Psychotropic medication in adolescence: psychodynamic and clinical considerations

Adolescence, Winter, 1996 by Gabriele Masi, Mara Marcheschi, Luciano Luccherino

Administering medication to adolescents frequently produces negative reactions, especially when treatment is prolonged; the problem of compliance is particularly marked during treatment with psychotropic drugs. This study discusses the psychological implications of psychotropic treatment, with specific reference to clinical and methodological issues (Doherty & Marder, 1977; Karasy, 1982).

In every phase of life, biochemical as well as psychological factors affect the outcome of psychotropic therapy. Included among the latter are the relationship with one's body and illness, caregivers, the psychiatrist, and medication. During adolescence, the effect of these psychological factors is amplified when such factors are modified, often unexpectedly, by the concurrent pubertal process. Moreover, adolescent psychopathology, with its impact on mental and bodily self representations, may alter the course and outcome of pharmacotherapy. Recognizing these potential problems should not lead to elimination of drug treatment a priori; rather it should lead to improvement of psychopathological investigation and awareness of biochemical and psychodynamic factors. In turn, this may prevent treatment refusal by the adolescent as well as iatrogenic effects, which sometimes depend more on psychodynamic than pharmacodynamic factors (Schowalter, 1989).

During adolescence, psychotropic treatment acts on two levels: the relationship with self and the external world, especially parents. The former is influenced by specific elements of adolescent psychology: during and after the pubertal process, the adolescent representations of bodily and mental reality are redescribed in a new format that is between omnipotent control and feelings of impotence (Jeamamet, 1983). Cognitive development during adolescence, in fact, promotes reflection on the functioning of body and mind, and the awareness of these new capacities gives adolescents the ability to control their physical and psychological changes which otherwise might be experienced in a passive and uncontrolled manner. In this way, adolescents organize a new theory of mental functioning that can act as an important defense mechanism and eventually allow them to reach a balance between psychic pain and its denial. This is where psychotropic medication makes its entrance.

Some adolescents may adopt a biological theory of mental functioning, which implies that there is a direct link between mind and brain. This reasoning will lead the adolescent to translate psychological disturbances into a somatic language, equating them to organic illness. He or she will treat the drug as a chemical substance that can modify, often in a magical way, the functioning of the brain. As a result, the adolescent becomes passive toward medication and illness.

Other adolescents may adopt a theory of mental functioning defined as psychogenic, which is detached from the physical dimension. This formulation will cause the adolescent to interpret his or her psychological disturbances as subjective psychic pain - as his "own way of being." In this case, the drug becomes an external and heteromorphic substance that acts upon the adolescent's subjective intimate level in a positive or negative way. Adolescents can be more active, depending on their relationship with the drug.

Our clinical practice with adolescents suggests that the above-mentioned mental representations may be the basis for formulating hypotheses on the outcome of psychotropic treatment. These representations are dynamically interrelated, and may be modified by illness or drug prescription. Understanding them can help us anticipate the way the drug will affect the balance between mind and body, activity and passivity, and awareness and denial.

Psychotropic treatment not only modifies adolescents' relationship with the bodily and mental self, but with the external world. In this phase adolescents must define a boundary between self and significant adults, particularly parents and clinician. Medication acquires symbolic meaning and may become a factor in the dependence/independence dynamics within the triad of adolescent-parents-clinician. The emerging equilibrium should therefore be investigated carefully during therapy.

We believe that during a consultation and before administering psychotropic medication, the clinician should attentively investigate the way the adolescent interprets his or her mental functioning, the meaning of his or her psychological disturbances, the effect of psychotropic medication, and his or her relationship with significant adults.

The following discusses clinical situations which delineate the methodological implications of psychotropic prescription.

The reactions of the adolescent toward psychotropic medication can vary. At one extreme is the adolescent who asks for medication, and on the other, the adolescent who refuses treatment. Some adolescents will ask for medication at the first consultation. Reasons offered are trouble in daily and/or school activities: concentration and memory difficulties (usually paralleling lower school achievement), various forms of anxiety (phobic or hypocondriac anxieties), and depressive mood. In more severe psychopathological conditions, such as obsessive-compulsive or impulsive behaviors, requests for pharmacotherapy are rare. At this stage it is important to understand the reasons behind the request for medication; that is, the role played by the drug on the adolescent's relation with self, family, and the clinician. At times, this request is the only acceptable way of seeking help because overtly exposing one's mental pain would damage the narcissistic dimension of adolescence. In these cases, it is possible, although not easy, to go beyond the request for medication in order to determine the true psychic pain. The pharmacological response can be a bridge to this deeper level, especially when it is the adolescent, and not the family, who asks for medication. Refusing to administer treatment could therefore be interpreted by the adolescent as a manifestation of emotional detachment.