Commentary from The Depressed Child:

The Phony War:  Drugs v. Counseling

The Real Enemy:  The Four I's --

Incompetence, Ignorance, Indifference and Indolence      

By James A. Kidney

Webmaster, The Depressed Child

© The Depressed Child

 Sad little boy on bleachers hugged by sad big sister           A report came out a few years ago showing that more children and adolescents are receiving drug treatment for mental illnesses, including depression.  The latest, published in the January 2003 issue of the Archives of Pediatrics and Adolescent Medicine, reported that persons under 20 years old were prescribed psychotropic drug treatments nearly three times more often in 1996 than they were in 1987.  Based on an analysis of three data records -- two Medicaid groups and one HMO -- 6.1 percent of the surveyed patient population (over 900,000 patients in 1996) were prescribed psychotropic medications in 1996, but only 2.2 percent received such treatment 10 years earlier.  Twice as many boys as girls were prescribed psychotropic drugs in 1996.

            Prescriptions for antidepressants grew at an even faster rate.  Antidepressants were prescribed for persons under 20 years old 5.6 times more often in 1996 than they were in 1987.  Prescriptions for stimulants, presumably mostly used to treat ADHD, were prescribed 3.6 times more often.  By 1996,  2 percent of the sampled population were prescribed antidepressants while nearly twice that number were prescribed stimulants.

Blame the Insurers?

            The survey’s authors did not attribute a specific cause to the increase, but did note that more recent data from other surveys indicates that the diagnosis of mental disorders among children is now approaching adult levels, which is reflected in the increased number of psychotropic prescriptions for children and adolescents.

            Although the data is seven years old, few experts would suggest the trend has not continued.  The real question is whether this increase is cause for celebration or concern.  While many newspapers treated the report responsibly, a handful weighed in firmly on the side that this was bad news.  The Times of London headlined its story “The Next Prozac Generation Starts at Seven.”  The headline on the inside portion of the story in The Washington Post         was “More Drugs, Less Therapy for Kids,” something not implied in the study itself. The award for worst headline on this subject goes to The Independent of London, which, perhaps in a bit of anti-American sentiment, headlined the news “American Children Put on Drugs to Save Money, Study Shows.”

            But the headline had some basis to support the headline it if the story was cribbed from the Post.  While the study did not reach conclusions about why prescriptions were increasing, the Post quoted speculation that insurers have increased their profits by decreasing the use of psychotherapy and increasing use of prescription drugs.  “The insurance system gave an incentive for medication and a disincentive for therapy,” Michael Jellinek, chief of child psychiatry at Massachusetts General Hospital told The Post.  Jellinek was less bellicose in The New York Times, where he was quoted as saying the study may reflect new understanding and “thoughtful efforts” to use adult drugs in children “to treat children with serious mental health needs.”

            Dr. Jellinek’s efforts to blame the insurers cannot be proved or disproved from the study, but we do know this:  As of 1996, very few Americans had health insurance plans that covered regular and routine treatment of mental illness by mental health care providers.  Those that did imposed strict limitations on cost and frequency.  Thus, many Americans with children suffering mental illness relied on their pediatrician or general practitioner for advice, counsel and drug treatment.  If regular counseling by a psychologist was not economically possible for these families, then the “good news” is that children were getting some treatment, albeit from drugs, rather than no treatment at all for these disabling mental illnesses.  The bad news probably was that M.D.s specializing in child psychiatry -- or, at least, psychiatry -- were not issuing the prescriptions.  While insurance company limits are involved, it is unlikely insurance practices changed much between 1987 and 1996.  It certainly is unlikely that the increase in prescriptions is attributable to insurers shifting from counseling to drug treatment alone, since insurance companies never covered psychological counseling.  Despite legislation purporting to bring “parity” with physical illness to insurance for mental health, the situation is only slightly improved today, and that is only for those who are able to obtainRed capsules of drugs flying in front of boy health insurance at all.  It seems unlikely that any adverse changes in insurance practices from 1987 through 1996 caused the upsurge in prescriptions.  A greater willingness by pediatricians to recognize depression in children is a more likely cause.  

Maybe This Is Good News

            It is difficult to know whether the increased drug treatment shown by the study is good news or bad.  The study itself doesn’t really tell you very much about the condition of mental health treatment in this country.  The press and professional reaction, however, tells you a lot about the continuing and phony "war" between counseling and drug treatment.  Every time there is a new report about drugs, whether a drug is found to be effective or ineffective, or that drug treatment is up, someone in the mental health profession can be found to say drugs are bad and counseling is best, or that drugs cure mental illness and counseling is just an add-on.  This website takes the position that both are useful in many cases, and that counseling and drug treatment should be evaluated for use in all cases in which depression has been diagnosed, including in children.

            Is it possible that increasing use of prescription drugs is good news?  NIMH estimates that 2.5 percent of the child population suffers from depression.  The American Academy of Child and Adolescent Psychology puts the number at 5 percent.  Some sources estimate that over 8 percent of adolescents are clinically depressed at some point in their young lives.  The drug use study suggests, based on its sample, that only 2 percent of children and adolescents are being treated with medications for depression.  And the sample itself is hardly representative of American kids.  Over 775,000 of the 900,000 patients in the study sample were Medicaid patients, meaning they came from poor families.  It is not difficult to imagine that problems faced by children in impoverished families increases the risk of mental illness.  Thus, it is possible to infer some good and bad news:  That more children needing treatment for mental illness were receiving some attention in 1996 than in 1987, but that many children still go untreated. 

Why Drugs Get No Respect

            While this website believes that good counselors can bring good results and are an important element of treatment, we also know that good counseling is hard to identify, especially counseling for children and adolescents.  The kids themselves are not equipped to identify good and bad counseling -- they often don’t even understand what they are being treated for.  Many kids won’t share their counseling experiences with their parents, sometimes getting a gleeful satisfaction from telling them the information is privileged or confidential.  They are legally correct: the doctor-patient privilege makes it difficult for parents to learn what goes on in counseling sessions so they can make an informed assessment.

            We are not aware of any “objective” tests of psychologists or psychological social workers or of the few remaining counseling psychiatrists that can be administered to reliably score their individual effectiveness.  The value of a counselor may be effected by many subjective judgments of the patient and the counselor.  One patient may feel anxious, angry or frightened while another is calm and forthcoming with the same practitioner.  With so many variables, from treatment method, to available toys, to office furnishings, which might impact on the effectiveness of child counseling, development of a standard scoring test seems unlikely.

            Drugs, on the other hand, are subjected to detailed testing and examination and, within limits, their effectiveness can be assessed with a considerable degree of objectivity.  We are no fan of drug manufacturers.  Drug companies are rapacious.  They guard their profits diligently and are blind to the economic realities faced by their true customers.  As Dracula fears sunlight, drug companies fear economic regulation.  They also oversell their supposed dedication to research while pushing their product on people who may not need it through costly advertising.  But it cannot be denied that their products must be proven to work (if not quite up to their own advertised claims) or they cannot be sold.  Unlike the counseling profession, there are some significant and meaningful checks and balances on the sale of drug therapy.

            Ironically, the counseling profession benefits from the absence of reliable testing.  There are few newspaper stories about bad counseling or that the psychologists at one hospital or practice group flunked their annual evaluations.  There are few unbiased studies demonstrating the most effective counseling methods.  Rather, each method has its fans, based on highly subjective criteria.  Other than the occasional critical news report of an oddball theory, such as wrapping people in blankets and shaking them to recreate the womb, the effectiveness of mental health counseling is assumed by press and public, even though surely it is the case that every day some counselors fail to perform their jobs and let down their patients.

            Stories of drug failures, new drugs, the unexpected side effects of old drugs and movies and plays that portray mental patients dragged down by drugs (“One Flew Over the Cuckoo’s Nest”) are commonplace.  It is not that these stories are not true, or that the plays don’t reflect realities of certain times and places, but drugs also are an easier target than counseling.  Drugs get no respect, while counseling sometimes gets away with malpractice -- or worse.

The Four Eyes

            Based on our own research, our own sad experiences and the stories we receive through Metal letter i in metal circlethis website, the greatest obstacle to adequate treatment of mental health problems in children (and in adults) is what we call the Four Eyes:  Incompetence, Ignorance, Indifference and Indolence.  Any of these can kill, mentally maim, or result in costly but ineffective treatment.  The “war” between drugs and counseling is a phony war.  The real battle is to find counselors and physicians who are capable, caring and involved.  Such counselors will give your child the attention and energy he or she deserves and you are paying for.  They will carefully consider if drug treatment is needed, be knowledgeable about the drugs to prescribe, and monitor your child’s progress, through conversations with both you and your child.  Such a counselor will have a network of M.D.s, if she is not one herself, that she trusts to supplement her own knowledge of drug therapy and she will be in regular consultation with that M.D.

            For most Americans, a world without the Four Eyes is Valhalla -- a heavenly fiction.  Health care economics -- mental health care economics especially -- permit only a few American children to avoid the Four Eyes.  But even with better health care delivery mechanisms, parents will require a lot of luck in finding a counselor right for their child.  This is why increased drug treatment can be deemed by itself neither good nor bad.  Perhaps if Valhalla were here, many more children would be identified who need treatment, the proper drugs would be prescribed, and as a consequence drug use might increase substantially, but to good effect.  Perhaps in Valhalla, competent and caring counselors would not routinely diagnose quarrelsome children bored in their classes as having ADHD or an oppositional disorder, but more often than now simply tell teachers and family that the patient is a wonderfully independent child who will grow into a fine, independent adult if the parents and teachers don’t screw him up.  In those cases, drug treatment would decline, also to good effect.

            As it is, one is left to ponder:  Is the increased drug use for mental illness a result of better identification and treatment of those in need?  Or is it because our health care system can’t deliver care that is needed and uses drugs as a dangerous substitute?.  If the latter, then one must ask:  Are the drugs better than nothing?  To which the only honest answer can be:  It depends.

DISCLAIMER:  Unless otherwise indicated, all commentary and information on this web site is provided by persons who have no formal training in medicine or mental health.  You should weigh the information and comment on this site in consultation with a mental health professional.