Scoop Essentials: The Rx Lowdown
Psychiatric medication is increasingly seen as an answer to the many behavioral and emotional issues faced by those with developmental disabilities. But when is medication appropriate and how can you tell whether it’s helpful or harmful?
In this installment of Scoop Essentials Dr. Ken Talan, a board-certified adult and child psychiatrist, tackles these issues and more.
Check out what Talan has to say and then click here to submit your own questions to him.
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Disability Scoop: In what circumstances is it appropriate to consider using medication with an individual with a developmental disability?
Dr. Ken Talan: You’re looking at the severity of the symptoms that they’re having and how much it might interfere with their functioning.
It could be anger outbursts, a lot of anxiety, depression, compulsive behaviors, obsessions. But the presence of symptoms alone does not warrant the use of medication. It has to do with the severity and how disruptive the symptoms may be in terms of day-to-day living.
When I see a patient I look at what their functioning is like and how much distress the individual is in. The child or adult might still be able to do the things that an outside observer might expect them to do, but they may have an intense amount of stress in terms of mood or anxiety.
I look at five criteria:
1. How frequent is the symptom?
2. How intense in the symptom?
3. How long-lasting is the symptom?
4. What are the consequences of the symptom?
5. How unusual or out of character is the symptom?
Disability Scoop: If someone is considering medication, what can they anticipate its role to be?
Dr. Ken Talan: The way I think of medication is to allow the person to be more available and to provide what they need to continue to grow and move forward in their development. To help a child be able to be more effectively present in school, to be more available to engage with peers, to develop social skills. Medication is an aid and a tool to assist them to move forward.
No sensible practitioner would prescribe medication without addressing also the behavior perspective, the psychological perspective, or whatever difficultly the child may have.
Disability Scoop: Who’s best qualified to prescribe psychiatric medication?
Dr. Ken Talan: Ideally you want someone who has a lot of experience with the medication. Usually that means a psychiatrist. Unfortunately child psychiatrists are in very short supply. So a good place to start is with your pediatrician or physician. Sometimes they can treat you or some adult psychiatrists will see children or adolescents down to the age of 12, even though they have no formal training. Pediatricians will also prescribe some medications that are less complex. They use stimulant medicines or anti-depressant medications.
Disability Scoop: How do you know if the medication you’re taking is right for you? How do you know if it’s helping?
Dr. Ken Talan: First off, entry into medication, particular for children and adolescents or people who are very vulnerable, is generally done slowly and starting with low doses of the medication. One thing I often run into with parents is they tell me, “I don’t want my child to be a zombie.” I tell them I don’t want your child to be a zombie either. It’s important to start low and go slow with medication. You’re more likely to avoid problematic side effects and disruptions that can come from negative reactions to medication.
In terms of the benefits, it often is helpful to focus on a specific symptom you’re trying to improve. Suppose the child is unable to get to school or participate in school, one would want to assess and have certain guidelines. For instance, is the child less overwhelmed at school? Look at the symptom or the behavior and look for changes in that specific area.
When I’m trying to assess whether a medication is helpful I look at the person, their sleep, appetite and their energy level. Similarly in terms of anxiety we look at how frequent the person experiences panic and how severe the symptoms may be. With younger kids and people with disabilities, it may not be so easy to get a self-report, so a lot of it is determined by behavior.
Disability Scoop: When you start taking medication how much change should you expect and how quickly will you see it?
Dr. Ken Talan: It varies. I break down all medications into five main categories:
1. Medications that are for symptoms of inattention, impulsivity, hyperactivity and distractibility. Generally speaking these medicines have a short turnaround time. You should be able to tell fairly quickly, within days, if a particular dose is helpful or not.
2. Depression medications. Generally speaking if a medication is going to work for depression, you would expect to see something within two or three weeks unless you’re starting with a very low dose. But with each dosage increase, you should expect to see something within two to four weeks. These medicines usually see a maximum benefit after 12 weeks.
3. Medications for bipolar disorder and severe mood instability. Some of these medicines have a short turnaround time and you may see something within a few days. But in terms of effects on depression, that’s going to take longer.
4. Anxiety medicine. Some medicines work very quickly, but others may build over a few weeks or a month.
5. Psychosis, severe mood disorder, severe aggression, Tourette’s syndrome, ticks. These medicines generally, you can start to see effects within a week or two. For certain symptoms like hearing voices, it may take longer, but in terms of aggression and agitation it will generally settle down within one to three weeks.
Disability Scoop: How often should your medication be evaluated or reevaluated?
Dr. Ken Talan: When a person first goes on medication it is important to have frequent monitoring, either face-to-face contact or telephone contact, probably weekly with the option of calling if there’s a concern. All medication has the potential for side effects. That needs to be monitored.
In the initial phase when someone is first put on medication, I would say once every week or every two weeks for a couple of times. Then, if medication can be established as an effective dose and the person is going to stay on it for a while, the monitoring may then go to once every two months or every three months. Generally speaking for children and adolescents you don’t want to go any longer than once every three months. They’re always growing and changing. With adults you may go to once every six months once the effective dosage is established.
Disability Scoop: Is there a limit to the number of medications you should take simultaneously?
Dr. Ken Talan: There’s no absolute limit. It’s much more common now for children and adults to be on more than one medicine at a time. The general idea is to only change one medicine at a time so that you have a sense of what’s working and what isn’t and to do it slowly. It’s important that parents and patients as much as possible know the name, the dose of medicine and what it’s supposed to do.
Disability Scoop: What warnings signs should you watch out for when taking medication?
Dr. Ken Talan: Symptoms that are disruptive in some way. Any kind of change that seems out of the ordinary. Let’s say a person goes on a medication and starts having more headaches or is experiencing dizziness or nausea, that should be reported. Almost any kind of out of the ordinary bodily change or mental change should be reported and checked on. If there are doubts, it’s important to call the doctor.
In terms of mental sate or mood, you would hope that whatever mental state or mood that is being addressed is improving. Less anxiety, not more anxiety. Less depression, not more depression.
Disability Scoop: What happens if you forget to take your medication or you just decide to stop taking it?
Dr. Ken Talan: That is a problem. Some medicines can be taken as needed, like when you’re feeling more anxious. However, a lot of medicines need to be taken on a daily basis for two reasons. The first is that the body is always getting rid of the medicine. With some medicine, the body cuts it in half within the first six hours. Other medicines if you miss, things start to go wrong quicker. You can feel sick from skipping medication because you’ve been on it for a while. It’s not that you necessarily continue to need the medicine. It’s that the body is used to having it.
One of the biggest problems that can arise when someone has been on a medication for say a year and they suddenly stop, is that we don’t know if they actually still need the medicine or if they’re having a reaction to suddenly going off of it. So when a person is ready to go off a medication or the person decides they don’t want to take it anymore, it’s very important to talk to their doctor about slowly tapering off the medicine. If a person has been on a medicine more than a few weeks, it’s really important to go off of it slowly.
Disability Scoop: If you’re on medication today, does that mean you’ll need it forever or is the goal to learn to cope without?
Dr. Ken Talan: No. Generally, the idea is that for right now, in this difficult period we’re going to try this and then reassess. Generally, start for six months and then we’ll lower the medicine slowly and see what happens. If the individual runs into difficulty, we’ll extend the period for another 8 months, 10 months and see at the end of that time.
Talan is the author of Help Your Child or Teen Get Back on Track: What Parents and Professionals Can Do for Childhood Emotional and Behavioral Problems.