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Psychopharmacology In Court

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A previously outgoing, athletic and scholastically proficient 12 year-old begins to show increasing academic problems. Over the course of 18 months, he is treated by HMO pediatricians and child psychiatrists for ADD (Attention Deficit Disorder) to which the diagnosis of Oppositional Defiant Disorder and Bipolar Disorder are progressively added on.

PsychiatristHe is treated with a variety of psychostimulants such as methylphenidate with an atypical antipsychotic added on. Increasing cognitive deficits and worsening school performance causes him to be moved to a special day-class. Early signs of handwriting deterioration and worsening sports performance are chalked up to clumsiness and "attitude". Increasing apathy and motor un-coordination prompt a referral to a major university center where a neurological work up results in a definitive diagnosis of adrenoleukodystropy. The child dies in 6 months. Early recognition could have resulted in bone marrow transplants which have been life-saving for the condition.

A 17 year-old with no prior history of violence was placed on antidepressants. He was receiving "split care "between his psychiatrist, primary care doctor and therapist. He began to experience increasing agitation. On the presumption of worsening depression, the antidepressants were increased with inadequate face-to-face follow up. A few weeks later, the patient exploded into catathymic violence, killing his neighbors and himself. Records suggest that he may have experienced an antidepressant-induced dysphonic (mixed) mania, a condition that is associated with serious violence and self-harm.

A 35 year-old male with a history of schizophrenia is given long-acting haloperidol against his wishes in a psychiatric in-patient setting. Increasing confusion, agitation and incontinence are interpreted as acting out, along with increased psychoses, for which he is given more antipsychotic medication. Elevated body temperature and elevation of white blood cell count are noted, but not aggressively worked up and examined. Eventually, increasing delirium and hyperthermia with shock follow. Neuroleptic malignant syndrome is diagnosed and the patient is transferred to a general medical hospital, where he dies in two weeks from complicating pneumonia.

A 70 year-old female has been treated for 20 years by her primary care doctor with Triavil, a popular non-addictive "sleep aid ". Triavil is a combination of elavil, a tricyclic antidepressant and trilafon, an antipsychotic /neuroleptic medication. Her adult son, who entered the medical field, becomes concerned about her frequent and progressive involuntary pouting, tongue thrusting and facial grimacing. Making the right assumption, that it was related to the Triavil, he has her stop the medication. The abnormal involuntary movements become more intense. Records reviewed note no indication that the patient was advised of the risk of tardive dykinesea, an irreversible neurological condition that occurs in a significant proportion of elderly people if they are given such medications for extended periods of time.

A 30 year-old female is prescribed Zyprexa for the diagnosis of Bipolar Disorder. Within a year she has gained over 100 pounds and now has diabetes mellitus.
The perfect storm of insurance restrictions for non-pharmaceutical interventions, combined with the introduction of better-tolerated psychiatric meds, has led to unprecedented use of powerful, prescription drugs among the public. Psychotropics that were formerly reserved for the seriously mentally ill are now prescribed for milder forms of depression and anxiety.

What constitutes a mental or emotional disorder that warrants medication is constantly being re-defined. The boundaries between bipolar disorder and attention deficient disorder have widened across populations and age groups. The thresholds for the diagnosis of these conditions have become lower and looser.

A significant proportion of these prescriptions are not coming from actual, qualified psychiatrists; the prescribing may be done by pediatricians, primary care doctors, nurse practitioners and physician assistants who lack familiarity with these medications and their potential complications. In many instances, these diagnoses are made by parents and teachers, or suggested by acquaintances that have been exposed to radio and television advertising.

Of great concern is the "off label" use of psychiatric meds, as well as medications used in treating neurological and general maladies. For example, drugs used for treating hypertension such as clonidine or propranalol may be used for treating ADHD and anxiety. Anti-epileptics are now prescribed for bipolar disorders, headaches, fibromyalgia, chronic pain, irritability, restless legs and aggressive behavior. Much of this off-label use is poorly researched and the attendant risks, benefits and alternative treatment options are often inadequately represented to the patient (or their caretakers).

Problems related to the use of psychiatric medications are compounded by poor communication between the therapists who do psychotherapy and the psychiatrists who prescribe medications. Sometimes there are limitations on the number of visits that a patient can have. There is an insurance-driven trend to give a three month supply of medications for cost cutting that results in poorer follow up. There is also the very visible and front-of-mind direct advertising of psychiatric medications in popular magazines.

Particularly vulnerable are those who receive mental health monitoring and treatment from public/ private partnerships where the goal is cost-cutting, resulting in poor access to knowledgeable professionals and frequent changes in providers. The list includes prisons and jails, juvenile detention centers and minors in the foster care system. Polypharmacy, without skilled supervision, carries considerable risk of morbidity and even mortality from drug interactions.

Not surprisingly, these trends are spurring a great deal of litigation. As professional psychiatrists and psychologists, our opinions are based on the facts of each case, which of course change from person to person. We focus on understanding both the causal factors that have lead to the alleged problems and the scope and nature of these difficulties.

by Dr. Mohan Nair M.D.

To schedule a complimentary consultation on any matter involving brain injury, emotional distress or product liability cases involving psychotropics, please contact Atrium Psychological Group at (866) 446-0991 or visit our website at www.atriumpsych.com.


Atrium Psychological GroupAtrium Psychological Group
11500 Olympic Blvd, Suite 580
Los Angeles, CA 99064
(866) 446-0991
(310) 464-1165

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