New England Journal of Medicine Adds its Voice to the Chorus

by Edward Opton

Our most recent post, “Mainstream Psychiatry Intensifies Criticism of Off-Label Antipsychotics for Children” (July 27, 2015), reported that an editorial[1] in the prestigious journal JAMA Psychiatry has criticized the widespread off-label misuse of “antipsychotics” on children.

The JAMA Psychiatry editorial’s significance, we suggested, is not in the substance of the criticism, for complaints that antipsychotics are being misused to restrain children and to suppress the expression of sadness and anxiety have circulated for years. What is new, we wrote, was that the acknowledgement of the problem appears in a mainstream psychiatric journal.

A second mainstream journal has chimed in. The New England Journal of Medicine, once and perhaps still America’s most respected medical journal, has published an editorial by Associate Editor Barbara Geller. She writes[2] that the research reviewed in the JAMA Psychiatry editorial:

“showed an unconscionably low use of psychotherapy, despite the existence of evidence-based nondrug modalities for childhood depression and anxiety. Ideally, antipsychotics should only be prescribed to children after specialist consultation, nondrug interventions (e.g., school placement, psychotherapy), and optimization of other medications.”

Dr. Geller, author of more than 130 articles on childhood disorders, is professor emerita of psychiatry at Washington University, and, among other distinctions, a recipient of the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill (NAMI).

A single word in Dr. Geller’s critique gives us pause. That word is “ideally.” For most children, especially children in foster care, the ideal of personalized psychiatric care is as remote as personal cooks, personal chauffeurs, and personal tutors. The widespread employment of antipsychotic medications to suppress behaviors might rightly be called “impersonal psychiatry.” The two recent mainstream critiques acknowledge that it is not good practice.

What shall we do instead?

[1] Correll, C.U. & Blader, J.C., Antipsychotic use in youth without psychosis: a double- edged sword. JAMA Psychiatry published online, July 1, 2015.

[2] Geller, B.   Antipsychotics are still prescribed for childhood nonpsychotic diagnoses. NEJM Journal Watch, 7/ 27/15  [http://www.jwatch.org/na38438/2015/07/27/antipsychotics-are-still-prescribed-childhood-nonpsychotic (subscription required)].

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