It was Michael’s first day at the Tony New Hampshire boarding school that his father thought would be a good idea. They arrived early because they had so many stops to make on the woody campus. First, academics, for the class schedule; then housing, for the room assignment. And then the nurse. For drug orientation. The infirmary had been open only fifteen minutes when they got there, but the line was already out the door and down the hall. After a long wait they reached the nurse, a thirty-year-old guy with long red hair.
“Take any medications?” he asked. “If so, please turn them in.”
Behind the nurse dude was a stack of brown-paper lunch bags. Michael was handed one and told to place all his meds in it, write his name on a label and staple the bag shut. While he followed orders, the nurse recited the school’s drug policy.
No pharmaceuticals were allowed in the dorms. Those students taking stimulants or antidepressants — and Michael was on one of each, Ritalin and Wellbutrin — were required to report to the infirmary for one pill at a time, regardless of the hour. And they weren’t allowed to skip doses.
Michael’s father, Jerry, a lawyer from Ohio, handed over the bag and watched as the nurse added it to the others on a rolling file trolley. He thought there seemed to be an awful lot of bags. Then he looked past the nurse and realized that was the third pile. There must have been 100 bags of medication already, and students had been checking in for less than an hour. Jerry was stunned by the sheer volume of what had been turned in. His son was more surprised, later, by what wasn’t turned in.
“Whoa, lotta drugs going on at that place,” says Michael, who is tall and lean with an angular face and a long jaw like a Modigliani. “They tried hard to keep it like it was controlled, but the kids would still snort lines of Ritalin because they thought it was like cocaine — which it isn’t, but tell them that. There was this kid who could get as many sleeping pills as he needed from his psychiatrist back home. It was Ambien [a fast-acting sleep inducer], which some kids were given to cool down from their regular dose of Ritalin, which can keep you up all night. So he would sell these Ambiens, and everyone would use them, because they made you feel drunk faster. At boarding school, beer is the thing that’s expensive and hard to get. There was also a guy who would crush Ambien, sprinkle it on marijuana and smoke it. He said it made him trip, but I never tried that one.”
Michael had been taking Ritalin on school days since third grade, when he was first diagnosed with attention-deficit disorder, a learning disability. He thought it was probably an accurate diagnosis, even though he wondered why he hadn’t been sent for evaluation until his parents got divorced. But only when he got to boarding school was he educated in the uses and broadening abuses of the pharmacopeia of legal and illegal drugs available to adolescents today.
At school, for instance, he learned the ABC’s of mixing medicine and alcohol. “If you’re drinking and on Ritalin, it probably doubles or triples the alcohol effect,” he explains almost clinically. “When you’re on an anti-depressant, it does the same thing, but it knocks you out. You know, it says so right on the bottle.”
Before long, Michael secretly stopped taking his Ritalin (although he still picked it up at the infirmary in the morning) because he felt it was making him depressed. He then started taking massive amounts of ginseng pills from a health-food store, because they seemed like a more natural stimulant. And he bought some Ambiens from his dorm mate, because he figured they would counteract the racing effect of the ginseng.
Since he had been on varying doses of different medications for nine years, Michael felt fairly confident in his ability to self-medicate without consulting his psychiatrist back home. But as winter break approached, he found himself in a mental whirlpool: panic attacks, paranoia and depressive psychosis.
When his dad brought him back home, Michael’s doctor gave him Xanax, a sedative that also treats acute panic symptoms, and Luvox, an anti-depressant also used to treat longer-term anxiety. Michael came very close to being hospitalized. In all his years of psychiatric treatment, it was the first time he felt like he was losing his mind.
When the drugs started working and he began to feel better, his doctor switched him to another anti-depressant, Paxil. Within a few days, he experienced a side effect that nobody had warned him about. He couldn’t get it up. “My penis was … well, specifically, it was limp,” he says sheepishly. “Also, I was not interested in sex for a couple of weeks after taking the medicine. During that period, there were times I wouldn’t have wanted to be with a girl.”
The childproof cap is off the pill bottle. Prescribing medications to kids as freely and haphazardly as to adults is no longer taboo. And a new drug culture has emerged, the legal one most familiar to kids today. This is the first generation ever to practice chemical manipulation of the brain with parent-approved medications long before being exposed to the standard illegal recreational substances.
And we’ve moved far beyond Ritalin, which is still one of the few psychoactive medications specifically approved for use in patients under 18. Today, drug companies are in the home stretch of the race to get Food and Drug Administration approval to market Prozac and other anti-depressants directly to kids — possibly even through TV ads.
When Prozac was approved for adult use in the late 1980s, it changed the way Americans felt about the use of psychiatric medicines. The same thing is likely to happen when the drug is approved for patients under 18. And kids being treated for serious mental illnesses will increasingly be joined by young patients who aren’t that sick, or might not be sick at all. But teens will still be asked to try some of the most powerful and expensive psychiatric drugs available — in part because the HMO-driven treatment market often views pills as more cost-effective than therapy or counseling.
Michael’s inability to get it up isn’t likely to be included in any managed-care cost/benefit analysis. Of all the questions unanswered — even unasked — about the side effects of anti-depressant use for children and adolescents, the ones about sexual development are among the most provocative. Nobody knows how psychiatric medications will alter a teenager’s emerging sexuality.
“We are so quick to criticize somebody who would drop a pill in somebody else’s drink,” says California research pharmacologist Dr. James Goldberg, who is a co-author of the only comprehensive textbook on the effects of drugs on sexuality. “But a lot of times the doctor is dropping a pill into the adolescent’s drink, and dropping it in every day.”
While it’s true that psychiatric illnesses themselves, especially depression, can dampen sexuality, Prozac and its chemical cousins have a proven desexualizing power. “A lot of times I doubt patients have even been told that they might find it difficult to have an orgasm,” says Goldberg. “The new drugs coming out are very nice, but they’re explained so poorly, especially to adolescents.”
A recent study in the Journal of the American Medical Association shocked the nation with its finding that Ritalin prescriptions for patients aged two to four had tripled between 1991 and 1995 and prescriptions for anti-depressants in the same age group had doubled. In response to those numbers, Hillary Clinton called for a major federal effort to reverse the rise in pediatric psychopharmacology.
But it’s more shocking that anybody is shocked. Giving psychoactive drugs to kids is so common today that the subject was recently parodied on The Simpsons: An experimental drug called Focusyn, which researchers promised would reduce “class-clownism by 44 percent, with 60 percent less sassmouth,” turned Bart studious and then psychotic. In the end he went back to “good old-fashioned Ritalin” and sang, to the Popeye theme, “When I can’t stop fiddlin’, I just takes me Ritalin.”
According to estimates provided by Ims Health, the organization that does the “Nielsen ratings” of pill-taking, this new culture is already firmly established in the medicine chests and metabolic systems of America’s youth. The use of selective serotonin reuptake inhibitors — the class of anti-depressants that includes Prozac — has increased 103 percent in patients under 18 during the past five years, while rising only 21 percent in adults. While Prozac and Zoloft sales still dwarf those of Wellbutrin, prescriptions for that non-SSRI anti-depressant — which is now being heavily marketed on television for its lack of sexual side effects — have quietly increased by 215 percent in patients under eighteen over the past five years.
The number of American teens and preteens taking anti-depressants — for everything from clinical depression to bed-wetting — has been estimated at more than half a million. A recent study of family physicians and pediatricians found that seventy-two percent had prescribed an Ssri anti-depressant for a patient under eighteen, even though only eight percent felt adequately trained in managing childhood depression.
The well-developed Ritalin market is changing. Stimulant use in patients under 18 is up 59 percent in the past five years, and that increase isn’t primarily for Ritalin — it’s for drugs that are stronger and less well-researched in kids, including Adderall and Dexedrine.
There’s also been an explosion in the use of the strongest psychoactive medications available, anti-psychotics, in younger patients. These drugs were once restricted to adult schizophrenics. Suddenly, in the mid-Nineties, a Johnson & Johnson product called Risperdal became the Prozac of anti-psychotics — the drug that made it easier for doctors and patients to use, and overuse, this potent class of medications. It was followed by Zyprexa, and in the past five years, anti-psychotic prescriptions for patients under 18 have shot up by 268 percent, compared with an increase of 38 percent for adults.
For decades, doctors who treat children and adolescents have bemoaned the fact that medicines are almost never studied specifically in patients under 18. More than 80 percent of all drugs prescribed to kids are still given to them for what are called “off-label” uses. When drugs are approved by the FDA, they are intended for a fairly narrow, specific use in a particular patient population. But once a medication is approved, a physician may legally prescribe it to anyone for anything.
Yet even with the explosion of new uses, doctors still make prescribing decisions for younger patients using information circulated by medical word-of-mouth, based on informed clinical opinion, case reports and uncontrolled trials — a low threshold of knowledge that was discarded as inadequate for adults nearly forty years ago. Some recent federal directives have government and pharmaceutical-industry researchers scrambling to do studies that can justify, or at least fine-tune, all this new psychiatric prescribing. In the meantime, kids are doing what kids have always done with drugs: experimenting.
It’s important to note that many of the new and newly prescribed psychoactive medications will save young lives: According to Dr. Kay Redfield Jamison’s recent book, Night Falls Fast, depression leading to suicide kills more teenagers and young adults than cancer, heart disease, Aids, pneumonia, influenza, birth defects and stroke combined.
But the new drug culture is being driven by more than symptoms. Perhaps more powerful are the new market forces. Psychoactive medication has been possibly the single most promising growth area in the pharmaceutical industry — in terms both of medicinal innovation and sales volume. And patients under 18 are now among the largest target growth markets for psychoactive drugs.
Eli Lilly is leading the competition: The company has begun the last set of trials needed to get Prozac approved for patients under 18. Lilly is racing against its competitors, who also want the youth market: SmithKline Beecham is not far behind in its clinical trials for Paxil, and Pfizer is coming in third with Zoloft. A handful of psychiatric medications have already been approved for use in adolescents and children — for attention-deficit and hyperactivity disorder, obsessive-compulsive disorder and seizure disorder. But the ability to market Prozac and other SSRIs directly for childhood depression is the killer app.
Besides the heightened focus on young patients who are clearly suffering, controversial new studies are exploring preventive psychiatric-drug use in kids who aren’t sick at all — at least, not yet. In the U.S. and Australia, a small group of young, healthy patients with family histories of schizophrenia is being treated with anti-psychotics to see whether the onset of the disease can be prevented. It’s a noble goal, but if the concept of preventive psychopharmacology for children and adolescents is ever accepted by demanding parents and pressured doctors, imagine the sales trends by 2005.
And as the 13-year-old who is taking anti-depressants, stimulants or anti-psychotics — or all three — becomes the regular kid rather than the oddball, the new drug culture is slamming headfirst into the old one. Kids are prolifically mixing legal and illegal drugs. For years, medical journals have published occasional case studies of such situations; in March, the front page of the New York Times carried the story of the Trinity College senior who died after he and three other students took Xanax, Valium, butalbital and sleeping pills — and possibly heroin.
Last year, the National Institute on Drug Abuse released the first major study to determine whether early use of Ritalin makes kids more likely to try illegal drugs as teens. The study said no, but it did little to undermine the widespread suspicion that early medication use must have an impact on how teenagers view recreational drug play. Michael, for example, believes that “the more familiar you are with drugs at a younger age, the more you think they are part of everyday life — and that humans need drugs to deal with reality. At least, that’s the way it was for me.”
Experts used to think that most drug abuse grew out of “normal” kids “experimenting” and “getting hooked.” NIDA director Dr. Alan I. Leshner explains that clinicians thought that only a small population of kids illegally used psychoactive drugs because they suffered from clinical depression, mania or some other mental illness — and were “self-medicating.”
Now Leshner thinks the opposite might be true, and of the 2 million kids under 18 who use illegal drugs, a substantial number may be self-medicating for mental illness.
“Ten years ago,” he says, “nobody believed there was such a thing as child and adolescent mental disorders. It’s almost as if people didn’t take what kids were feeling seriously. We figured, ‘You’ll grow out of it.’ Ten years ago, nobody thought there was childhood schizophrenia. Kids were just weird.
“Now we believe there are 8 to 10 million kids with untreated mental illness,” he says. But he concedes that the medical system’s approach to prescribing for patients under 18 still isn’t ideal. “I help run a clinic at Yale, and in my private practice I see children,” he says. “Many of these kids have tried medicines they thought would work that didn’t. Many haven’t been monitored adequately. Some were misdiagnosed in the 15 minutes a doctor has to see a kid. It’s fair to ask how well these medications are being used. It’s not something the prescribers take lightly. But some drugs certainly are being prescribed without proper evaluation. And a lot of kids who need drugs don’t get them.”
Sandy is a teacher at a large suburban high school that runs a special program for teenagers with psychiatric histories. There are few programs like it in the country, which is why Sandy asks that no further identifying details be given — her classroom is already overflowing. Before this job, Sandy worked at a large, old psychiatric hospital where analysis was still practiced and older psychiatrists shared the traditional reluctance to medicate children. So she has seen the new drug culture grow up right before her eyes. She has mixed feelings.
“The problem is that behaviors considered normal in adolescents would be pathology in adults,” she says. “And medication has come to be seen as one way of controlling aberrant behavior. There are some behaviors which are so destructive and cannot be controlled in any other way: It’s better to control them with medication than to lock the person up. On the other hand, one of the biggest issues I hear from kids is that medication changes who they are as people. They get very angry about that and resentful of people imposing their values on them.”
Sandy hears from her kids about the fine line between legal and illegal drug use. “There’s a strong feeling of the hypocrisy of a society that can so easily prescribe so many of these mind-altering medications and still have so much trouble with illegally defined drugs — especially marijuana,” she says. “I hear a lot of, ‘How come I can go to the doctor to relax when I could just smoke a joint and relax?”‘
Sandy suggests that I speak with Katie, a former student who has been on various psychoactive medicines since the ninth grade. Katie is now a college freshman and is sometimes amazed at people’s casual attitudes about the world of meds. “You have the mini pill book in your bedroom somewhere — everybody has one,” she jokes. “You know what every pill does, and if somebody has something new that nobody else has tried, the ‘therapy kids’ will all talk about it.”
It hasn’t always been this way. Katie’s first years of treatment were torturous. “In ninth grade I was lethargic, crying a lot — the normal things a teenage girl would go through,” she says. “Didn’t like going to classes, got anxious all the time. So my mom sent me to a psychiatrist, who tried a lot of different things and then started me on Prozac.
“Taking Prozac was hard because of the way people talk about it. I kinda resent the name Prozac, because of all those articles about ‘Why are we medicating our children?’ and family values. The message is, ‘You’re weak; you have to take something unnatural; your brain works right if you’d let it.’ When I read a magazine, I feel belittled.”
During much of her experience with psychiatric meds, Katie was also smoking pot. “A lot of people self-medicate with marijuana because they don’t want to take their pills,” she explains. “Maybe you don’t trust authority, or you know you could sell your pills to get other drugs, I remember in high school, if you had your wisdom teeth out, people would say, ‘Want to give me your Percocet?’ I finally stopped smoking marijuana and mixing it with meds because I had a really bad night. I smoked a lot of pot, and I snorted some Ritalin. I had a panic attack. I was hallucinating. I felt there was a helmet going over my head and when the helmet got over my chin, I would die. Finally, I threw up.”
Katie has no doubt that psychoactive drug therapy has saved her life many times over. Yet it’s significant how her ambivalence about what she is doing still tugs at her. “I talk to people who have depression and won’t take medication,” she says, “and it’s hard for me to converse with them after they say they just stopped taking it. They go into their little speeches about the evils of medicating yourself with things that aren’t natural. Yet sometimes I think they’re right.”
Katie does understand that in the new drug culture, medicine and metaphor can never be separated completely. “It’s more acceptable in my generation to take medications, but my generation also wants to get riled up,” she says. “I don’t think a lot of people want to take medications. They don’t want to trust authority, because they want to have a cause.” To her, the war of words over kids on psychoactive meds is “our Vietnam. Medication is a symbol of authority, of being controlled by something that isn’t your own emotions. We don’t want adults telling us to take this. We don’t want to make things easier for adults by taking these meds.”
Much attention has been focused on the risks our society takes by medicating so many children, but little has been said about the dangers to individual patients. Adverse reaction to prescription drugs is the fourth-leading cause of death in America, according to a study in the Journal of the American Medical Association. Ten times as many people die from legal drug use as from illegal drug use.
Dr. Peter Jensen, director of the new Center for the Advancement of Children’s Mental Health at Columbia University, knows better than anyone how little is understood about psychiatric drugs.
Last May, he and his colleagues published a powerful series of articles in the Journal of the American Academy of Child and Adolescent Psychiatry, examining the science beneath the explosion in psychoactive-medication use by patients under eighteen. Along with the usual suspects, Ritalin and Prozac, they explored more than thirty different medications in 11 classes, from sleep inducers to anti-psychotics.
The “bombshell,” Jensen says, is that — except for Ritalin use for attention-deficit hyperactivity disorder — there isn’t “first-class evidence of safety and efficacy” for any of the child and adolescent prescribing that defines the new drug culture. Jensen and his group studied drug treatments for 15 major psychiatric diagnoses; they found proof of safety and efficacy for children and adolescents in only two cases: the use of stimulants for ADHD and the use of anti-depressants, SSRIs specifically, to treat obsessive-compulsive disorder.
This does not mean that the drugs aren’t safe or effective. It simply means that we still don’t know for sure.
When the use of drugs is researched in kids, it’s often easier to study younger children, whose parents still fully control their medical care and whose metabolism, while faster than adults’, is still relatively stable. In teenage patients, wide metabolic swings can really screw up expensive controlled clinical trials.
Teenagers are also notorious for not taking their medications. “It is sad but nevertheless true,” says researcher Ken Gadow, “that many teenagers elect not to take their prescribed medication for the required amount of time because of side effects or social stigmatization. And there’s something else in there — an unwillingness to accept the presence of a disability.” Because of this, even the modest clinical research data we have might be misleading.
There is also fear of more subtle adverse drug reactions caused by the muting or altering of processes in developing bodies. Several animal studies — primarily on rats — show that long-term Prozac treatment appears to permanently change certain sites and receptors in the adult brains of these animals. In a cautionary 1998 paper in the Canadian Journal of Psychiatry, the outgoing head of NIMH Child and Adolescent Research, Dr. Benedetto Vitiello, noted that while it was reassuring that “no persistent behavioral toxicity” has been reported in children taking psychoactive drugs, the possibility of “more subtle effects” hasn’t been ruled out.
He said that it took years before “a well-designed study” was able to show that one of the earliest common uses of medications in young patients — the prescription of phenobarbital for children at risk of recurrent febrile seizures — resulted in “a lower IQ after two years of treatment,” an impairment still detectable six months after the drug was discontinued.
Drug-safety experts are also concerned about what happens when children and adolescents go off their medications. “What I wonder about is whether there’s a rebound,” says research pharmacologist Dr. James Goldberg. “If you suppress the system and then take the top off, will that in itself cause a disruption to the system that could, ultimately, make it worse? SSRIs have a general muting function — they decrease impulse. When adolescents stop taking these drugs, things can become more disruptive and less predictable. I wonder, in the cases of kids shooting people where later we find out they have been treated with SSRIs. Now, they may have psychiatric problems — but if they go on and off psychiatric drugs, it might be jiggling the system and causing the more extreme effect.”
These are risks that science hasn’t come close to assessing. “We need to know that in terms of academic performance, sociopathic behaviors and social-adjustment issues, these kids are getting something for the risk — that controlling the central nervous system is worth it,” says Dan Safer, a prominent clinical psychiatrist and researcher. “We’re trusting that because nobody is calling us up saying thousands of students are failing to get into Harvard or winding up in jail because of Ritalin, then everything is OK.”
While parents might worry about developing brains, teens on medication are more likely to focus on how side effects intrude on their daily lives. Do the meds worsen their acne or cause them to gain weight? And what about their sex lives?
The sexual effects of psychiatric drugs range from a slight lessening of sensation to complete dysfunction, with all kinds of weird variations. There have been, for example, reports of patients on Prozac who experienced spontaneous orgasms when they yawned.
Goldberg is wary of the desexualizing power of the SSRI anti-depressants. “Paxil, for example, is one of the only drugs I’ve ever seen that can just stop orgasm in men,” he says. “Men cannot come to orgasm. In younger men, they begin sounding more like women — who often complain there’s no crescendo of feeling.”
The anti-psychotic Risperdal is also known to cause sexual dysfunction in some patients. It’s a risk that might be worth taking with floridly psychotic patients when all other treatments fail. “But I know doctors whose patients come in complaining of depression, and their thought processes are off,” says Goldberg. “They give them anti-psychotics and don’t even really tell them what the drugs are. I’d take Prozac any day over Risperdal.” (Even a staple like Prozac can be the wrong drug. Harvard psychiatry professor Martin Teicher recently said he believes that as many as half of all children diagnosed with depression and given Prozac or stimulants actually suffer from manic-depression, the symptoms of which can be worsened by these medications.)
A teenager’s sexuality can be affected by medication in other ways. “Ritalin does stimulate noradrenaline, so sometimes the penis tends to shrink,” Goldberg says. “Well, it doesn’t physically become smaller, but it’s more constricted in its resting state.” He says that if Wellbutrin is taken along with the Ritalin, then “the penis hangs better.”
For this reason, Wellbutrin has quietly become a sort of wonder drug. It doesn’t cause negative sexual side effects; in fact, it may even enhance sexuality somewhat, perhaps because of its slight stimulant effect. It became the drug of choice for adult men and women who couldn’t have orgasms on Prozac. And apparently it is catching on for patients under 18.
It pleases Goldberg to hear that patients are being switched from an anti-depressant that blunts their sexuality to one that doesn’t. Too often, he says, doctors would rather prescribe yet another drug to treat a side effect, a practice known as “polypharmacy.”
“Every day they’re coming out with some new cocktail,” Goldberg says. “The patient has dry mouth, they put him on another drug for that — until you get multidrug use that is really a form of drug abuse. I hear about people going off their Ssris for the weekend, or they take ten different drugs along with the SSRI, just on the day they’re going to have intercourse.”
He knows of adult patients with drug-induced sexual dysfunction who add Viagra to their drug regimens whenever they plan to have sex. And not just men — female patients are now experimenting with the drug to conjure sensation in anti-depressant-dulled loins. Goldberg says he hasn’t yet heard of any teenagers on Paxil being given Viagra by their psychiatrists, but it’s probably only a matter of time.
Michael, happily, didn’t have to go to that extreme. And while he’s obviously embarrassed to talk about it, he wants to make one point perfectly clear. “The side effect eventually went away,” he says. “And don’t you worry, I haven’t had any problems being erect since.”