Feeling frustrated... Parent wanted meds for his child but I refused to prescribe

[SpongeBob DoctorPants]

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A 14 year old boy was brought in by his father. The boy denied any psychiatric complaints. His father raised concerns about suicidal thoughts, depression, anxiety, and poor judgment from having a high libido.

Regarding suicidal thoughts, the patient has only had passive thoughts of wishing he wasn't alive on one or two occasions, most recently a month ago, but never any active thoughts, suicide attempts, nor self harm. Regarding depression, it turns out he isn't really depressed much. He admitted to feeling sad once in a while, approximately one day per month on average, and has never felt depressed more than two days in a row. He has also been in a good mood for the past few weeks. His father confirmed this history.

The father also said the boy has had lots of anxiety, which upon further questioning, turned out to not really be anxiety at all, but rather just some stress from not wanting to meet his parents' expectations of getting good grades in school.

With regard to high libido, the father explained that his son recently sent a message to a female peer which contained some sort of sexual content. That's it. No sending or receiving texts of nude photos, no sexual activity, no inappropriate touching of others, no concerns about masturbation or pornography use. When speaking privately, the boy revealed to me that he had touched the girl on her thigh and back, but they've never touched each other's sexual anatomy. The father expressed concern that his son's libido was too high, and requested an SSRI to fix this, but I could not elicit any description of abnormal or excessive sexual behaviors.

The mental status exam was pretty normal; just an average looking kid with appropriate affect, mood, behavior, and so forth.

My overall impression was that the patient has mild symptoms of depression approximately one day per month, there was no acute risk of suicide, and his mood recently has been good. There did not appear to be any anxiety, compulsive behaviors, poor attention span, irritability or argumentative behavior, etc. His libido as far as I could tell was normal for an adolescent boy. I felt that the main problem was actually an anxious parent who has a teenager.

I did not recommend medication, explaining that at the present time, the risks of medication outweigh any potential benefit, but we can certainly consider medication at a future date if his mood worsens and he becomes depressed more frequently. I recommended meeting with a therapist instead to discuss these concerns, but the patient was not interested in therapy, perhaps because he doesn't think there's anything wrong with him. The father was frustrated and made a comment like "I guess I shouldn't take my kid to doctors anymore." (Of note, he had previously tried getting the PCP to prescribe an SSRI to control the kid's libido but didn't mention anything to him about suicidal ideation then.)

The thing that frustrates me is the fact that this parent is obviously very concerned about his child, but in his eyes, all I did was say his kid is normal and doesn't need to take an antidepressant. I think I made an appropriate recommendation to meet with a therapist, but neither the patient nor his father were interested in that. I still don't think this kid needs an antidepressant, but I can't help but wonder if I might have missed something, and that's why the father was disappointed.

Have any of you experienced encounters like this? With the information presented here, is there anything you might have considered or recommended?

 

[LadyHalcyon]

I find it somewhat concerning his father is so focused on his libido. What is his reasoning for this? Is the boy complaining about this symptom?

A 14 year old boy was brought in by his father. The boy denied any psychiatric complaints. His father raised concerns about suicidal thoughts, depression, anxiety, and poor judgment from having a high libido.

Regarding suicidal thoughts, the patient has only had passive thoughts of wishing he wasn't alive on one or two occasions, most recently a month ago, but never any active thoughts, suicide attempts, nor self harm. Regarding depression, it turns out he isn't really depressed much. He admitted to feeling sad once in a while, approximately one day per month on average, and has never felt depressed more than two days in a row. He has also been in a good mood for the past few weeks. His father confirmed this history.

The father also said the boy has had lots of anxiety, which upon further questioning, turned out to not really be anxiety at all, but rather just some stress from not wanting to meet his parents' expectations of getting good grades in school.

With regard to high libido, the father explained that his son recently sent a message to a female peer which contained some sort of sexual content. That's it. No sending or receiving texts of nude photos, no sexual activity, no inappropriate touching of others, no concerns about masturbation or pornography use. When speaking privately, the boy revealed to me that he had touched the girl on her thigh and back, but they've never touched each other's sexual anatomy. The father expressed concern that his son's libido was too high, and requested an SSRI to fix this, but I could not elicit any description of abnormal or excessive sexual behaviors.

The mental status exam was pretty normal; just an average looking kid with appropriate affect, mood, behavior, and so forth.

My overall impression was that the patient has mild symptoms of depression approximately one day per month, there was no acute risk of suicide, and his mood recently has been good. There did not appear to be any anxiety, compulsive behaviors, poor attention span, irritability or argumentative behavior, etc. His libido as far as I could tell was normal for an adolescent boy. I felt that the main problem was actually an anxious parent who has a teenager.

I did not recommend medication, explaining that at the present time, the risks of medication outweigh any potential benefit, but we can certainly consider medication at a future date if his mood worsens and he becomes depressed more frequently. I recommended meeting with a therapist instead to discuss these concerns, but the patient was not interested in therapy, perhaps because he doesn't think there's anything wrong with him. The father was frustrated and made a comment like "I guess I shouldn't take my kid to doctors anymore." (Of note, he had previously tried getting the PCP to prescribe an SSRI to control the kid's libido but didn't mention anything to him about suicidal ideation then.)

The thing that frustrates me is the fact that this parent is obviously very concerned about his child, but in his eyes, all I did was say his kid is normal and doesn't need to take an antidepressant. I think I made an appropriate recommendation to meet with a therapist, but neither the patient nor his father were interested in that. I still don't think this kid needs an antidepressant, but I can't help but wonder if I might have missed something, and that's why the father was disappointed.

Have any of you experienced encounters like this? With the information presented here, is there anything you might have considered or recommended?

 

[wolfvgang22]

Good on you for not putting a normal teenage boy on meds. A parenting class might also be a good referral, or you can recommend some self help parenting books. Reassure and educate father in normal teenage behavior, course, and prognosis.

 

[SpongeBob DoctorPants]

I find it somewhat concerning his father is so focused on his libido. What is his reasoning for this? Is the boy complaining about this symptom?

The boy wasn't complaining about anything. The father told me that he and his son are alike in many ways, and when he was his son's age, he believed that he had a higher than average libido. I didn't really find out what he meant by that, but I think he was just worried that his son might end up having premarital sex.

 

[LadyHalcyon]

Ohhh ok. Seems like the dad is the one with the anxiety!

The boy wasn't complaining about anything. The father told me that he and his son are alike in many ways, and when he was his son's age, he believed that he had a higher than average libido. I didn't really find out what he meant by that, but I think he was just worried that his son might end up having premarital sex.

 

[SpongeBob DoctorPants]

Good on you for not putting a normal teenage boy on meds. A parenting class might also be a good referral, or you can recommend some self help parenting books. Reassure and educate father in normal teenage behavior, course, and prognosis.

Thanks for the suggestions. I did reassure and educate the father, which I think helped a little. I'll have to look into parenting classes and books I can recommend; I didn't even consider this.

 

[birchswing]

That is bizarre. To want to chemically castrate your son because you think he has the same sexual desires that you had at his age.

I can't even come up with an armchair theory on that.

 

[michaelrack]

That is bizarre. To want to chemically castrate your son because you think he has the same sexual desires that you had at his age.

I can't even come up with an armchair theory on that.

I can't either, but I am sure the more psychodynamically oriented on this forum would have no problems coming up with a theory

 

[whopper]

I've told the residents I've trained that a mark of a good psychiatrist is knowing when not to medicate. E.g personality disorders, adjustment disorder (sometimes meds are the right thing, but sometimes it's not), and just typical inappropriate behavior that is age appropriate.

 

[roastedcapers]

Whopper, can you comment more on when you think meds are right for adjustment disorder?

Hilarious story. OP, thank you for posting this and reminding when not to prescribe.

 

[whopper]

If the level of the adjustment disorder is mild consider no medication. Also if the you are able to know the duration will likely be short. E.g. leaky roof in the house and it'll take a week to repair, in the meantime the person has to live with their very annoying family member.

Anything on the order of moderate to worse and a long duration? Consider medicating. Just cause it's Adjustment Disorder doesn't mean it's not worth treating with meds. While I was a resident I saw 2 patients who attempted suicide due to their Adjustment Disorder.

The first patient was someone who did it cause his best friend was copulating with his girlfriend. The second was a guy trapped in a hermetically sealed room due to TB and was going to be there for several weeks with nothing, literally nothing to do in the room. He came in with no depression, after a week of nothing to do there other than just lay in a bed, he started showing signs of depression and that's when I saw him for a consult, then after about 2 weeks of it he attempted to hang himself and appeared severely depressed even showing some vegetative symptoms.

Several hospitals now have entertainment for such patients (e.g. TV with 100+ channels, smart tv, Internet access, video games) but when I was a resident this guy had nothing. I even recommended in a consult he be allowed a game system and the hospital was like WTF? I even got some nurses looking at me as if offended I even brought up that they need to try to accommodate his boredom with some responses of things to the effect of I was being disrespectful to the nurses and that trying to offer him things to keep him occupied wasn't "real medicine." Now this was the first consult, the second consult, after the suicide attempt, the same nurses I can tell knew I was right in the first place but wouldn't fess up and just gave me a dirty look. (Hey made me even more confident that I was right to piss them off, especially since I never intended or wanted to piss them off in the first place plus kept up my decorum the entire time).

This does leave quite a bit of grey area just as to what is short and when to medicate when it's mild to moderate. I often times just leave it up to the patient which is really what is just supposed to be done. You offer treatments. You don't force any treatments unless the person's committed.

 

[birchswing]

I often times just leave it up to the patient which is really what is just supposed to be done. You offer treatments. You don't force any treatments unless the person's committed.

If the patient is 14 and the father wants the son to take the treatment, who is the patient you are offering the medication to and who has agency? You might not be forcing it, but the father might. You would be endorsing the father's idea to the child that he has a disease of sexuality, which probably will amplify itself. And if the child was forced to be put into the position of standing up for himself against the father, which will probably also amplify, maybe a diagnosis of conduct disorder next.

In this case, offering medication sounds like cart blanche for the child to be heavy-handed into taking it, and whether to take a medication for such spurious and odd reasons as the father was concerned about is not a normal parenting decision like whether to take antibiotics for strep throat.

 

[thoffen]

I'm sure you were missing something, and I'm also sure it wasn't a prescription for an SSRI.

Surprised no one brought up the BB warning for suicidality. That ought to be a strong argument against prescribing here albeit an unnecessary one. You recommended an appropriate intervention (therapy) for his concerns.

Separately, I wouldn't necessarily say this is a normal kid either, but obviously nothing you elicited is clearly abnormal.

One actual consideration here is OCD, particularly sexual OCD. There's a definite inheritance there. People with OCD often have a very difficult time talking about it directly. Whenever you have the experience of someone desperately trying to get your help without being able to explain why, I think OCD really needs to be considered. In this case you have a strong set of moralistic statements and a desire to suppress the urges completely.

 

[LadyHalcyon]

I agree that you didn't get the whole story. Something has Dad concerned. Either dad is extremely odd and anxious (and maybe even a little creepy), or the kid is doing something disturbing, but doesn't want to explicitly say bc it's somewhat deviant or unusual

I'm sure you were missing something, and I'm also sure it wasn't a prescription for an SSRI.

Surprised no one brought up the BB warning for suicidality. That ought to be a strong argument against prescribing here albeit an unnecessary one. You recommended an appropriate intervention (therapy) for his concerns.

Separately, I wouldn't necessarily say this is a normal kid either, but obviously nothing you elicited is clearly abnormal.

One actual consideration here is OCD, particularly sexual OCD. There's a definite inheritance there. People with OCD often have a very difficult time talking about it directly. Whenever you have the experience of someone desperately trying to get your help without being able to explain why, I think OCD really needs to be considered. In this case you have a strong set of moralistic statements and a desire to suppress the urges completely.

 

[Liquid8]

My first thought was the father has some religious hang-up about sex which is being projected on the son and no medication is going to treat that. Waiting and not prescribing is a perfectly fine approach.

 

[SpongeBob DoctorPants]

Surprised no one brought up the BB warning for suicidality.

That is an important thing to consider, and I actually brought this up during the encounter when discussing the risks of medication. Thank you for your other comments, too, especially about OCD.

My first thought was the father has some religious hang-up about sex which is being projected on the son and no medication is going to treat that. Waiting and not prescribing is a perfectly fine approach.

Religion is indeed very important for this family, and of course premarital sex would be a big concern. I think the father was mainly worried about that.