In case of children you need to be doubly cautious while prescribing psychotropic medicine. This presentation should help those who work in developing countries like India.

1. STRIKE THE RIGHT BALANCE WHILE PRESCRIBING
PSYCHOTROPICS TO CHILDREN IN DEVELOPING
ECONOMIES
Devashish Konar MD Consultant Psychiatrist
Mental Health Care Centre, Kolkata, India
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WPA 2014 Madrid, Spain

2. DISCLOSURE
I don’t have any financial disclosures to make.
Literature whenever quoted source has been mentioned.
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3. THE CHALLENGE
• Mental health issues are being recognised more and at an earlier age.
• Issue is alarming, at the same time recognising them early is good for
the child.
• Treating and maintaining them in the society with
trained-manpower- crunch remain the main challenge in developing
economies.
Frellick 2014
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4. CAN’T DO IT ALONE
• The shortage of clinician with specialised training in assessing and
managing the treatment of patients with mental disorder is a major
barrier to providing adequate services in low and middle income
countries (Saraun & Dua 2009, Saxena 2007 Kakuma et al 2011).
• Current models that rely on mental health professionals to deliver
care are unsuitable for low and middle income countries, where
number of mental health professional in lacking (Patel 2009).
Raynaud 2014
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5. TAKE HELP
A shift to collaborative care to emphasise training, supervision, and
tertiary care while transferring the bulk of direct service delivery to
community health workers or primary care professionals who would
receive specific training and supervision in mental health is needed.
(Patel 2009)
Raynaud 2014
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6. ADJUSTING WITH REAL LIFE SITUATION
• Inadequate trained personnel remains the fore concern for
developing economies.
• So managing the work load with constraint of resources makes the
work difficult.
• Clinical work-up has to be brief.
• Therapeutic sessions may have to be cut down to counselling.
• Medication may become important part of treatment.
• Judicious prescribing and never, ever, over-prescribing should be the
mantra.
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7. PSYCHOTHERAPY VIS-A-VIS PHARMACOTHERAPY
• Targeted psychotherapy by appropriately trained mental health
clinicians remains the safest and most efficacious treatment modality
for many psychiatric disorders in the pediatric population.
• Medication is only one piece of treatment plan.
• Relying on it may be the need if other trained personnel are not
available.
• And then, if we know that psychotherapy is the safest and most
efficacious treatment, training has to be taken up urgently. Culture
specific models need to be tested and popularised without delay.
Szigethy 2014
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8. FACILITATING EARLIER PSYCHIATRIC CONSULTATION
• One of the most important points is facilitation of earlier psychiatric consultation.
• Too often, referral for psychiatric evaluation is only considered in the context of a significant
worsening of clinical status, such as onset of suicidal ideation, or when a patient or family is
beginning to lose hope and turn to medications “as a last resort.”
• It is important for providers to inform patients and families that waiting for symptoms to become
more severe may decrease the probability of response or remission of symptoms.
So, on the one hand they need to be educated to come early for assessment and on the other
hand you need to restrict yourself in prescribing medication unnecessarily or at the drop of hat.
Trivedi 2012
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9. IT IS IMPORTANT TO IDENTIFY EARLY
• Childhood and adolescence is a period of extraordinary biological,
psychological and social growth.
• However, at such times, individuals are also vulnerable to disruptions
of healthy development.
• 50% of all adult psychiatric disorders have manifested by age 14,
with 75% manifesting by age 24.
• Two thirds of pediatric-onset psychiatric disorders are moderate or
severe, and most continue into adulthood.
• So early identification and appropriate treatment of psychiatric
disorders as early as possible to preserve healthy development and to
reduce individual suffering and societal burden is important.
Rapoport 2013
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10. INVESTIGATION: IF NOT ADEQUATE, BE OPTIMUM
• Adequate investigation may not be feasible due to financial
constraints but important ones cannot be omitted and safety
concerns may never be downplayed.
• So taking hints from clinical presentation regarding adverse effects
may be more important in the context of developing economies.
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11. SERVICE DELIVERY MODEL HAS TO BE INDIGENOUS
• With limited trained child psychiatrists, training other general
psychiatrists and even pediatricians and family physicians may be
more important than in developed economies.
• Sensitisation about diagnostic clarity, proper drug selection, some
minimal counselling and psycho-education skills and identifying
adverse effects are the minimum targets that we need to foray into.
• Copying western models may not work across the countries and
cultures.
• Chances of being biased in diagnosis and treatment in favour of
multinational pharmaceuticals may be a serious trap.
• Culture specific models need to be worked up.
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12. TRANSMITTING INFORMATION IN THIS COLLABORATIVE MODEL
HAS TO BE SPECIFICALLY VERY RESTRICTED AND SIMPLE
Antipsychotics
Risperidone
Aripiprazole
Quetiapine
Antidepressants
Fluoxetine
Escitalopram
Sertralin
Mood-stabilizers
Lithium
Divalproex
Drug for ADHD
Methyphenydate
Atomoxetine
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13. SOCIAL PRESSURE MAY DECIDE TREATMENT OPTION
• Usually acute crisis brings the child in contact with services.
• In these instances, parents and school personnel may demand rapid
results.
• Waiting lists for psychosocial treatment and longer periods to initial
symptom control may further diminish the attractiveness of
psychotherapy.
• Psychopharmacology may be in demand.
Rapaport 2013
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14. CHILD PSYCHOPHARMACOLOGY BECOMING MORE IMPORTANT
• There have been a number of groundbreaking developments in the
management of pediatric psychiatric disorders.
• No more exclusive reliance on psychological and behavioral
interventions, psychopharmacologic advances have provided
important biological management tools for severe pediatric
psychiatric disorders.
• The advent of modern psychopharmacology has further informed the
efficacy and tolerability of major psychotropic drug classes in youth.
• This progress has been facilitated by regulatory agencies encouraging
and, more recently, requiring adequate studies of pharmacologic
agents in pediatric patients.
Rapoport 2013
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15. NEED TO HAVE ONE’S OWN RESEARCH AGENDA
• Research even though may seem a luxury in developing economies,
there is a definite role of it for having country specific, culture specific
and need based models of delivery.
• Copying western models blindly may neither serve the purpose nor
address the problem adequately.
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