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by Gertrude Carter, MSW and Jeffrey Winseman,
MD, Bennington College
December 2002
Foreword
Treating the emotional problems of children with medications
is increasing as a principal component of contemporary mental
health care. That is the reason we included "An Introduction
to Pediatric Psychopharmacology" by Sandra DeJong, MD,
in this web site section.
Yet it would be a disservice to our readers if we failed
to provide an alternative point of view. In the "Illusion
of Certainty," Gertrude Carter, MSW, BS/RN, Director
of Psychological Services for Students and Jeffrey Winseman,
MD, Medical Director of Health and Psychological Services at
Bennington College, Vermont, raise questions about the
increase in the use of psychotropic medications. The authors
make a number of observations that may be of interest to
both pediatricians and parents.
- They are concerned that an increasing number of students
are coming to college mental health clinics for prescription
refills only. They note that the prescribing of psychotropic
medications, without adequate psychosocial diagnostic mental
health evaluations or counseling, is becoming an accepted
standard of care even though such "medications are
most effective when used in conjunction with psychotherapy."
- They point out that a "medication only" approach may not acknowledge these young people's increased
capacity for self-examination, for critical thinking, and
for developing personal responsibility for their emotional
lives. Bennington clinicians provide students with a professional
relationship, which gives students the opportunity and the
time to "understand the complexities of their development
and life experiences."
- They observe that adequate justification for the use of
these medications is sometimes lacking upon review of
students' medical histories. The authors note, "We live in a
culture that loves a quick fix, seeing a myriad of daily
visual images that portray a utopian existence without the
blemish of ambivalence or struggle." The writers suggest
that medications may not always be in the best interest of
the child, and propose an alternative approach that respects
the students' abilities to work at understanding their life
stories, helping them make "responsible, independent
decisions about their health and their lives."
- Howard King, MD
The Illusion of Certainty
College mental health clinicians have witnessed a steadily
increasing number of students who present for the sole purpose
of refilling prescriptions for psychotropic medications. Many
of these students tell us they are not interested in working
towards an understanding of their lives, asking only that
their medication regimes be continued or adjusted. Students
often want medications refilled but arrive without medical
records. When we have successfully obtained records
of students' mental health histories, they are frequently
incomplete. Diagnostic, psychosocial, psychological and psychiatric
evaluations are either absent or insufficient. Ongoing treatment
plans are not discussed or recorded. Prescriptions for psychiatric
medications are maintained over a decade while psychotherapeutic
interventions remain brief and intermittent.
These fractured interactions with caregivers seem to mirror
the student's past inconsistent interactions with caretakers.
Their need to restore and strengthen interpersonal relationships
is not recognized in the effort to control symptoms with medication.
The message is, "If you are to remain stable emotionally
and attain academic success, stay on medications to handle
all problems."
What does it mean when medical caregivers reject the complexity
of all of the factors contributing to a student's problems,
embracing the idea that "pills are sufficient"?
Psychotropic medications, which were once only tentative forays
into the neurobiology of mental disorders, have for many become
the treatment of choice for psychological problems. Developed
as a therapeutic tool for psychiatrists in the early part
of the twentieth century, these medications are now most frequently
prescribed by family physicians, nurse practitioners and physician's
assistants, who do not have expertise in the field of mental
health. This approach, what Claridge and Healy (1994) have
termed the "psychopharmacology of individual differences,"
has gradually replaced the more traditional, thorough examination
of patients.
A triumvirate of mental health professionals (psychiatrist,
psychologist and social worker) used to evaluate a patient's
mental functioning, establishing a diagnosis. The diagnosis
took into account the patient's symptoms, feelings and intrapsychic
configurations as well as the interpersonal dynamics of the
family, school or work environment. Once the evaluation was
complete, the team would recommend a highly individualized
treatment plan. Any prescription of medication was accompanied
by recommendations for psychotherapy and necessary changes
in the patient's environment.
The prescription of one or more psychotropic medications
without accompanying psychotherapy or social interventions
has become an accepted standard of psychiatric care. Pharmaceutical
industrialization (Eichenwald and Kolata, 1999) and powerful
corporate health care organizations have helped to set this
standard. Clinical and empirical evidence, however, indicates
that medications are most effective when used in conjunction
with psychotherapy (Elkin et al., 1989). Despite these findings,
Kaiser Permanente, one of the first HMOs, recently published
guidelines for the treatment of depression (1998) which suggested
that psychotherapy be recommended only after two consecutive
trials of antidepressant medication have failed. Thorough
psychosocial evaluations and multidimensional treatment plans
have been set aside because they are considered too expensive
and too time-consuming. As the nature vs. nurture
debate increases in complexity, mental health professionals
are encouraged to simplify their conceptualization of the
diagnosis and treatment of mental illness. Our attention to
the intrapsychic world diminishes just as we are faced with
an increasing demand for relief from psychological pain in
an increasingly complex society. Perhaps this trend is not
surprising, for we also live in a culture that loves a quick
fix, seeing in a myriad of daily visual images a utopian existence
without the blemish of ambivalence or struggle.
College clinicians are particularly aware of the burgeoning
problems associated with the medication Ritalin. Its use and
abuse as a recreational and "study" drug is up on
all campuses. The abuse of this medication was first noted
in New England preparatory schools, according to Dr. Heligenstein,
the head of psychiatry at the University of Wisconsin Health
Services, where "access is easy because so many students
have prescriptions, often not warranted by medical need."
The Drug Enforcement Administration (1990) classifies this
psycho-stimulant medication as a Schedule II substance. These
substances include amphetamines (of which Ritalin is a derivative),
cocaine, morphine, opium, and barbiturates. While Ritalin
is more stringently regulated in other countries, Americans
use five times as much Ritalin as the rest of the world (International
Narcotics Control Board Annual Report, 1999). The United Nations
has advised the World Health Organization to investigate the
phenomenon of Ritalin use in the United States and, similarly,
the International Narcotics Control Board has issued multiple
warnings about America's dependence on this drug (INCB Annual
Report, 1999). The prescription of Ritalin for children continues
to increase despite these warnings. Simultaneously, the list
of possible disorders for which Ritalin is proposed as a potential
cure continues to grow.
To further illustrate this problem, consider our experience
with Norvartis, the manufacturer of Ritalin. We asked the
company to send us a representative to speak to us about the
drug, and to discuss current protocols for tracking the abuses
of this medication and typical courses of treatment. We were
particularly interested in the problems and successes with
students who take this medication, on college campuses and
in boarding schools. After two months of telephoning, the
company representative told us, by telephone, that Novartis
had made a decision "not to promote Ritalin" and
that information on these topics was not available. Such a
response was puzzling coming from a company that is making
a fortune from prescriptions of this Class II substance, primarily
for children, the majority of whom are students.
The scientific community remains perplexed about the potential
hazards of this medication. Some researchers consider amphetamine
derivatives "gateway drugs," drugs that make the
brain more susceptible to the addictive power of drugs like
cocaine and other forms of speed. Articles debating the risk
of habitual use of psychostimulants in children diagnosed
with Attention Deficit Hyperactivity Disorder (ADHD) report
contradictory results. For example, one group (Lambert and
Hartsough, 1998), linked Ritalin use in children and adolescents
with the onset of substance abuse disorders in adulthood.
Another group (Biederman, et al., 1999) found its
use to be an effective protection against the development
of substance abuse disorders in adult life. The proliferation
of psycho-stimulant medications is of concern to both researchers
and clinicians, but attempts to tease out useful conclusions
regarding these medications are difficult. Confusion over
the evidence supporting or disputing biological treatments
which are poorly and often insufficiently proven or even explained
(Healy, 1997) contributes to the widening rift between caregivers,
the public and researchers. Unmanageable tensions between
mental health clinicians who support categorically-based diagnoses
and psychopharmacological interventions on the one hand, and
those who subscribe to multidimensional diagnoses and longer
term, in-depth treatments, such as psychoanalytic psychotherapy
on the other, make this dilemma particularly difficult for
students in need of psychological care.
Psychodynamic psychiatrists and psychotherapists on college
mental health services can correct the prevailing trend toward
the use only of psychotropic medications without concurrent
psychotherapy. To assume that ancient and complicated tensions
between concepts of mind and body have been resolved diverts
attention away from the richness and interaction of all aspects
of mental activity and life experience. As the array of medications
available to students from health care professionals and pharmacies
on-line increases, college clinicians are pressed to meet
increasingly distorted expectations. Some students arrive
on campus with abundant supplies of medication with no encouragement
to contact a college-based treatment team. Many students come
to college health services requesting refills for their medications,
anticipating no contact with a mental health provider. Others
come in requesting Ritalin, with the specific intent of improving
"their ability to study." Can mental health professionals
on a college campus address the confusion regarding diagnosis
and treatment? How can they stem the tide of a burgeoning
pharmacopoeia of drugs?
An Internet survey of campus health services illustrates
some colleges' attempts to address these questions. Most problematic
were those students requesting amphetamines for a presumed
diagnosis of ADHD (the most frequent diagnosis associated
with amphetamine-like prescriptions). The health service at
the University of Kansas established a battery of tests to
tighten diagnostic criteria for ADHD. Tulane University created
an ADHD Task Force and tried over the last year to establish
a standardized diagnostic procedure. Though the use of tools
such as psychological tests remains controversial, Tulane
researchers, too, have turned to batteries of tests reviewed
by a psychiatrist who interviewed the student initially, and
when appropriate, makes the diagnosis.
Most schools, however, do not have staffing that allows for
a careful and conservative approach to this problem. At one
school, once stabilized on medication (Ritalin, Dexedrine,
or Adderall), the students see a psychiatric nurse. She continues
to review side effects. At the end of the term, the students
present their grades, and if the grades are satisfactory,
they remain on their medication. The nurse described this
procedure as "the efficacy of treatment." Another
school has the staff physician follow the students on medications,
requiring phone contact each month, maintaining the prescriptions
which are picked up without a face to face appointment. The
physician sees the students early in each semester, requiring
one visit per semester for students who are suffering from
anxiety and depression. He stated that these medications make
the students able to study more effectively, and indicated
that this approach helps fulfill the educational mission of
the institution because students are able to study.
Mental health clinicians at Bennington College subscribe
to a different mission. Our goal is not just to help students
study well. We understand that adolescents arrive in a college
community simultaneously struggling with their own unique
individual, family and interpersonal tensions, as well as
rapidly developing institutional, cultural and political undercurrents.
Students arrive on campus with their own unique attitudes
about psychopharmacology and psychotherapy. College clinicians
also have their own beliefs about optimal care. Both are affected
by the policies and standards endorsed by their particular
college communities, which are in turn shaped by accommodations
and resistances to the continual fluctuations of sociopolitical
tides. We encourage students to understand the complex themes
affecting their psychological lives, particularly when their
previous experiences in the medical community have led them
to expect that caregivers will give them prescriptions on
demand after fifteen-minute meetings with the college nurse
or physician. We discourage professionals from viewing medication
management as their only function. For not only can college
therapists and physicians encourage debate and reflection
on our culture's over-reliance on medication, they can provide
students with a therapeutic relationship in which they can
work to understand their complicated pasts (disintegrated
family lives, inadequate schooling, fractured communities).
When students arrive on our campus, they are often for the
first time responsible for managing and organizing their time
as well as pacing their interpersonal lives, their sleep,
exercise, eating and work habits. Students who request medicine
for problems in these areas often discount their own ability
to begin to modulate the rhythms of their lives. Prescribing
medications when these elements have become disturbed (for
example, disrupted sleep due to college life), without consideration
of the personal meaning and context of these disturbances
(e.g., the effects of living in the particular college
environment), does not encourage self-reflection or responsible
self-regulation. A "medication only" approach fails
to encourage the hallmark of late adolescent development,
the dramatic increase in capacity for self-examination and
ability to think critically, the development of responsibility
for one's self.
Physicians and other professionals who maintain a laissez-faire
stance about prescription medications give students the message
that they cannot handle the complexities of their inner worlds
without pills or other substances. This dovetails the attitudes
of students who are experimenting with all sorts of substances,
and is especially problematic for those students who experiment
heavily with alcohol and other drugs. By taking a conservative
approach toward medication and substances, campus-based clinicians
can address students' personal use of substances more effectively.
Students are exquisitely sensitive to current social standards,
and are prone to meld their own attitudes and resistances
from those of the larger society. When substance abuse and
prescription medication treatments are present in the clinical
picture, the difficulty in determining the cause of symptoms
and effecting change in these students' lives is formidable.
To intelligently interpret the problems presented by the
numbers of students who arrive on campus with prior treatment
histories, our clinicians recognize the usefulness of medication,
and maintain a view that is respectful of the complexity
of late adolescent development. This requires a review of
students' medical histories, contact with students' previous
caregivers and, when appropriate, contact with their parents
in order to clarify the history of the problem and rationale(s)
for treatment. On campus, we require an initial evaluation
of the student. When students are on psychotropic medications,
they meet with our psychiatrist for a thorough evaluation.
We do not refill medications in fifteen-minute sessions. We
encourage all students who are on medication to enter or continue
psychotherapy. We take this position out of respect for our
students' abilities to begin to piece together their life
stories and to encourage responsible decisions about their
health. We hope to help students establish a basis for questioning
current societal values, for analyzing the biological determinacy
so blithely accepted in current models of mental health care
and, more importantly, to ask the broader questions of the
possible meanings in life and one's own responsibility to
live it thoughtfully.
The process of personal discovery and change, so important
in adolescent development, is in danger of being lost within
a medical model devoid of the richness of life histories,
conflicting motivations, and interpersonal experience. Such
a loss affects us all, for the tasks of late adolescence are
complex and varied, exhilarating and frightening, and filled
with the promise of self-assurance and doubt. We are keenly
interested in helping students understand these developmental
tasks: the striving for autonomy in the midst of longings
for dependency, identity integration in the midst of confusion,
and the reorganization and consolidation of a new sense of
self intellectually, emotionally, and socially. While we appreciate
the advancements in neurobiology, we continue to consider
the complexities of the mind and its interactions with the
environment. For if we respond to our students' psychological
pain in purely biological terms, we exclude the potential
for change through understanding important meanings
of our experiences, and cement further the false belief that
pills are the only effective means to healing and change.
References
Biederman J, Wilens T, Mick E (1999). Pharmacotherapy
of attention deficit hyperactivity disorder reduces risk for
substance use disorder. Pediatrics 104: 20-25.
Claridge G and Healy D (1994). The psychopharmacology
of individual differences. Human Psychopharmacology 9:
285-298.
Eichenwald K and Kolata G (1999). Drug Trials Hide Conflicts
for Doctors. The New York Times: May 16, 1999.
Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins
JF, GlassDR, Pilkonis PA, Leber WR, Docherty JP, Fiester SJ,
Parlof MB (1989). NIMH treatment of depression collaborative
research program: General effectiveness of treatments.
Archives of General Psychiatry 46: 971-982.
Healy D (1997). The antidepressant era. Cambridge,
MA: Harvard Univ Press.
International Narcotics Control Board (1999). Annual
Report. United Nations Information Service, 23 Feb 1999,
Release No. 4.
Kaiser Permanente (1998). Adult depression services and
resource guide. In: Depression identification and
treatment in adult primary care. Clinical Practice Guidelines,
second edition. Kaiser Permanente.
Lambert NM , Hartsough CS. Prospective study of tobacco
smoking and substance dependence among samples of ADHD and
non-ADHD subjects. J Learn Disabil 1998: 31: 533-44.
United States Department of Justice Drug Enforcement Administration
(1990). Physician's manual: An informational outline of
the controlled substances act of 1970, sixth edition.
Washington, D.C.: United States Department of Justice Drug
Enforcement Agency.
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