Are psychiatrists guessing about what to prescribe?

If you have a teenager with a mental health disorder that requires medication, you may become discouraged if the first medication their psychiatrist prescribes does not improve their symptoms or offer them any relief.

We understand how hard that can be.

The types of mental health conditions that may require medication include:

• Depressive Disorders
• Anxiety Disorders
• Psychotic Disorders
• Behavioral Disorders

For children and adolescents, psychiatrists may prescribe psychiatric medication for a variety of specific conditions. These may include major depressive disorder (MDD), bipolar disorder (BD), attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder, disruptive mood defiance disorder (DMDD), oppositional defiant disorder (ODD), and other mood or behavioral disorders.

That covers most of the types of mental health disorders children and adolescents experience. While not all children and adolescents diagnosed with these conditions require or receive prescriptions for psychiatric medication, those who do are often optimistic that the medication will help manage their condition. They hope taking the medication will help. They want it to result in a significant improvement and/or reduction in the frequency and duration of their symptoms.

And you, as a parent, are often more hopeful and optimistic than they are. Your goal is to relieve any discomfort your child experiences.

That’s why it can be a major disappointment when the prescribed medication does not live up to expectations. It’s also why you may be skeptical about your child trying a second medication. If that medication does not help, you may be even more skeptical about trying a third.

At that point, it may seem like the psychiatrist is just guessing about what might help. You may get the impression they don’t know what they’re doing. You may suspect the whole process is simply a hit-or-miss exercise in trial-and-error.

They Are Not Guessing

We needed to get that out of the way immediately.

And say it again: really, they’re not guessing.

We’ll elaborate.

Doctors (MDs) are trained professionals who do not guess. Psychiatrists are doctors (MDs). They spend years studying the basics of science. They study the foundational concepts of biology, chemistry, and physics as undergraduates. In medical school, they study the advanced specifics of disease and pathology. You all hear stories about how hard medical school is. Here’s an insight: a lion’s share of study time in the first two years of medical school is spent on the hard sciences. Organic chemistry. Biochemistry. Molecular biology. Pharmacology. Genetics. The list goes is long. Aspiring doctors have to succeed in these classes – and take exams to demonstrate their knowledge – before receiving their degree.

Then they train in their specialty, when they learn more about the critical details of their area of focus. Their specialty training involves close contact with experienced mentors who understand the ins and outs of treatment – including medication – in that specialty area.

That’s when they begin prescribing medication. It’s only after years of training in hard science and under the guidance of the physicians training them in practical application in their specialty.

And there’s more to it than that.

Here’s a checklist recommended by the World Health Organization (WHO) that appears, in various forms, in all physician training related to prescribing medication.

A Doctor’s Prescription Checklist: 8 Steps

1. Evaluate and clearly define the patient’s problem.
2. Specify the therapeutic objective.
3. Select the appropriate drug therapy.
4. Initiate therapy with appropriate details and consider nonpharmacologic therapies.
5. Give information, instructions, and warnings.
6. Evaluate therapy regularly. Monitor treatment results.
7. Consider drug cost when prescribing.
8. Use computers and other tools to reduce prescribing errors.

Doctors follow these steps each time they write a prescription, and each time they write a prescription, they take into consideration all the information included in the patient’s medical history. That’s one reason you fill out all the forms before your child or teen begins treatment. A prescribing physician will review every aspect of your teenager’s history – medication, injuries, treatment, social factors, family factors, everything – before prescribing medication.

That’s Not All

In addition, child and adolescent psychiatrists follow general prescribing principles for children and adolescents defined by the American Academy of Child and Adolescent Psychiatrists (AACAP). Here’s an example of the overall guidelines published by the AACAP. Child and adolescent psychiatrists are encouraged to ensure that:

• Informed consent and shared-decision making are consistent with family-driven and youth-guided care.
• Screening and assessment are consistent with a public health approach.
• The use of psychotropic medication with an indicated psychosocial intervention is consistent with individualized care.
• Collaboration among prescribers, professionals, and agencies is consistent with care that is integrated across systems, reflecting that medication prescribing is embedded in a broader, holistic, strength-based approach to care.

That’s still not all – but we won’t share all the guidelines and best practices established by mental health experts that psychiatrists have to stay current on. Upon writing, we identified at least a dozen publications that include detailed guidance for prescribing psychiatric medication to children and adolescents. You can read an overview of those published by the AACAP in this article: “Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems”

With all of that said, we need to tell you something else:

The process of finding the best psychiatric medication for any given patient does, indeed, involve a process that resembles trial and error.

We’ll explain.

Medication Monitoring and Assessment

First, please understand that the trial and error we refer to is not what most people think of when they hear the phrase.

The trial happens after a thorough process of assessment and evaluation that includes all aspects of your child’s situation. It encompasses biological, psychological, and social factors.

It is not a guess.

It’s an informed decision based on both specific knowledge of your child and the generations of medical knowledge about your child’s diagnosis. Psychiatrists have access to volumes of information on the medications they prescribe, and in most cases, have a set of medications they’re familiar with and know almost everything there is to know about – and they keep abreast of any recent developments by reading peer-reviewed journal articles and participating in mandatory, ongoing professional development.

Second, the word error is somewhat misleading. Yes – doctors make errors – but that’s not what we mean. In this context, error means that the medication did not result in the desired clinical outcome. For instance, an ADHD medication for a 12- year-old does not improve their focus. Nor does it help them in the academic work. Or an anti-depressant prescribed for a 16-year-old does not result in a decrease in symptoms. The frequency of their persistent depressive mood does not change in any significant way.

When the medications do not result in the desired clinical outcome, the clinicians and physicians adjust. They may change dosage, frequency, or suggest a new medication altogether – in collaboration and communication with you, the parent, and your child, their patient. This is analogous to adjusting their individualized treatment plan. If one aspect of the plan does not have the desired therapeutic outcome – say, for instance, cognitive behavioral therapy (CBT) doesn’t help – then your child may switch to dialectical behavior therapy (DBT).

That’s the way things should work – and it’s the same for medication.

The Big Picture

It’s also important for you to understand what medication can and cannot do for your child. According to the experts at the AACAP, the primary goal of psychiatric medication is to “level the physiological playing field.” Medication can decrease levels of arousal in hyperactive children and adolescents, decrease anxiety in a child with an anxiety disorder, and decrease the frequency and intensity of depressive episodes in a child with a depressive disorder. Medication can also help to improve “cognitive distortions related to psychosis.”

All of these outcomes can be game-changing – and that’s why psychiatrists prescribe medication, despite the fact that every medication does not work for every person.

What medication cannot do is change the past or eliminate the presence of the diagnosis. If your child experienced trauma, medication cannot change that fact. If your child is diagnosed with a mental health disorder, the presence of medication does not erase diagnosis. Medication does not provide your child or teen with the practical psychological tools and coping skills they need to manage their symptoms. It cannot teach them to identify their thoughts and feelings. It cannot connect those thoughts and feelings to their behavior and help them change life-interrupting or treatment-interfering behaviors with life-affirming or treatment-supporting behaviors – that’s what therapists and counselors do.

What medication can do is what we stated above. It can level their internal playing field and help them achieve a state where they can participate in therapy. In the words of the AACAP:

“One practical effect of increased physiological regulation gained through use of psychotropic medication is that some youth previously unable to benefit from psychotherapy and other mental health treatments can now do so.”

Be Patient and Stay the Course

We understand that getting to that therapeutic space may not happen in a stepwise, linear manner. In most cases, there are starts and stops. There are successes and setbacks. We understand how frustrating that can be because we’re right there on the journey with you. We want what’s best for your child, because helping children is what we do. The first attempt at therapy may not be a perfect fit, and the first medication prescribed may not work as expected.

However, we want you to know that when we design a treatment plan and prescribe a medication, we are not guessing.

We follow the evidence, pay close attention to your child, and change their course of treatment or alter the treatment plan when necessary. When we want to make changes, we collaborate with you and your child first. We ensure you any proposed changes are data-driven, evidence-based, in accord with the latest scientific information available, and align with the best practices in adolescent mental health. Together, we arrive at a decision that offers your child the best possible chance of treatment success. That’s what we want, that’s what you want, and we know that’s what your child wants: a chance to create a better life and embrace the hope of a bright future.