As a pediatric psychiatrist, I’m in a privileged position as the “expert” when it comes to the mental well-being of another person’s child. Yet here was a parent in my office with their bright, school-aged child, facing the challenge of explosive behaviors at home and at school in response to provoked anxiety. If it were my child, of course I would give them a drug to alleviate their distress and reduce these behaviors, wouldn’t I?
I had suggested they consider an antidepressant to reduce the reactivity. Silently, however, I wasn’t sure. Probably because of my own complicated history with psychiatric drugs that began when I was 16.
Like many of my teen patients, I was a ruminator, an all-or-nothing type thinker, perfectionistic, and self-critical. A surefire setup for depression. My parents enrolled me in weekly therapy and a primary care physician started me on 60 milligrams of fluoxetine. I continued the drug into college when I eventually self-discontinued but by then my environment had significantly changed. I’d matured, was surrounded by a community of supportive individuals, active in collegiate athletics, and absorbing vitamin D in Southern California where I resided.
Did fluoxetine facilitate all that?
I’m not sure. I was tired — a lot, and had adopted a socially acceptable, highly caffeinated lifestyle yet still fought to stay awake when seated for more than 15 minutes. I also perspired — a lot. The wet shirt stains that circled to my waist caused panic-inducing social mortification. Only decades later, during my psychiatric training and listening to patients, did I realize that fluoxetine can make people very tired and induce hyperhidrosis. As a patient, I hadn’t been asked about side effects or if I wanted to discontinue.
Probably more so than being asked, “What would you do if this were your child?” I get asked about the long-term harms, an equally difficult question to answer. “I don’t know,” I have to say. Evidence on long-term harms of antidepressants in adolescents remains limited, with most data derived from observational studies and adult populations. However, some research suggests potential concerns, including reduced bone mineral density during critical developmental periods, possible endocrine and metabolic effects, and reports of persistent sexual dysfunction following discontinuation. These risks remain incompletely understood, in part due to the methodological and ethical challenges of studying long-term outcomes in youth. As I had one parent tell me, “I don’t want my kid to hate me someday for putting them on a drug they can never get off of.”
In residency, I began to listen to well-respected psychiatrists who questioned the politics of medicine and their relationship with the pharmaceutical industry, reading books like "Unhinged," and I studied mental health systems in other countries, having a particular interest in Finland’s open-dialogue model. I even grew critical of the language we use. Can I truly call an antidepressant a medication? The definition of medication is a substance that prevents, treats, or cures a disease. A drug is something that alters one’s mood, thoughts, or behaviors. In psychiatry, we have no objective tests, only checklists of symptoms that we collate into a diagnosis. But because symptoms overlap so significantly in our myriad diagnoses, patients and clinicians feel frustrated and stuck when seeking pharmacologic interventions.
This doesn’t render psychiatry as a specialty less valid or lifesaving, or negate the usefulness of drugs. It only challenges me to have honest conversations with families and patients. No small feat for pediatricians, who are the front door for the majority of mental health management in children. Strapped for time, training, and resources, and pressured by distressed families, they prescribe the majority of psychiatric drugs. And then they are left grappling with how to manage side effects, questions, adverse outcomes, and the discontinuation of them.
My first year as an attending on a child and adolescent inpatient psychiatric unit, controversial meta-analyses began emerging that antidepressants for adolescents were likely no better than placebo. Some argue these studies did not include individuals most at risk, those with self-harm and suicide, and that even so, we should harness the placebo effect. Also, isn’t there an inherent risk not prescribing something?
Conflicted, I recall asking my colleague if he would continue prescribing antidepressants knowing this data. “Of course,” he said. I’m guessing because he had experienced what I did years later in my outpatient office: parents returning after I’d placed their child on an antidepressant, thanking me and saying, “I have my child back!”
However, I can count an equal number of these responses:
“This is terrible, they’re so agitated.”
“I don’t think it’s doing anything.”
“I thought it was helping, now it’s clearly not.”
“I’m worried they are now thinking about suicide more.”
And the most difficult dilemma: “It’s obvious they need it to function.”
There is a difference between needing a drug and finding relief from a drug. Our brains are not deficient in certain levels of neurochemicals, that if we just find the right medication to balance it all will be well. This message was largely a marketing gimmick.
Instead of restoring an imbalance, psychiatric drugs modulate the signals of neurotransmitters, either through activation or inhibition, resulting in a psychoactive effect. Most psychiatric drugs suppress emotions or thoughts. I likely experienced this as a desirable effect when taking fluoxetine. It’s not that my ruminations disappeared; I simply became less interested in them. However, like the gas pedal of a car, when pressed by exogenous or unnatural amounts of neurotransmitters, it boosts the amount in the brain, and we are hardwired to push the brake when something external is introduced, eventually adapting.
This is why discontinuing a drug often mimics the very same symptoms that the drug was initially prescribed to alleviate, leading to the erroneous conclusion the individual has always needed the drug.
How do we determine the difference? Especially in children who don’t often have the capacity to explain? The first clue is to determine whether the symptom existed prior to initiating the drug. If someone is experiencing agitation, akathisia, feeling physically ill, it’s likely they were not prescribed the drug to alleviate those symptoms. It can be much trickier if they are mostly psychological symptoms: irritability, poor concentration, dysphoria, tearfulness. Ultimately, the key is patience. If the individual is safe from harming themselves or others, sometimes it’s a matter of weathering the storm much like weathering an awful and prolonged bout of the flu. It can be a slow and creative process based on an individual’s unique genetic makeup and the proportion of receptors that were occupied by the drug. Sometimes removing half or even a majority of the dosing doesn’t tip the receptor occupancy until reaching extremely low levels of dosing. Other times, the reduction needs to be accomplished in micro amounts, allowing the receptors to regenerate after being downregulated for so long. This is where compounding pharmacies are key, or one can utilize dissolving strategies, or counting beads in capsules which can be a painstaking but necessary process, something few, if any, clinicians are trained in assisting and supporting patients through.
It’s now been almost 20 years since I took any psychotropic drug, and I still have very hard days where I’m stuck in neutral from the way anxiety squeezes my chest, when I snap at my children, or ruminate for hours. But I also read and practice what’s published in updated literature about the brain and psychology, meditation, the importance of nature, exercise, and disconnecting (frequently) from technology. I understand the importance of human connection, and that there isn’t a simple answer to alleviating our distress.
The best I can offer any parent when they ask me if I would do this for my child is to partner with them and critically examine all the tools available, the risks, and the benefits, and empower them to become the true expert in their child’s mental health.
