In college, adolescents are in a time of transition, and some students very much want to remake themselves. I sometimes hear, “I don’t want to be that kid who takes the medication his parents tell him to take.” In addition, it’s key to make sure students can get the care they need at college. Because the college stressors may aggravate their symptoms, this is not the time for them to abruptly change or stop their treatment (Brinkman WB et al, American Pediatrics 2017, doi:10.1016/j. acap.2017.09.005).
It’s also important to address the issue of substance abuse, which is very common in college. I tell kids that alcohol and marijuana will contribute to depression and anxiety; it will also distract them from learning and being involved in the sorts of activities that will help them grow into the person they want to be. But discussing this with teens requires some finesse.
I recommend you begin by making it clear that you don’t want them drinking at all while on the medication, and outline the risks associated with doing so. I also tell adolescents that, even though young people often don’t feel the immediate negative effects of drugs and hangovers as much as older people do, the negative impact upon their brains and neural tissue is far greater. At the same time, though, you also need to let them know that you understand they will want to go to college parties, where they might well be tempted to drink alcohol or smoke marijuana. Depending upon the patient, I may then give them some advice about harm reduction. This is not a perfect solution, but some teens may not feel they can be honest with you if you simply forbid them from drinking or smoking; they may instead just drink and skip their medication for fear of a terrible interaction. As their doctor, you need to know the truth about their behavior.
For example, I might suggest that a teen have a maximum of 2 drinks at a party, and that it’s imperative to drink 12 ounces of water between drinks. I explain that a “drink” is a 12-ounce beer, 4 ounces of wine, or a single shot of spirits. I also emphasize the importance of making a plan before they arrive at the party. Deciding in advance how much they will drink, or role playing how they will say no or not have a second or third drink, is a way to potentially reduce harm with the acknowledgement that they will otherwise be without any guideposts to follow.
It is also important to talk about serious drug-drug interactions, such as serotonergic interactions between SSRI/ SNRIs and MDMA/ecstasy, while we monitor as usual for severe medication problems such as agitation and withdrawal, either of which could increase suicidality (Groenman AP et al, J Am Acad Child Adolesc Psychiatry 2017;56(7):556–569).
Some clinicians find that, as their patients grow into their late teens and early 20s, they don’t require as much medication. In my experience, there are at least two reasons for this. First, younger kids metabolize drugs more quickly than teens and young adults. I sometimes think of kids as hummingbirds, and they slow down as they grow older. We certainly see this with ADHD medicines, where dosing is much higher per kilogram of body
weight in younger people. I sometimes see this with antidepressants, too.
Aside from changes in metabolism, there are also psychological changes that may explain why dosing decreases. As young adults develop more insight into their behavior, learn skills through psychotherapy that help them regulate their emotions, establish a good network of social support, and develop more self-efficacy, we sometimes find that they require less medication. Conversely, however, for those who don’t develop these supports, continued higher dose treatment may remain essential.
CCPR VERDICT: Figuring out how to help young people handle their own medications can be a challenge for both parents and psychiatrists. Keeping kids organized and responsible when it comes to taking and securing their meds involves careful consideration, specific strategies, and counseling.