Our Real Child Psychiatry Challenges

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

On last Thursday, the day before Valentine’s Day, an executive order from our federal government established a “Make America Healthy Again” commission, to be led by newly approved Health & Human Services Secretary Robert F. Kennedy, Jr. As reported in the Washington Post on Monday, February 17, Presidents’ Day, “Trump casts psychiatric and weight-loss drugs as threats to children.”¹

As to psychiatric drugs specifically, one of the commission’s tasks is to scrutinize the “threat” to children from antidepressants, stimulants, and other common psychiatric drugs. The data apparently justifying this plan were from 2021, as 8% of children between 5 to 17 years old received psychiatric medication. Is that just about right, too little, or too much? As claimed, is there undue difficulty in withdrawing from some of these medications? And is there too much off-label usage?

Already, the American Psychiatric Association (APA) leadership made an important initial public response in the APA Psychiatric News Alert of February 14th with this commentary: “‘Make America Healthy Again’ Commission to Examine Use of Psychotropic Medications.”² APA CEO and Medical Director Marketa Wills wrote to APA members:

“We know from the evidence and from our own clinical practice that the psychiatric drugs mentioned in the order when prescribed and used as directed by properly trained psychiatrists are safe, effective, and in some cases, lifesaving.”

Yet, I wondered, do we need to also present evidence to support such an ideal, as it behooves us to not be defensive about any apparent public criticism of our clinical care? This need to do so is complicated by the fact that ever since the takeover of medicine and psychiatry by for-profit managed care, reimbursement, cost savings, and profits have led psychiatry to not only eliminate some unnecessary treatment, but also to prescribe more medication in view of systemic obstacles to psychotherapy, including family therapy, play therapy, and other established options.³

The government claims that they will continue to review current best practices and relevant scientific research. In the meanwhile, given my extensive participant/observer experience in managed care, here is my own limited review.

One of Kennedy’s conveyed solutions is to create “wellness farms” where getting off psychiatric drugs would be easier. In particular, and conveying possible racism, is the contention that such places could be very especially appropriate for Black youth.

Back in the 1990s, the research about the effectiveness of psychiatric treatment, not broken down into adults and children, was that about a third of patients improved significantly, a third remained about the same, and a third worsened.³ When my own not-for-profit academic managed care system asked for justification for treatment decisions, most clinicians replied that it was the way they always prescribed. With our increasingly fragmented systems of care, it is harder to put together such a summary now, but here is some of what I have initially found for child mental health care in the United States:

• A review from 2021 indicated that overall youth outpatient outcomes were positive, but modest.⁴ About half received evidence-based treatments and they improved the most.
• A 2023 systemic review and meta-analysis for youth indicated that less than half of those needing mental health care received it, especially for anxiety and depression.⁵
• Another 2023 review of psychotropic medication for school-age youth concluded that caution is needed and a “whole-child” approach was generally best.⁶

Conclusions

My own limited review indicates that for the most part, psychiatric medications have an important role, but a very limited one if it is quickly prescribed as an isolated treatment. Bigger problems may be a continuing rise of mental disorders among youth due to various social determinants of mental health; a lack of any indicated treatment; an insufficient workforce; and obstacles to “whole-child” interventions. To paraphrase a popular saying, there seems to be no scientific justification for throwing out the medicated baby with the dirty bathwater of the business control of medical interventions.

There are major and distressing problems in youth mental health and treatment, but it is not primarily the medication one that the commission is going to examine.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Nirappil F, Cha AE, Gilbert C. Trump casts psychiatric and weight-loss drugs as threats to children. The Washington Post. February 17, 2025. Accessed February 21, 2025. https://www.washingtonpost.com/health/2025/02/16/trump-psychiatric-medications-drugs-weight/

2. Psychiatric News. ‘Make America Healthy Again’ commission to examine use of psychotropic medications. February 19, 2025. Accessed February 21, 2025. https://www.psychiatryonline.org/doi/10.1176/appi.pn.2025.04.4.13

3. Moffic HS. The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.

4. Lang JM, Lee P, Connell CM, et al. Outcomes, evidence-based treatments, and disparities in a statewide outpatient children’s behavioral health system. Children and Youth Services Review. 2021;120:105729.

5. Wang S, Li Q, Lu J, et al. Treatment rates for mental disorders among children and adolescents. JAMA Netw Open. 2023;6(10):e2338174.

6. Shahidullah JD, Roberts H, Parkhurst J, et al. State of the evidence for use of psychotropic medications in school-age youth. Children (Basel). 2023;10(9):1454.