Drug Treatment in Child Psychiatry -a recent history (A West of Scotland Perspective for the Memorial Seminar for Dr Anne-Marie Discombe, 2017)
Dr Michael Morton Hon Clinical Senior Lecturer University of Glasgow Chapter 18; Kutcher, S. Child and Adolescent Psychopharmacology, Philadelphia, 1997 Chapter 19, Drug Therapy, 10/438 pages plus <30 references Alienists’ Attitudes to Children
Henry Maudsley
“How soon can a child go mad? Obviously not before it has got some mind to go wrong, and then only in proportion to the quantity and quality of mind which it has ..”
(The Pathology of Mind, 1895) Alienists’ Attitudes to Children
Sir Thomas Clouston “The Neuroses of Development” (Morisonian Lectures, 1891)
The child should be ruled by “system, order & punctuality” (The Hygiene of Mind, 1906) Alienists’ Attitudes to Children
Henry Maudsley “Children are… naturally boastful, scornful, passionate, envious, curious, selfish, idle, prone to steal…” “eager and pleased to inflict suffering” “savages” (Body & Will, 1883) Child Guidance to Child Psychiatry
• 1907 Eugenics Education Society Founded- UK – 1913 Mental Deficiency Act Child Guidance to Child Psychiatry
• 1907 Eugenics Education Society Founded- UK • 1908 Binet-Simon Intelligence Scale in English Child Guidance to Child Psychiatry
• 1909 Freud publishes his Analysis of ‘Little Hans’ Child Guidance to Child Psychiatry
• 1907 Eugenics Education Society Founded- UK • 1909 Freud Publishes Analysis of ‘Little Hans’ • 1908 Binet-Simon Intelligence Scale in English • 1920’s Mental Hygiene Movement –USA – 1927, Buck vs Bell – “3 generations of idiots is enough” (Oliver Wendell-Holmes) Child Guidance to Child Psychiatry
• 1920’s Mental Hygiene Movement -USA – 1923 Maudsley Hospital Children’s Dept – 1931 Glasgow, Notre Dame Child Guidance Clinic Child Guidance to Child Psychiatry
• 1907 Eugenics Education Society Founded- UK • 1908 Binet-Simon Intelligence Scale in English • 1909 Freud Publishes Analysis of ‘Little Hans’ • 1920’s Mental Hygiene Movement • 1928 British Paediatric Association founded • 1935 “Child Psychiatry” – US textbook, published by Leo Kanner Different Treatment Approaches for Children • Until 1950s there were few specific drugs for mental disorders; • Specific therapies for children with; – Anxiety, Insomnia, Enuresis, Hyperkinesis – Mental aspects of physical conditions (epilepsy, pain, Sydenham’s chorea) And …Thyroid extract in melancholia (Dawson, 1924) Emmi G, 16-year-old diagnosed as schizophrenic in the State Hospital, Meseritz- Obrawalde, 1942.
http://imagesoftheholocaust.blogspot.co.uk/2010/04/emmi-g.html Emmi G, 16-year-old diagnosed as schizophrenic & transferred to Meseritz-Obrawalde Euthanasia Centre.
-died after an overdose of tranquillisers, December, 1942. http://imagesoftheholocaust.blogspot.co.uk/2010/04/emmi-g.html Chlorpromazine
• 1937 Daniel Bovet discovers first anti- histamine • 1952 Delay & Denniker publish on Psychiatric Use of Chlorpromazine • 1954 FDA License • 1957 Tardive dyskinesia described Diagnosis & Formulation
• 1949 6th revision of International Classification of Causes of Death -> ICD 6 – Primary Childhood Behaviour Disorders – Mental Deficiency – Other & unspecified character, behaviour & intelligence disorder • 1975 ICD 9 ratified by WHO includes: – CDD, PDD & Autism – Hyperkinetic Disorder – Conduct disorder etc 1992, Gadow, JCPP Review
• Aggression; Neuroleptics, Lithium, Carbemazepine • Anxiety; Tricyclic Antidepressants, Alprazolam, Propranolol, Fluoxetine • Autism; Fenfluramine • Depression; ?Tricyclic Antidepressants • Enuresis; Tricyclic Antidepressants, Desmopressin 1992, Gadow, JCPP Review
• Hyperactivity; Stimulants, Clonidine, Desipramine • Learning, Dyslexia; ?Piracetam • Mania; Lithium • Tourettes; Haloperidol, Clonidine • Schizophrenia; “No controlled studies” 1992, Gadow JCPP review
Mental Retardation (Relies on All Age Studies) • Affective disorders; Imipramine, Valproic Acid • Behaviour; Fenfluramine, Pimozide, Pipothiazine, Haloperidol, Thioridazine, Propranolol, Carbemazepine, Lithium &c. • Prader -Willi; Fenfluramine • Hyperactivity; Stimulants • SIB; Naltrexone, Neuroleptics Clozapine for a Child -1995
• Very Early Onset Schizophrenia – Hallucinations, age 6 • Severe Distress, Aggression & Regression – Admitted to Yorkhill, transfer to Ladyfield, age 8 • Resistant to Treatment – Hdol 30mg, Cpz 280mg, Thz 200mg, Tfp 20mg, &c • Detained under MHAct, age 9 – Considered for Clozapine Clozapine for a Child -1995
• Very Early Onset Schizophrenia • Second Opinion • Clozapine to 325mg • Progress Monitored • Discharged, age 10 Scottish Psychotropic Use -1995 Survey by Drs D Renfrew & M Morton • 38 Child Psychiatrists & 96 Paediatricians contacted • 18 Excluded (survey not applicable) • -> 92% response rate to postal questionnaire
Psychotropic initiated in under 12s in 1/12? • 6/36 Child Psychiatrists had not prescribed and 3/6 stated psychological treatment preferred
• 23/90 Paediatricians had not prescribed and 11/23 stated that prescribing was done in liaison Scottish Psychotropic Use -1995 Survey by Drs D Renfrew & M Morton ->105 prescriptions to under 12s in one month
Drug Type Child Psychiatric Paediatric
Antidepressants 7 9
Sedatives 1 18
Stimulants 37 24
Antipsychotics 4 5
Total 50 55 Scottish Psychotropic Use -1995 Survey by Drs D Renfrew & M Morton
CONCLUSIONS:
1) 105 prescriptions a small number in child population of 775,000
2) Antidepressants used for enuresis by Paeds , mixed use by Psychs
3) Sedatives prescribed by Paeds, mainly in younger children
4) Stimulants most frequent psychotropic - from both clinics
5) Antipsychotics used occasionally by both specialties (tics, psychosis, behaviour) ADHD Story
• 1937 Charles Bradley, Trial of low dose Benzedrine on Institutionalised Boys – “the origin of the problem is generally sought in the development of emotional conflicts,”
• 1964 Conners et al – “In some respects children with behavior disorders share important common features with the brain damaged child. . . . These children function as though they lacked central cortical inhibitory capacity over their internal drives and the external stimuli impinging upon them.” ADHD Story
Conflicting Theoretical Positions: • Medication as Social Control • Medication to Support Learning • Medication to Remedy a Biological Deficit • Medication impacts on Development UK Incidence of ADHD Medication
Beau-Lejdstrom et al BMJ Open vol 6 e010508 2016 ADHD Medication 2012 4.8% US Children were on ADHD Meds
• 4.8% =2,700,00 children@ $15/month (minimum cost) =>$40,000,000 /month (minimum) revenue
• 3% US adults = 7,200,000 => $107,000,000 per month! Sunday Times 1995 Emotional Disorders & SSRIs
• 1991 King et al report Self Injurious Ideation/Behaviour in 6/42 OCD child patients • 2001, Smith Kline Beecham’s ‘Trial 329’. Published in JAACAP with ‘spin’ on Paroxetine, ‘ghost-written’ minimising adverse events. – 2004 GSK settle NY lawsuit for $2.5m – 2012 GSK fined $3bn in US fraud action • 2007 Bridge et al meta-analysis; C&A Suicidality & SSRIs UK C&A Incidence of Antidepressants Sarginson et al (2017) Policy & Practice
• 1993 SIGN established • 1999 NICE established • 2005 BNF for Children Published • 2008 NICE ADHD Guideline – 1.5.2; Drug Treatment is not indicated as the first-line treatment for all school-age children…. • 2009 SIGN ADHD Guideline – 7.2; Methylphenidate and dexamphetamine reduce core ADHD/HKD symptoms and improve quality of life in children diagnosed with ADHD/HKD.83 Medico-Legal Factors NHS Clinical Negligence Compensation
• 1990-91 Cost £53m • 1996-97 Cost £235m • 2015-16 Cost £1,488m
– A twenty eight fold increase over 16 years
• NHS Resolution (formerly NHSLA HC312 p10) Medico-Legal Factors
• 2000 Harold Shipman convicted 15 Murders
• 2012 GMC Revalidation Introduced ‘Therapeutic Orphans’
• 1997 FDA Modernization Act • 2003 Pediatric Research Equity Act (US) • 2007 Regulation (EC) 1901/2006 – The Paediatric Regulation – Requires a ‘paediatric investigation plan’ – Rewards compliance – Does not resolve off-label use of older drugs C&A Psychopharmacology Practice West of Scotland • 2002 Paediatric Telemedicine Project • Concerns over ‘Off-Label’ Prescribing • Link to Guys Hospital Paediatric Psychopharmacology Interest Group • Founding of West of Scotland Child & Adolescent Psychopharmacology Interest Group – Supported by Medical Director W&C Conclusion
• Relevant aspects of the historical context: – Societal Change – Development of Specialist Practice – Public Attitudes – Public Policy – Commercial Interests – Scientific Progress Additional References (not found in slides)
• Stewart JW, 2006, Child Guidance in Interwar Scotland: International Influences and Domestic Concerns, Bulletin of the History of Medicine, V 80, Number 3, pp. 513-539, Johns Hopkins University Press , DOI: https://doi.org/10.1353/bhm.2006.0117 • Comstock EJ, 2011, THE END OF DRUGGING CHILDREN: TOWARD THE GENEALOGY OF THE ADHD SUBJECT Journal of the History of the Behavioral Sciences, Vol. 47(1), 44–69 • Evans B, Rahman S, Jones E, 2008, Managing the ‘unmanageable’: interwar child psychiatry at the Maudsley Hospital, London History of Psychiatry, 19(4): 454–475 • Gadow K, 1992, Pediatric Psychopharmacotherapy: A Review of Recent Research J Child Psychol & Psychiat Vol. 33. No, 1, pp 153-19 • MacEwan T, Morton MJS, 1996, The Use of clozapine in a Child with Treatment Resistant Schizophrenia, BJ Psychiat. 168(3) 376-8 • Parry-Jones W, 1989, The History of Child and Adolescent Psychiatry: Its Present Day Relevance. J Child Psychol. Psychiat. Vol. 30, No. 1, pp. 3-11 • Le Noury J, Nardo J M, Healy D, Jureidini J, Raven M, Tufanaru C, Abi-Jaoude E, 2015, Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence, BMJ;351:h4320 doi: 10.1136/bmj.h4320 • Lunney M, Nolan D, Oliphant K, 2017, Tort Law, Text & Materials, p985, OUP. • Seeman MV. 2005, Psychiatry in the Nazi Era, Can J Psychiatry, Vol 50, No 4, • Von Gontard A, 1988, The Development of Child Psychiatry in 19TH Century Britain. J Child Psychol. Psychiat. Vol. 29, No. 5, pp. 569-588