN-08-493PS/JacksonOnNLtoxicity.pdf
http://psychrights.org/States/Alaska/CaseXX/3AN-08-493PS/AffidavitRWhitaker.pdf

Anthony Martignetti, Ph.D., DAC

People have discussed healing psychotic states through relationship(s) for a long time right up to fairly modern times (e.g. R.D. Laing, Anton Boisen, Thomas Szasz), and so have many other wonderful and interesting clinicians and writers, many of them from times when psychiatric medication was essentially non-existent. There are ways of seeing the schizophrenic cluster of symptoms as a “psycho-spiritual” crisis, something that could be worked through. Working through such a crisis would take superior skills on the part of the clinician, and a lot of money and time.  So, as far as acceptable alternatives, there aren’t many. But there are brief psychotic episodes, there are signs, which mimic psychotic states, there are individuals who choose not to take medication and instead work with therapists. There are functioning professionals in every field who carry the diagnosis, many of whom never took or no longer take meds. Many people who carry a schizophrenic diagnosis live in and/or with supportive families. The healing power of relationship is enormous.  But as for an “acceptable” alternative, acceptable to whom is really the first question to ask. 

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Answers to Question 11

Grace E. Jackson, M.D.

The phenomenon of “childhood bipolar disorder” is a relatively new (and predominantly American) development. Notwithstanding the ambiguity which surrounds the use and meaningfulness of the term “bipolar” when applied to adults, the notion of manic-depression in infants, toddlers, children, and teenagers has attracted appropriate criticism from pediatricians and psychiatrists alike:

http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/06/19/misguided_standards_of_care/
http://medicine.plosjournals.org/perlserv?request=get-document&doi=10.1371/journal.pmed.0030185

Because of the fact that bipolar disorder has been conceptualized by biological psychiatrists as a lifelong condition which requires the use of polypharmacy, many concerned professionals understand that the application of this label to young children almost always results in chronic therapy with potent chemotherapies. Resultingly, they believe that it is ethically and scientifically imperative to challenge both the use of the bipolar label and its associated neurotoxicants in this age group.

Anthony Martignetti, Ph.D., DAC

I believe the diagnosis is premature, as you describe it.  We are living a socio-cultural phenomenon where acting up (as children are bound to do) is now seen as pathology, thanks to an odd mix of “appropriate” behavioral requirements, and an aggression-averse culture where everyone has to be a winner. Our culture has turned everything from shouting, pushing, even crying, into a “brain disease.”  Now, ordinary adolescent rebelliousness can be viewed as a mental illness in some of our more educated, wealthy and “enlightened” communities.  I think it is a travesty to treat this boy with the medication cocktail described and to label him as a “brain-diseased,” mentally ill being. This child may live (as you suggest) in an environment where his behavior could actually be adaptive, where the way he's acting may be a kind of creative and successful way to bear the unbearable.  He should be seen in context, not as a set of symptoms or as a labeled entity. Labels are for jars. Only when accurately and thoughtfully arrived at, can diagnostic labels guide effective treatment).

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