Tuesday, August 22, 2006

Medicine: ADHD stimulants getting black box for heart problems, psychotic behavior

The FDA has become trigger-happy with its cute little black box warnings. Here's a sample from one of their latest meetings.

FDA wanker 1: Oh know! People shouldn't take these really important psychiatric medications! It might have a 1 in 100,000 chance of making them piss themselves on Tuesday nights! And I'm basing this statement off really lousy data, but it's better than we had for Vioxx!

FDA wanker 2: I know! I mean, Johnny might have a 1 in 50 chance of blowing his brains out with his dad's Glock, but if he takes this anti-depressant, he'll have a 1 in 50,000 chance of thinking about shooting himself more than he would have!

FDA wanker 3: And fuck stimulants. God knows that people with ADHD are just lazy assholes who should learn how to drink coffee like the rest of us!

FDA wanker 2: Any new ideas on how to osbtruct plan B?

FDA wanker 1: They should have to shoot their babies with Glocks like the rest of us instead of getting to avoid the consequences of being dumb enough to get raped. That girl should have known better than to walk around the streets at 7pm without her burka on...

FDA wanker 3: Sorry, I wasn't paying attention. What did you say? Oh, look at the bird in the tree!
I'm all for informing patients (and parents of patients) about the reality of being on psychotropic medications. Sure, stimulants are overused by primary care docs who have rich white patients who are getting B+'s instead of A-'s and only got a 1900 on their SAT because they couldn't pay attention well enough to study after playing World of Warcraft for six hours every night.

However, scaring patients is not the same thing as educating them. If the FDA is going to add a black-box label to a psychiatric medication, it should say a little more than "Abandon hope, all ye who enter here!"

Patients are okay at saying that they don't want to take lisinopril to lower their blood pressure if it might wipe out their last little bit of kidney function. Patients are okay at saying they don't want to take their coumadin to keep from having a stroke if it means that when they fall next week they're going to bleed to death.

But parents aren't good at saying, "Well, if my child isn't on this medication, they might wind up flunking out of high school and smoking crack, but if they are, they have this theoretical risk of a heart problem. Hmm." Parents are scared of giving their kids ANYTHING with a risk, because if a kid gets hurt by a disease, that's the disease's fault. If a kid gets hurt by a drug, that's the doctor and the parent's fault for letting the kid take the drug.

Bottomline of this angry ramble: Yes, psychiatric medications have significant and important medical risks. But, yes, untreated psychiatric disease can be fatal in and of itself and has immense functional consequences for the future. Psych meds for serious psychopathology are no more "optional" than are antihypertensives for folks with high blood pressure.

We owe our patients, and especially their parents in the case of kids, a full education concerning the benefits and risks of putting their kids with real psychopathology on powerful medications that haven't been studied as well as we'd all like. I don't care if the rich, white B+ students get their Concerta or not. But I'm scared to death that a poorly educated parent could make a completely uninformed decision about their children's future because the FDA wants to freak them out with a big black box.

Bad FDA. No Plan B for you.

No comments: