Pharmacological Treatment of College Students with Psychological Problems

Leighton Whitaker, Stewart Cooper, Leighton Whitaker, Stewart Cooper

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317954446
• Topic: Education
• Subtopic: Higher Education

Get valuable insights into best practices and procedures for treatment Mental health practitioners across the country are increasingly treating students by combining the use of psychotropic medication with psychotherapy. Pharmacological Treatment of College Students with Psychological Problems explores in detail this uncritically accepted exponential expansion of the practice. Leading psychiatrists, psychologists, and social workers discuss the crucial questions and problems encountered in this widespread practice, and also present specific and differing models of combined therapy. This book critically examines several of the key issues, practices, and competing perspectives. Professionals working in college mental health are provided with valuable insights into best practices and procedures in split and integrated treatment. Various clinicians beyond the psychiatric field are prescribing psychotropic medications with increasing frequency. Pharmacological Treatment of College Students with Psychological Problems presents a wide range of viewpoints on this issue, offering evidence, arguments, and recommendations to clearly illustrate the need for increased attention to the use of psychotropic medications and show how psychotherapy may be safer and more beneficial. Chapters include discussions on withdrawing from medication successfully, long term perturbation effects, and differing models of combined therapy in practice. This resource is comprehensively referenced. Topics in Pharmacological Treatment of College Students with Psychological Problems include:

• identification of the key issues and practices of combining psychotropic medication with counseling in treatment
• elements of two separate university counseling centers and how they provide combined treatment
• emerging research on perturbation effects of use of psychotropic medications
• best practices in the combined treatment in college settings
• key unresolved questions that need further research
• bringing a more sophisticated level in the practice of combined treatment with college students

Pharmacological Treatment of College Students with Psychological Problems is a valuable resource for all professionals from seasoned professionals to beginning practicum students.

Part I
Issues and Concerns

Chapter 1.
Forces Pushing Prescription Psychotropic Drugs in College Mental Health

Leighton C. Whitaker

SUMMARY. A complex of forceful influences is greatly accelerating the use of what are usually referred to as "psychiatric drugs," although most prescribing is not done by psychiatrists. Many other clinicians, including other kinds of physicians, and recently psychologists, prescribe these medications. The influences contributing to this dramatic surge include the pharmaceutical and managed care industries, the more exclusively biologically-oriented "new psychiatry," lack of governmental supervision and safeguards, and the gullibility of consumers, Americans especially, in accepting misleading and unproven claims. The nation's future college and university students are increasingly medicated instead of nurtured and disciplined in more traditional ways. Yet, a strong counterbalancing force can be effective; institutions of higher education represent the kinds of critical thinking that could improve a rapidly deteriorating picture of medication misuse. doi:10.1300/J035v21n03_01 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2007by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Psychiatric drugs, college mental health, pharmaceutical industry, the new psychiatry

Introduction

One sees the big picture with the entire retina and the combined hemispheres.

Leonard Shlain

A little over two decades ago, only a small fraction of college students were given or expected to be given a prescribed mind altering medication. During the last twenty years of mental health services in higher education, the prescribing of psychotropic drugs has accelerated so rapidly that the current scene is all but unrecognizable compared to earlier eras.

Presenting Problems in the Medication Picture

By 1992, it was becoming common for students to arrive at campus mental health centers already on "psychiatric drugs" or asking for them immediately without questioning their supposed need for them (Whitaker, 1992). Only a decade later, according to the National Alliance for the Mentally Ill (NAMI, 2003), 40% of incoming undergraduates seeking help in college health clinics were already using one or more prescription psychotropic drugs. Shortly thereafter, it became common for students to "prescribe" for themselves and one another (Harmon, 2005). The growing numbers of students arriving on campus with a history of use, legally prescribed or not, usually expect that their past prescribing practitioners, or practitioners on campus, will continue their medications or start them on other psychoactive drags.

Whereas the Group for the Advancement of Psychiatry (GAP), in a 1990 publication on college mental health gave only passing mention to prescription psychotropic drugs, less than a decade later GAP observed: "As the number and variety of drugs increases, psychopharmacology becomes ever more complex. Psychiatrists must learn about drug interactions and the effects of drugs on different individuals and in different age groups, and so prescribing appropriate medications is no longer a simple procedure" (1999, p. 80).

By 2006, the complexity and, accordingly, the care needed to prescribe with any modicum of safety and efficacy have become even more extreme, and not only because of the proliferation of legally prescribed psychiatric drugs. Many other drugs used by college and university students are commonly adding to the mix. Alcohol is consumed by two-thirds of students and more than one-third engage in "current episodic heavy drinking" or "binge drinking" (Reppert & Johnson, 2002). But "Most students who are experiencing ill consequences related to abuse of alcohol will not present to the clinician complaining of a drinking problem" (p. 211) and clinicians are unlikely to inquire about drinking habits unless the students bring up the topic. Tobacco use, which "... kills more Americans each year than alcohol, cocaine, crack, heroin, homicide, suicide, car crashes, fires and AIDS combined" (p. 216), climbed among college students in the 1990s. The combination of alcohol and tobacco contributes synergistically, not just additively, to most forms of oral, esophageal, and laryngeal cancers. Clinicians considering prescribing psychotropic medication would do well to check first on these drug uses plus marijuana, hallucinogens, stimulants, methamphetamines, heroin, "club drugs" (e.g., "ecstasy"), LSD (lysergic acid), GHB (a central nervous system depressant), inhalants, and anabolic steroids. Steroids and other strength and performance "enhancing" substances have been used increasingly among college athletes despite evidence of many forms of damage that may not be quickly apparent but have serious long term consequences. As Mark Jenkins (2002) noted in his review of drags in sports, "The willingness of governments and private organizations to cheat and the advent of new technologies may herald a dark future" (p. 279).

Clearly, even the most assiduous clinicians are not going to pick up on all forms of drag use among their student patients but they should be aware of the hazards of drug prescribing not only in terms of the drags they prescribe but the considerable possibility that students will combine their prescribed drugs with drugs that clinicians do not prescribe. Unfortunately, some clinicians incautiously, without greatly needed inquiry, go ahead and prescribe though they know that drug use is endemic among college students. Besides doing careful inquiries and having considerable knowledge of prescription drugs and their interactions, prescribing clinicians should diligently monitor their patients to try to minimize harm. Meeting even such minimal standards is almost certainly not typical of prescribing practices.

What could account for these very serious flaws in prescription procedures? First, most prescribing is done by non-psychiatrists, including other physicians, physician assistants, and nurse practitioners. Second, psychiatry residency programs, including at leading universities, provide less and less training and experience in understanding the importance of personality dynamics so as to gauge the consequences for patients, for example in regard to drags with stimulant effects, including SSRIs, to discern a proclivity to hyper-responsiveness. Third, monitoring and follow-up after prescribing are inadequate in most cases, even totally absent in some cases. Fourth, health care has tended to become a business at the expense of the doctor-patient relationship, so that personalizing and humanizing care is often compromised. Whether an appointment is seven or seventeen minutes, there is not enough time to gather a thorough drug or other medical history, much less to get to know the personal dynamics of the individual in one's care.

The Surge in Prescribed Psychotropic Drug Consumption in the United States

To understand the significance and consequences of prescription psychotropic drug proliferation we must acknowledge and address the omnipresent commercial efforts promoting them, especially since about the mid 1980s. Increasing college student use is part of the burgeoning use of these drags in the general populati on of the United States throughout their life spans. By 2004, it was estimated that over 44% of Americans were prescribed at least one "psychiatric drug" and 16.5% were taking at least three (cited in Long, 2005). But the usage figures are rising so fast that even such recent statistics as these are quickly outdated.

What factors can account for this rampantly increasing use of "psychiatric drugs," a term that like many others associated with prescription psychotropic drugs, is misleading. The great majority of prescribing clinicians are not psychiatrists; they are non-psychiatrist physicians, nurse practitioners, and physician assistants. Psychologists, on a fast track to obtaining prescribing privileges despite opposition even from other psychologists (e.g., Kovacs, 1988; Albee, 2005), are now prescribing in New Mexico and Louisiana (Long, 2005) and in the U.S. territory of Guam. Thus, the expansion of prescribing providers beyond the profession of psychiatry helps account for much of the trend.

Both the rapidly rising numbers of prescribing practitioners and patients receptive to prescription psychotropic drugs are largely attributable to the monetary success of the drug companies' highly aggressive marketing strategies. Like the vast majority of the general population, by far most of the information that students and staff in institutions of higher education get about prescribed psychotropic drugs comes from the mammoth marketing of the drugs by the pharmaceutical industry. "Big Pharma," as some authors call the industry, has accrued such profit and influence that it now thoroughly permeates every facet of mental health policy, legislation, research, education and practice. One of the most telling accounts of how the pharmaceutical industry has dwarfed independent research and education at the expense of real science and ethical practice has been provided by Antonuccio, Danton, and McClanahan (2003). Here is a sample of their findings:

The pharmaceutical industry has more lobbyists than there are members of the Congress of the United States and spent more on lobbying and campaign contributions than any other industry;

The SSRIs have been the class of drug most common in adverse drug events which often are unaddressed by the physician in a primary care outpatient environment;

The industry is the most profitable in the U.S. and arguably the most successful industry in the world from a business perspective;

Antidepressants are the top selling drug category, with revenues growing about 25% per year;

The volume of television drug ads increased sevenfold from 1997 to 2003 after the Federal Drug Administration (FDA) relaxed the rules for such advertising;

About 60 million people annually ask their doctors about a particular medication they have seen advertised, and most of the time doctors prescribe that drug;

"Social anxiety" was mentioned in media stories over a billion times in 1999, 96% of the stories indicating that the SSRI Paxil was the first and only FDA-approved medication for the treatment of "social anxiety disorder";

It is difficult to think of any arena involving information about medications that does not have significant industry financial or marketing influences.

(p. 1030).

Drug advertising, which is now endemic to television and other media in the U.S., tells the often hapless viewer to "talk to your doctor to see if this (insert name of the advertised drug here) is for you." Television ads have claimed, in slickly portrayed cartoon-like fashion, that a psychoactive drug can "correct a biochemical imbalance." Many television ads nearly stoop to the level of connotative deceptions such as those in the iconic "Marlboro Man" ads for cigarettes which, at least until the actual representative model perished from lung disease, paired health and vigor with the macho man's ingestion of a disease-causing commercial product which greatly lowers life spans. For example, a drug ad repeatedly shown on network TV (e.g., September 24, 2006) shows a man dressed as Abraham Lincoln, the quintessential icon of honesty, seemingly endorsing a prescription sleeping medication together with a cute-looking talking ground hog. Together, they assure a tired young man that commonly people have sleep disturbances a "few days a week," that his problem is typical, and that a new drug (that has not yet been proven to cause addiction) can help him, in this case get back to playing chess. Meanwhile, "Record Sales of Sleep Pills Cause Worry" as a New York Times article put it (Saul, 2006). "Drag makers spent $298 million in the first 11 months of 2005 to convince consumers that the sleep aids are safe and effective. That was more than four times such ad spending in all of 2004" (p. C4).

Illogical, reality-bending ploys, engineered by advertising and public relations experts, cultivate an absurdist mentality that, at its extreme, is similar to the impaired, unwitting, illogical thinking central to schizophrenic disorders (Whitaker, 1980, 1992, 2000). When masses of people gullibly succumb to such nonsense, the result is reminiscent of the disastrous pretense of Utopian mentality depicted in Aldous Huxley's 1932 novel Brave New World.

Paralleling the direct-to-consumer advertising campaigns, physicians are also barraged with drug promotions, often delivered by suave, attractive "drag reps," Many of these ostensibly scientifically knowledgeable sales representatives are trained cheerleaders from institutions of higher education and professional sports teams (Saul, 2005) who enter doctors' offices personably touting a particular brand of drugs and handing out literature and samples of their drugs. Further, the drug reps give physicians and their assistants pens, memo pads, coffee cups and other office supplies, all marked with the name of the drug and its supplier.

Even if physicians place restrictions on drug reps' access to their offices, as a physician group in my area did recently, massive inducements await physicians perusing medical journals abounding with drug advertising to such an extent that the revenue from the ads is crucial to the very existence of the journals. At professional medical meetings, which are often basically funded by drug companies, attendees are proffered delectable, often sumptuous food, expertly linked with the advertisers' names and products.

Research grants and even (euphemistically-termed) "help" with preparation and what amounts to ghost-writing of research reports for publication are generously provided, all slanted to promote one or another drug. Consequently, medical journals, which traditionally have been in the forefront of reporting new medical knowledge, have become unreliable. For example, the New York Times (2006) in one of its many articles about the pharmaceutical industry's corrupting influences, reported "For the second time in two months, the Journal of the American Medical Association says it was misled by researchers who failed to disclose financial ties to drag companies" (p. A19). While most of the 13 authors of a study suggesting pregnant women who stop taking antidepressants risk falling back into depression had financial ties to drag companies, only two had disclosed their ties when the study was published. "The lead author... on the speakers' bureau for eight drag companies, disputed that such ties could influence findings" (p. A19).

Meanwhile, nothing less than human nature itself proscribes biting the hand that feeds you, thus forestalling any consensual revolt against what a July 13, 2006 New York Times editorial called an insidiously corrupting influence, even if it consists only of free lunches: "Doctors are deluding themselves when they say their medical judgment can't be influenced by something as simple as a deli sandwich." A former sales rep for two drug companies said lunches were "incredibly effective" in raising the number of prescriptions. The editorial concludes: "Surely it is time for the entire medical profession to go cold turkey and decline these favor-seeking handouts."

Physician John Abramson (2005), clinical instructor at Harvard Medical School, noted that whereas prior to 1980 most clinical research was publicly funded, now most is funded by the drag and other medical industries motivated to maximize returns for investors, that 90% of clinical trials are commercially funded, as well as 75% of published clinical research and 70% of continuing education events required of doctors. He observes that many people prefer a pill to changing their lifestyle although two-thirds of our health is determined by the way we live. A currently running television ad for a fat-reducing medication admits that major causes for obesity are lack of diet and exercise but goes on simply to recommend the medication despite its "side-effects."

Among the industrialized nations of the world, only the U.S. and New Zealand allow prescription drag ads. So, except for the four million New Zealanders, the now more than three hundred million U.S. citizens are the only people in the "developed" world not protected governmentally from exploitation by the free-reigning ways of the pharmaceutical indust...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• About the Editors
• About the Contributors
• Foreword
• Preface
• 1 Forces Pushing Prescription Psychotropic Drugs in College Mental Health
• 2 The Escalating Use of Medications by College Students: What Are They Telling Us, What Are We Telling Them?
• 3 Matters of Substance: Students' Voices
• 4 The Current Status of Prescribing Psychiatric Drugs for College Students: A Nascent Science or a SNAFU?
• 5 Reality Check: What Science Has to Tell Us About Psychiatric Drugs and Their Long-Term Effects
• 6 Combined Psychotherapy/Medication Treatment: The Valpo Model
• 7 The Pharmacological Treatment of Depression in College Age Students: Some Principles and Precautions
• 8 Does Adding Medication to Psychotherapy for Depression Improve or Worsen Outcome?
• 9 Helping Individuals Withdraw from Psychiatric Drugs
• 10 The Fall and Rise of Resilience: Prevention and Holistic Treatment of Depression Among College Students
• 11 The Big Picture and What Can Be Done to Improve It
• Index