Front Matter

Prescriber, Prescribe Thyself (By Way of Introduction)

Andrés Martin, M.D., M.P.H., and Shashank V. Joshi, M.D.

Part I: Principles

1 Think Again About Prescribing: The Psychology of Psychopharmacology

Kyle D. Pruett, M.D.

2 The Many Facets of Alliance: The Y-Model Applied to Child, Adolescent, and Young Adult Pharmacotherapy

Magdalena Romanowicz, M.D., Sarah Rosenbaum, M.D., M.P.H., and Carl Feinstein, M.D.

3 Psychodynamics of Medication Use in Youth With Serious Mental Illness

Barri Belnap, M.D., Erin Seery, M.D., John Azer, M.D., and David Mintz, M.D.

4 “What’s in It for Me?”: Adapting Evidence-Based Motivational Interviewing and Therapy Techniques to Adolescent Psychiatry

John J. DiLallo, M.D.

5 Providing Psychoeducation in Pharmacotherapy

Srinivasa B. Gokarakonda, M.D., M.P.H., and Peter S. Jensen, M.D.

Part II: Partners

6 #KeepItReal: The Myth of the “Med Check” and the Realities of the Time-Limited Pharmacotherapy Visit

Max S. Rosen, M.D., and Anne L. Glowinski, M.D., M.P.E.

7 Pharmacotherapy or Psychopharmacotherapy: When Therapist and Pharmacologist Are Different People—or the Same Person

Mari Kurahashi, M.D., M.P.H., Elizabeth Reichert, Ph.D., Nithya Mani, M.D., and David S. Hong, M.D.

8 The Pharmacotherapeutic Role of the Pediatrician, Advanced Practice Clinician, and Other Primary Care Providers

Katherine M. Ort, M.D., and Amy Heneghan, M.D.

Part III: Settings

9 The Pharmacotherapeutic Alliance in School Mental Health

Andrew Connor, D.O., and Shashank V. Joshi, M.D.

10 When Time Is Tight and Stakes Are High: Pharmacotherapy, Alliances, and the Inpatient Unit

Andrea Tabuenca, Ph.D., Jung Won Kim, M.D., and Shih Yee-Marie Tan Gipson, M.D.

11 Telepsychiatry Goes Viral: Psychotherapeutic Aspects of Prescribing Via Telemedicine Amid (and After) COVID-19

Jeff Q. Bostic, M.D., Ed.D., Sean Pustilnik, M.D., and David Kaye, M.D.

Part IV: Populations

12 Alliance Issues to Consider in Pharmacotherapy With Transition-Age Youth

Jennifer Derenne, M.D., Farrah Fang, M.D., and Anthony L. Rostain, M.D., M.A.

13 The Pharmacotherapeutic Alliance When Working With Diverse Youth and Families

Takesha Cooper, M.D., M.S., Michelle Tom, M.D., and Erin Fletcher, M.D., M.P.H.

14 The Psychopharmacotherapeutic Alliance When Resources Are Limited

Arthur Caye, M.D., Ph.D., Brandon A. Kohrt, M.D., Ph.D., and Christian Kieling, M.D., Ph.D.

Part V: Research

15 Building a Therapeutic Alliance in Psychopharmacology During Clinical Trials: Ethical and Practical Considerations

Manpreet K. Singh, M.D., M.S., and Janice Cho, M.D.

16 The Power of Placebo

Jeffrey R. Strawn, M.D., Jeffrey A. Mills, Ph.D., Tara S. Paris, Ph.D., and John T. Walkup, M.D.

Part VI: Becoming

17 The “Good Enough” Pediatric Psychopharmacotherapist: Practical Pointers in Six Parables

Ian Tofler, M.B.B.S.

18 Teaching and Mentoring the Next Generation of Pediatric Psychopharmacotherapists

Dorothy Stubbe, M.D., Isheeta Zalpuri, M.D., Mandeep Kaur Kapur, M.D., and Donald M. Hilty, M.D., M.B.A.

Gratitude

Shashank V. Joshi, M.D.

Index

The Austen Riggs Center, Stockbridge, Massachuseutts

The Austen Riggs Center, Stockbridge, Massachuseutts

Department of Psychiatry, MedStar Georgetown University Hospital, Washington, D.C.

Division of Child & Adolescent Psychiatry, Hospital de Clínicas de Porto Alegre; Department of Psychiatry, School of Medicine, Universidade Federal do Rio Grande do Sul, Brazil

Resident Physician in Psychiatry, University of California, Los Angeles, Los Angeles, California

Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of Monterey Peninsula, Monterey, California

Program Director, Psychiatry Residency Training Program; Vice-Chair of Education; Equity Advisor; and Chair, Admissions Committee, Department of Psychiatry and Neuroscience, University of California, Riverside School of Medicine, Riverside, California

Clinical Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Stanford, California

Psychiatrist in Private Practice, Dobbs Ferry, New York

Staff Psychiatrist, Stamps Health Services, Georgia Institute of Technology, Atlanta, Georgia

Clinical Professor and Vice Chair, Child and Adolescent Psychiatry, Department of Psychiatry and Neuroscience, University of California, Riverside School of Medicine, Riverside, California; Emeritus Professor of Psychotherapy, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

PGY 3 Psychiatry Resident, Department of Psychiatry and Neuroscience, University of California, Riverside School of Medicine, Riverside, California

Instructor, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Weill Institute for Neurosciences, Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, University of California, San Francisco, San Fransisco, California

Assistant Professor of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Yale School of Medicine, New Haven, Connecticut

Pediatrician in Private Practice, Palo Alto, California

Professor and Vice Chair of Veteran’s Affairs, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California

Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California

Board Chair, The REACH Institute, New York, New York; Adjunct Professor of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Professor of Psychiatry, Pediatrics, and Education, Stanford University School of Medicine and Graduate School of Education; Director of Training in Child and Adolescent Psychiatry and Director of School Mental Health at Lucile Packard Children’s Hospital Stanford, Palo Alto, California

Administrative Chief Fellow, Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California

Professor of Psychiatry and Vice Chair of Academic Affairs, Department of Psychiatry, Jacobs School of Medicine & Biomedical Sciences, University of Buffalo, Buffalo, New York

Division of Child & Adolescent Psychiatry, Hospital de Clínicas de Porto Alegre; Department of Psychiatry, School of Medicine, Universidade Federal do Rio Grande do Sul, Brazil

Faculty, Department of Psychiatry, Boston Children’s Hospital, Department of Psychiatry and Behavioral Sciences, Harvard Medical School, Boston, Massachusetts

Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, D.C.

Clinical Associate Professor, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California

Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California

Riva Ariella Ritvo Professor, Child Study Center, Yale School of Medicine; Medical Director, Children's Psychiatric Inpatient Service, Yale New Haven Health, New Haven, Connecticut

Professor of Economics, Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio

The Austen Riggs Center, Stockbridge, Massachuseutts

Clinical Assistant Professor, Departments of Child and Adolescent Psychiatry and Pediatrics, NYU Grossman School of Medicine, NYU Langone Health, New York, New York

UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California

Clinical Professor of Psychiatry, Yale Child Study Center, Northampton, Massachusetts

Department of Psychiatry, MedStar Georgetown University Hospital, Washington, D.C.

Clinical Associate Professor, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California

Program Director of Child and Adolescent Fellowship Training, Mayo School of Graduate Medical Education, Division of Child and Adolescent Psychiatry; Assistant Professor of Psychiatry, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Division of Child and Adolescent Psychiatry, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri

Clinical Instructor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Chair, Department of Psychiatry and Behavioral Health, Cooper University Health Care; Professor of Psychiatry and Pediatrics, Cooper Medical School of Rowan University, Camden, New Jersey

Medical University of South Carolina, Charleston, South Carolina

Associate Professor, Department of Psychiatry and Behavioral Sciences, and Director of the Stanford Pediatric Mood Disorders Program and the Pediatric Emotion and Resilience Lab, Stanford University School of Medicine, Stanford, California

Professor of Psychiatry, Pediatrics, and Clinical Pharmacology, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio

Associate Professor and Program Director, Child Study Center, Yale University School of Medicine, New Haven, Connecticut

Clinical Assistant Professor, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, Stanford, California

Kaiser West Los Angeles; Visiting Faculty, Department of Psychiatry, Department of Psychiatry, UCLA, Los Angeles, California

Child and Adolescent Psychiatry Fellow, Department of Psychiatry and Neuroscience, University of California, Riverside School of Medicine, Riverside, California

Margaret C. Osterman Professor of Psychiatry, Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois

Clinical Associate Professor and Associate Program Director, Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California

We were elated on first seeing the cover options for Thinking About Prescribing. Initially drawn to an all-blue design, we were perhaps giving an unconscious nod to the colors of one of our august institutions. Too august in fact; too serious. We did not want to convey from the get-go a sense of staid heaviosity that so often alienates kids from self-important polysyllabic pediatric psychopharmacologists. Instead, we aimed for a cover that transcended “treatise,” “tort,” or “textbook” trends. We wanted visual messaging that conveyed the playfulness and mystery-solving at the core of our profession. The complementary color scheme and fonts we settled on are child-friendly; the images on the frontispiece a puzzle fit for avid codebreakers. What are angels doing in there? More disturbingly perhaps: what are grenades, of all things, doing on the cover of a pediatric book? The nine complementary panels appear to form a sequence of sorts: did the artist aim for a case of Elgar-like Enigma Variations? The figures are indeed intended to be enigmatic: to invite questions and head-scratching; to lure the prospective reader in. If we have succeeded as well-intentioned tricksters to draw you in this far, the introduction that follows, Prescriber, prescribe thyself, will reveal the underlying mystery—grenades and all. We are deeply grateful to Simone Hasselmo for her artistry, for moving well beyond cartooning the illustrations that grace the cover and enrich the text that follows. We were in awe by what Simone produced: we had merely asked for new perspectives through which to convey complex and abstract concepts. We had asked for different angles; Simone instead blessed us with her angels.

By Way of Introduction

It may seem unbecoming to open a book on children’s mental health on a surgical note. But there are at least two good reasons to do so. First, there is the answer to that old chestnut “Why did some of us become psychiatrists?” Because surgery wasn’t invasive enough. Surgery simply did not go sufficiently deep for some of our sensibilities. Second, and to learn from our colleagues in surgery and not just use them as strawmen for a tired quip, let’s give them this: Surgeons don’t for a second forget that scalpels are instruments, base metals at that. If only we psychiatrists had a similar mindset when prescribing our own pills. Alas, we forget all too often that our potions are partly instruments, base salts at times.

This volume is an invitation—an entreaty—to make good on the fact that our remedies are only as good as the way in which we dispense them, that prescribing psychotropic medications to developing children is as much the cold facts of molecules as it is the warm way in which we envelop them for delivery. It is a reminder that no matter how accurate said delivery may be, it all goes to naught—molecules be damned—if there is no one on the receiving end; a psychotropic not taken is perfectly inert and useless. But our goal should not end at mere “compliance” (an unfortunate term that reeks of power dynamics and hierarchical paternalism); ingesting a pill and letting its molecules fulfill their job description is but the start of a therapeutic process.

Simple conceptualizations of depression as a low serotonin condition or of stimulants as dopamine enhancers are as incomplete today as they are misguided. A chemical’s docking, Apollo-like, onto a receptor’s site to right a neurotransmitter’s tenuous balance is as romantic a throwback as a 1960s moon shot. Advances in molecular psychiatry over recent decades have made it clear that psychotropics are more than simple “keys” to neurotransmitter “locks.” The contact of molecule and receptor may be a start, but it is the secondary, tertiary, and subsequent messengers where the action truly lies. It is these elusive messengers that get in deep, that get closer to the actual machinery of the cell, that get the job done.

In a similar way, we should be not mere prescribers, the holders of key rings on our proverbial tool belts. We are—or should be, or aspire to be, or reclaim being—pharmacotherapists. Our own job description gets started well before molecules reach their targets; we are cognizant that the moment of chemical bonding is but another start; we remain humble in our commitment, recognizing that to deliver on the full potential of our treatment, we, too, must become and remain secondary, tertiary, and subsequent messenger systems. In his paraphrasing of Donald Winnicott in the book’s opening chapter, Kyle Pruett reminds us that “there is no such thing as just a prescription.” The prescription, the prescriber, and the prescribed are inherently intertwined; we ignore such bondings (chemical or otherwise) at our own therapeutic detriment.