One of our new MHRN research projects, led by Rob Penfold at Group Health, will implement and evaluate a program to curb over-prescribing of antipsychotic medication to children and teens. The program focuses on youth prescribed antipsychotics for non-psychotic disorders – especially attention deficit disorder, oppositional defiant disorder, conduct disorder, and depression.  Nearly two-thirds of antipsychotic prescriptions for young people are for these “off label” indications.  Three MHRN health systems (Kaiser Permanente Colorado, Henry Ford Health System, and Group Health) and the Partners for Kids network in Ohio will implement a two-part intervention. 

First, a second-opinion consultation with a child psychiatrist (usually via telemedicine) will be required prior to starting off-label antipsychotic treatment.

Second, evidence-based and family-oriented behavioral interventions will be offered routinely – supported by care management to promote engagement and adherence.

The hope is that this combined intervention will reduce unnecessary use of antipsychotic medications and increase use of preferred behavioral treatments.

In a recent conversation about the allure and risks of aggressive treatments, my colleague Jerry Jarvik from the University of Washington described to me his conversations with people who live with chronic back pain. One of his patient partners described spinal fusion surgery for back pain as “the nuclear option”.  It’s the treatment of last resort, ideally reserved for those situations when all lesser options have failed.

The nuclear option analogy certainly fits much of the prescribing of antipsychotic medication to children and teens. Whatever your views on nuclear disarmament, most of us would agree that off-label prescribing of antipsychotic medication to manage disruptive behavior in young people should be a last resort rather than an early one.  And, continuing the analogy, the fallout from antipsychotic prescribing to young people is sobering – including significant weight gain and increased risk of cardiovascular disease. 

Unfortunately, prescribing of antipsychotics to young people is often not a last resort. Borrowing from a classic film about the nuclear option, antipsychotic prescribing sometimes resembles the plot of Dr. Strangelove.  Like Major “King” Kong, the enthusiastic but uninformed bomber pilot (watch funny/scary YouTube clips here and here), we may arrive unnecessarily at the nuclear option via miscommunication and disorganization.  All other options have not been exhausted – and preferred options may not have been tried at all.  Rob Penfold’s pilot work found that only half of children and teens prescribed antipsychotics for a nonpsychotic disorder had received any psychotherapy in the prior year.  Only 40% had received family therapy, the preferred initial treatment.  If we would hope to reduce unnecessary antipsychotic prescribing, we will probably need to make the right thing easier to do.  And make it a bit more difficult to do something drastic that we might later regret.