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Greg Fritz, MD (Host): (Host) Welcome back to Mindcast. Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital. I'm your co-host, Greg Fritz.

Tanuja Gandhi, MD (Host): And I'm your other co-host, Tanuja Gandhi. Today we are excited to welcome Dr. Jeff Hunt to Mindcast. This is his second time on our podcast and we are so happy to have him back. Jeff is the Director of Inpatient and Intensive Services at Bradley Hospital, which is a freestanding children's psychiatric hospital. We're extremely grateful that he has joined us today and is willing to help us dive deeper into this topic around medications and therapy for children.

Jeff Hunt, MD: Thank you guys so much for inviting me. I've been treating children and adolescents, for their emotional disorders for over 35 years, and have been teaching residents and medical students about strategies to use both medications and therapy in this treatment. I am concerned that there's a lot of confusion about the use of medication for treating mental illness in youth and appreciate being here to discuss these issues today.

Greg Fritz, MD (Host): Great to see you, Jeff. Thanks for being here. Let's start with the basics. So when treating a child for their mental health problems, the first treatment is therapy. Would you agree with that?

Jeff Hunt, MD: Yes. Therapy is often the first thing you look for for most disorders, and I can talk a little bit more about that.

Greg Fritz, MD (Host): So sometimes though, therapy alone is not enough. We all have experienced that. And my question is then, how do you know when therapy's no longer enough and when it's time to prescribe a medication for a child? Really, the basic question.

Jeff Hunt, MD: A lot depends upon the assessment of the illness that needs to be treated. In the case of anxiety and depression, it's always appropriate to try therapy, hopefully using evidence-based treatment. Usually you would see several weeks of therapy before starting a medication, and if there's improvement, you would continue to wait.

If the symptoms are severe at baseline, and sometimes that is the case, especially with major depression and some severe forms of anxiety, sometimes you would start medication early on. Really, you're looking at severity at baseline and how much distress and impairment and functioning across school, friends and family.

Then medication may be indicated. For some very severe disorders like bipolar disorder with mania and any disorder with distorted thinking and altered perceptions, medication may be warranted early in the treatment course. Often patients are seeing pediatricians or other primary care clinicians, and they've already tried to address some of the concerns.

So sometimes when child psychiatrists see patients, it's already been a while and the severity's already worsening.

Greg Fritz, MD (Host): Say something, not a whole summary of all medication classes, but basically what kinds of medications are there and sort of a corollary to that, do you think there's a medication for every diagnosis?

Jeff Hunt, MD: So there are a handful of types of medications for kids. So the ones that we hear most about are meds for attention deficit hyperactivity disorder. There's one main category called the stimulants, and then there's some others that help with impulsivity and, maybe a little bit less so with inattention.

And those are very robustly studied and very effective. The most effective medications that we have. The stimulants are very effective. Then the other types of medications are antidepressants that are used for both depression and mood disorders, but also for anxiety and OCD.

And for both stimulants and antidepressants, there's a host of them that have different characteristics and they're coming from adult literature and we're borrowing from that literature for the most part until studies have been done with the child and adolescent population.

And then there's the other big category of medications for more severe disorders, the antipsychotics that there's again, a host of those type. There's another category called mood stabilizers. And those are primarily the types of medications that, that we use.

Greg Fritz, MD (Host): So can you mix and match these different meds based on diagnosis or the presentation? And if you can, in your experience, how do you know what is the right combo for each kid?

Jeff Hunt, MD: I think sometimes, especially with more complicated kids, they might end up on more than one type of medication. And that usually is something that happens when kids have more than one problem. So not, uncommon to have ADHD and then you also have anxiety or you also develop depression. You still need to treat the ADHD, and then you have another new problem that often happens as you get older going into being a teenager, depression rates go up, so it wouldn't be uncommon to be on a stimulant plus an antidepressant.

And then if you happen to have autism spectrum disorder and intellectual deficiency and lots of aggression or irritability; you also might end up being treated with a stimulant or something, to combat aggression or impulsivity like guanfacine or clonidine. And then in, very severe cases, you might end up on a low dose of an antipsychotic.

And so the more complex your presentation, the more likely that you might end up on more than one medication.

Greg Fritz, MD (Host): I've heard you say that it's not just throwing everything at the wall and seeing what sticks. It's more thoughtful process in that. Elaborate on that if you would for.

Jeff Hunt, MD: Yeah. So I think any time you start medication, there should be at first a very clear assessment of what's going on. And often we have validated measures to compare to the larger population to know how, you know, if somebody is depressed, how depressed are they compared to another group of teenagers. And same thing with OCD, the same thing with ADHD.

So looking at level of severity, impairment across settings and how much distress the child is feeling. And this is one of those situations where if somebody is in this situation where they need more than one medication, they also need family therapy, individual therapy, and potentially group therapy if it's available to try too. While the medication can reduce some of the core symptoms, they still need to continue to develop and to learn new skills, and that's what therapy is helpful for.

Tanuja Gandhi, MD (Host): So what I'm hearing is that, not every child is the same and not every kid presents in the same way. So there could be a cluster of symptoms that are unique to each case that we assess. And then based on the assessment, the clinician can then decide if it's going to be a first medication or a first therapy or a combination of therapy and meds first as an approach, and then you go from there. What I wonder is how do you explain to children, about the medications that they're going to take and how do we help them understand what medications are and why they need them?

Jeff Hunt, MD: I think that's a very common challenge and it starts early in kids' lives when they have to take antibiotics or need to get vaccines. The parents' involvement in the education is very important. How you frame why they're taking the medication and the developmental level that the child can understand is really important. And I think the child psychiatrist or pediatrician, are able to meet the child, see where they are developmentally and during the initial assessment, can figure out what worries they might have about taking the medication. What often it's related to is what side effects they're going to feel. Are they going to feel different? Is grandma going to have some reaction to her or him taking the medication? And what often happens is in parental divorce, there are two separate parents.

They have two separate ideas about medication. And if they're not on the same page, the kids, react to that very quickly. But the main point is, trying to know where they are developmentally and also, asking the kid to help tell you how they understand why they're taking a medication.

Greg Fritz, MD (Host): So you mentioned the parents having issues about it and questions. What are some of the concerns that are most common that parents have when meds are introduced that might be useful for their child?

Jeff Hunt, MD: I would say one of the most common is my child going to have to take this medication for the rest of their life? And that's a question that is something that the child psychiatrist, depending on the type of disorder, might be able to say, well, this is anxiety and we're gonna use fluoxetine or Prozac for the next year. See how they do, see how they benefiting from therapy.

And if things are improving a year from now, we might be able to reduce it and stop it. The same thing is true with depression in a early adolescent. After a year or so, if the symptoms of depression have improved and they're back to their baseline, then you can gradually taper and discontinue the medication. The things that for both anxiety and depression, that might lead you not to do that, is if there's a really strong family history of both anxiety and depression or in a middle to late teenager, if they've already had two episodes of depression, their chances of a third one is close to a hundred percent.

So if you know that the episodes are going to come back, then you have a discussion about that you're going to do better off as you head off to college remaining on your antidepressant or your anti-anxiety medicine.

Tanuja Gandhi, MD (Host): I think that's such wonderful advice given that sometimes people feel medications are going to be for life or don't feel hopeful about recovering once they're on a medication. And so important for us as clinicians to note that de-prescribing or taking medications off when things look good or when there's an indication to do so, is a reasonable practice. How do clinicians decide between different types of medications, which one would work better or which one we should be prescribing?

Jeff Hunt, MD: Yeah. Again, depend on the diagnosis that you're trying to treat, and also how long they've been in treatment. A lot of patients that end up in the hospital might have had two or three trials of medication. So there's, there's some decision about what other meds have been tried. Then you start looking at different categories of medication. If for example, the, selective serotonin reuptake inhibitors don't work, there's another category of antidepressants that you would want to make sure that you, you would try, and sometimes the first medication that you try might be informed by whether a parent has done well on a medication. Whether it's for anxiety or depression. And that even though it's a little far from a genetic profile, it does serve the purpose of a starting place. And many times it's a very helpful strategy.

Greg Fritz, MD (Host): Can you give us sort of just a case example of how medications and therapy of one form or another have been used to both complimenting each other?

Jeff Hunt, MD: Yeah, I think in a major depression, in a middle teenager, they begin to develop the symptoms of depression by being sad, lack of interest. They're staying in their room. Not exercising, not talking to friends and then with their parents, they're often quite irritable. And medication will help a lot of those things. But as I mentioned before, a lot of the strategies to get better can be dramatically improved with psychotherapies like cognitive behavioral therapy. Like, some components of cognitive behavioral therapy are behavioral activation. Which is, getting out of bed and making a schedule. It's also helpful to learn the strategy of assessing how you think and sometimes when kids are depressed, they think everything is bad, nothing's going to ever be good, so, having that form of therapy is very useful. I think the medication is helpful in those severe cases where they can't even participate in therapy and medications allow them the energy and the ability to participate and then, that combination, I think the research has pretty clearly shown that there's a benefit to combined treatments.

 Um, and that's a good example. The same with anxiety disorders and OCD. Those kind of things.

Tanuja Gandhi, MD (Host): So I know, in working with families that sometimes families are under immense pressure, be it internal or from other family members or their partners to avoid meds altogether. Sometimes there is this fear of medication side effects, it's a true phenomenon. You do have side effects from medication and sometimes the need for a medication is very clear, but families have this pressure to avoid it because they don't want to have their child on medication and feel guilty or hesitant to accept a treatment which might otherwise be indicated.

 So do you have any ideas or tips on how to talk to families who are experiencing this kind of pressure about making that choice about a medication or not?

Jeff Hunt, MD: I think it's first important to validate their feelings of ambivalence about this. Most of the time this is new for families coming to a child psychiatrist or to even a pediatrician and thinking about taking a medication for an emotional disorder.

There's a lot of misinformation on the internet. There's usually lots of opinions within families, as I mentioned before about taking medication. There's that expression of opinions falls to the parents when they have to decide. And they also have a pretty intimate knowledge of what's happening with their child, which is why they're pursuing getting some help for their child and, and using medication.

It's also helpful to have them think about the impact of not treating and what's the impact of persisting depression or anxiety when we have a, a known treatment that can help a child, to reassure them that this is a evidence-based process. You know, that we are following and these medications have been studied.

Doesn't mean that we will pick the perfect or right one each time, or that the child won't experience side effects, but it is something that we will monitor it closely together. The other thing is that with the exception of maybe a very severe psychotic disorder, that parents still get to make the decision about when they choose to start medications.

And so if they're not ready to start for their son or daughter, then you wouldn't just say, see you later. You would say, let's see you back in a month. See where things are, and if things are improving or the symptoms are improving, then you continue. Hopefully they have gotten into, uh, some therapy. At some point, it sometimes does take a few weeks for families to decide, or takes a few weeks for both parents to decide that they're going to start medication.

And then I think as you mentioned, there's a worry about stigma. What's this mean for my son or daughter to be on a medication. And that I think is slowly improving in the community where more kids are talking about being on medication, more parents are talking about having depression treated for themselves.

Tanuja Gandhi, MD (Host): Yeah. It's mind boggling, how we think about physical illness and mental illness and it's oftentimes not the same. I do agree with you that there is more awareness about children having mental health difficulties and struggles that it does not always, mean putting them on medication, but knowing that children can experience depression, anxiety, and a host of other mental health challenges just like adults do. I think there is a little bit of a change in that understanding.

Greg Fritz, MD (Host): So Jeff, you mentioned the stigma, both of you were doing that. And you know that this is one of the goals we had in this particular podcast was to break down the stigma that is associated with psychiatric medications.

So as a first, we have a quick lightning round to wrap up our episode today. Assuming you are ready to take this.

Jeff Hunt, MD: I am ready.

Greg Fritz, MD (Host): Okay. Tanuja hit it.

Tanuja Gandhi, MD (Host): So name one sign a child might benefit from a medication evaluation.

Jeff Hunt, MD: Persisting distress and impairment from the illness.

Tanuja Gandhi, MD (Host): I think that's 10 on 10. Were we scoring for 10?

Oh, well, the next one, one myth about psychiatric medications for kids.

Jeff Hunt, MD: You'll become addicted to them.

Tanuja Gandhi, MD (Host): That is true. As in it's not true. A phrase parents can use to talk to a child about meds.

Jeff Hunt, MD: We are going to include you, the child in the discussion about taking medications in ways that you understand.

Tanuja Gandhi, MD (Host): And the last one, best place to start if you're unsure about medication.

Jeff Hunt, MD: Talk to your primary care pediatrician or the family practice doctor or other primary care clinician. They often have a longitudinal perspective of your child that can be very helpful in deciding how changed they might have been because of the mental illness that you're worried about.

Tanuja Gandhi, MD (Host): Oh, that sounds perfect. That was great. Thank you Jeff. I do want to go back taking a little bit of a pivot to one of the rapid round questions that we asked, one myth about psychiatric medications for kids. And you'd mentioned that the child would get addicted to it. Can you speak a little more to what you mean by that?

Jeff Hunt, MD: Particularly for kids with ADHD taking stimulants that because they have the potential to be abused, why are we giving this to six, seven, or 8-year-old kids? And the reality is that the research shows that if you aggressively treat ADHD with medication and therapy that the likelihood of substance abuse is significantly less than if it's untreated ADHD.

And that's been, you know, over the last 20 years of research. So we know a lot about them, but that's probably the main one. And then sometimes they have a misrepresented idea that any of these medications that we use like antidepressants, that somehow it's changing their brain so that they need them.

And that isn't what the definition of addiction is. There's no craving of antidepressants. They're actually no craving of stimulants for kids with ADHD. And so that remains a very common worry. It is something I think we can continue to address through podcasts like today.

Tanuja Gandhi, MD (Host): That's wonderful. I think you mean when you said it decreases the risk of substance use when the kids grow older, right? Right. and to add to that, I think I've seen a change in children when medications do work and when therapy works, when the combination works, all of that. And sometimes when we take medications away, there is a reaction that the brain has to readjust to not being on meds. But I think the subtlety is in listening to your response, that addiction has a very specific meaning as you explained.

Jeff Hunt, MD: Yes.

Tanuja Gandhi, MD (Host): This has been remarkable. Thank you, Jeff. I hope all of you have found this as informative as we have. Thanks to our listeners, and be sure to check out all our other podcast episodes at www.bradleyhospital.org/podcast. Thanks and take care.