Is it okay to give patients medicine without their knowledge?

[SpongeBob DoctorPants]

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I have an adolescent patient who had been doing well on Zoloft and Ritalin LA for anxiety, ODD, and ADHD. After an extended period of stability, I decided to taper her off the Zoloft but then ODD symptoms emerged. I decided to restart the Zoloft, anticipating the ODD would improve. However, I learned that at home she adamantly refused to go back on Zoloft, although she was agreeable to staying on the Ritalin LA. Her mother decided to secretly place the Zoloft tablets inside of the Ritalin LA capsules, and so for the past few weeks, my patient has been receiving the Zoloft without being aware of it.

Unfortunately, she has also recently been having some mood problems, which are new. She cut herself last week and her mother discovered some writings in her journal suggesting that the patient was depressed. However, the patient herself minimizes the symptoms and denied any depressive symptoms to me, and even denied cutting herself until she was confronted about it. I suggested going back on the antidepressant (to see if she would agree to taking it), or switching to a different one, but she refused, saying her mood is fine and she doesn't want to take any antidepressants. Her mother believes she's been hearing misinformation from her father, who is against psychiatric medications in general. (Parents are divorced, btw.) After several attempts of persuasion, the patient continued to be against taking any antidepressants.

So, in terms of prescribing an antidepressant, my options were to:

1. continue having the mother secretly administer the current dose
2. have the mother secretly administer a higher dose
3. have the mother secretly administer a different antidepressant
4. stop the practice of secretly administering the antidepressant and only renew the stimulant

I decided to go with option #4 above, because I don't like the idea of secretly giving a medication to someone if they refuse to take it. My reasoning is that this is ethically questionable, and if she were to ever discover that the tablets are hidden inside of the capsules, this could cause trust issues, not only with her mother, but also with me, and in the long run I don't think that would help. I know the mother was disappointed with my recommendation, and she expressed concern that her mood will worsen without the antidepressant and that the self-harming might occur again, or worse. I suggested that we follow up again in 2-3 weeks and if there is a worsening of mood or lack of improvement, I would be more firm about recommending an antidepressant to the patient next time.

What would you do in this situation? What is ethically permissible regarding the administration of medication to pediatric patients without their knowledge or consent? And what are some helpful strategies for treating kids who refuse certain medications?



TL/DR: Adolescent patient refuses antidepressant but agrees to take stimulant. Mom has been hiding antidepressant inside of stimulant, and patient has therefore been taking both meds unaware. Mood has recently been worsening but she continues to refuse antidepressant therapy. How to proceed?

 

[birchswing]

So the experiment is failing?

Is it possible it's worsening because of how she's adulterating these tablets? I don't know what these look like, but is she actually getting both medications? I'm not sure how you fit an antidepressant inside a stimulant and still dose both.

Even if this were legal or ethical, and I'm not sure it is (it doesn't jibe with Article 12 of UNCRC which is not binding in the US anyway), wouldn't you have legal considerations with the father, especially given that he's opposed to psychiatric treatment?

And empirically it seems to be failing, so it seems like a moot point.

The part that's especially confusing is when you offered her to go on the antidepressant that she is already taking (unwittingly), if I am reading that correctly.

Personally, I think it's unethical. I think she should have the right to know what was done to her. But given how devastating that information would be to an adolescent in this case I think it's probably better not to disclose the ruse. I think she would rightly see it as a heinous violation of trust and loss of autonomy over her body and mind.

Also problematic, she's now going to be in SSRI withdrawal and not know where the symptoms are coming from, assuming the mother stops dosing her.

Edit: I just googled ODD " a condition in which a child displays an ongoing pattern of an angry or irritable mood, defiant or argumentative behavior, and vindictiveness toward people in authority."

I think that sounds normal given the circumstances. Her parents for whatever reason broke up her family (which no matter how common does not negate the psychological ramifications). She's shuffled between two homes. And she has adult figures in her life drugging her against her will and knowledge.

What about family therapy for all three of them?

 

[SpongeBob DoctorPants]

Is it possible it's worsening because of how she's adulterating these tablets? I don't know what these look like, but is she actually getting both medications? I'm not sure how you fit an antidepressant inside a stimulant and still dose both.

Supposedly the mom talked with the pharmacist and they said this could be done and it wouldn't alter the properties of either medicine. I know that Ritalin LA capsules can be opened and the contents sprinkled onto food, but I haven't seen the insides of them so I don't really know how much room there is to fit a small tablet inside.

The part that's especially confusing is when you offered her to go on the antidepressant that she is already taking (unwittingly), if I am reading that correctly.

The mother created a situation in which the patient was unwittingly receiving a medication. I did not want to divulge the secret and destroy any trust the patient had in her mother. Therefore, I asked the patient if she would be willing to go back on the medication (even though she was already taking it), so that if she agreed, the mother could then stop the secret dosing and just give it to her as a separate dose. Sorry about the confusion; I was trying to avoid a lengthy explanation.

Also problematic, she's now going to be in SSRI withdrawal and not know where the symptoms are coming from, assuming the mother stops dosing her.

I don't expect withdrawal symptoms necessarily. She is on the lowest dose they make, and the only way to taper it would be to cut the tablet in half. Plus she's only been back on it for the past month. Should be fine with just stopping it.

 

[birchswing]

Supposedly the mom talked with the pharmacist and they said this could be done and it wouldn't alter the properties of either medicine. I know that Ritalin LA capsules can be opened and the contents sprinkled onto food, but I haven't seen the insides of them so I don't really know how much room there is to fit a small tablet inside.


The mother created a situation in which the patient was unwittingly receiving a medication. I did not want to divulge the secret and destroy any trust the patient had in her mother. Therefore, I asked the patient if she would be willing to go back on the medication (even though she was already taking it), so that if she agreed, the mother could then stop the secret dosing and just give it to her as a separate dose. Sorry about the confusion; I was trying to avoid a lengthy explanation.


I don't expect withdrawal symptoms necessarily. She is on the lowest dose they make, and the only way to taper it would be to cut the tablet in half. Plus she's only been back on it for the past month. Should be fine with just stopping it.

I think it sounds like you handled it the best way possible.

And I suppose the mother handled it the best way she could.

I agree with not creating more trust issues.

Since the parents are not on the same boat on this and perhaps other issues, I think family therapy sounds ideal. In fact as common as divorce is, it's still hard for me to imagine a scenario in which family therapy following divorce would not be ideal.

 

[clausewitz2]

I have an adolescent patient who had been doing well on Zoloft and Ritalin LA for anxiety, ODD, and ADHD. After an extended period of stability, I decided to taper her off the Zoloft but then ODD symptoms emerged. I decided to restart the Zoloft, anticipating the ODD would improve. However, I learned that at home she adamantly refused to go back on Zoloft, although she was agreeable to staying on the Ritalin LA. Her mother decided to secretly place the Zoloft tablets inside of the Ritalin LA capsules, and so for the past few weeks, my patient has been receiving the Zoloft without being aware of it.

Unfortunately, she has also recently been having some mood problems, which are new. She cut herself last week and her mother discovered some writings in her journal suggesting that the patient was depressed. However, the patient herself minimizes the symptoms and denied any depressive symptoms to me, and even denied cutting herself until she was confronted about it. I suggested going back on the antidepressant (to see if she would agree to taking it), or switching to a different one, but she refused, saying her mood is fine and she doesn't want to take any antidepressants. Her mother believes she's been hearing misinformation from her father, who is against psychiatric medications in general. (Parents are divorced, btw.) After several attempts of persuasion, the patient continued to be against taking any antidepressants.

So, in terms of prescribing an antidepressant, my options were to:

1. continue having the mother secretly administer the current dose
2. have the mother secretly administer a higher dose
3. have the mother secretly administer a different antidepressant
4. stop the practice of secretly administering the antidepressant and only renew the stimulant

I decided to go with option #4 above, because I don't like the idea of secretly giving a medication to someone if they refuse to take it. My reasoning is that this is ethically questionable, and if she were to ever discover that the tablets are hidden inside of the capsules, this could cause trust issues, not only with her mother, but also with me, and in the long run I don't think that would help. I know the mother was disappointed with my recommendation, and she expressed concern that her mood will worsen without the antidepressant and that the self-harming might occur again, or worse. I suggested that we follow up again in 2-3 weeks and if there is a worsening of mood or lack of improvement, I would be more firm about recommending an antidepressant to the patient next time.

What would you do in this situation? What is ethically permissible regarding the administration of medication to pediatric patients without their knowledge or consent? And what are some helpful strategies for treating kids who refuse certain medications?



TL/DR: Adolescent patient refuses antidepressant but agrees to take stimulant. Mom has been hiding antidepressant inside of stimulant, and patient has therefore been taking both meds unaware. Mood has recently been worsening but she continues to refuse antidepressant therapy. How to proceed?

I mean, what do you think the likelihood is that the "ODD symptoms" are the result of a Zoloft taper rather than having the sort of father who is comfortable telling her that what her mother wants her to do (get mental health treatment) is bad/wrong/poisonous/whatever? This doesn't seem like a medication issue, so I definitely second your inclination to not secretly administer questionably effective zoloft.

Last I checked SIB was not a classical depressive symptom, although it is obviously related to distress. I would be very cautious in drawing inferences about her typical mood state from what she writes in her journal; many people journal specifically to get thoughts that bother them but are not dominant out into the open or to vent when acutely upset.

Please tell me she is seeing a therapist.

 

[SpongeBob DoctorPants]

wouldn't you have legal considerations with the father, especially given that he's opposed to psychiatric treatment?

I mean, what do you think the likelihood is that the "ODD symptoms" are the result of a Zoloft taper rather than having the sort of father who is comfortable telling her that what her mother wants her to do (get mental health treatment) is bad/wrong/poisonous/whatever? This doesn't seem like a medication issue, so I definitely second your inclination to not secretly administer questionably effective zoloft.

Last I checked SIB was not a classical depressive symptom, although it is obviously related to distress. I would be very cautious in drawing inferences about her typical mood state from what she writes in her journal; many people journal specifically to get thoughts that bother them but are not dominant out into the open or to vent when acutely upset.

Please tell me she is seeing a therapist.

I appreciate your input. For what it's worth, her parents divorced when she was a baby, and she lives with her mother, but visits her father occasionally. And yes, she is seeing a therapist.

And I suppose the mother handled it the best way she could.

Although I disagree with the whole concept of sneaking medication into a child's body against their will, I agree that this mom was just trying to do her best to help her daughter. Interestingly, I discussed this scenario with my wife, and her reply was "Smart mom!"

 

[Attending1985]

This is really f***ed up on the mother's part to be secretly forcing antidepressants on her. Maybe she has "ODD" because her mom lacks the tools to have a healthy relationship with her. That is evident. I would call mom out on the role she's playing in her daughter's distress. Sounds like mom needs some help.

 

[TexasPhysician]

I can see merits to both sides. Before 18 years of age, parents are in control and sign my consent forms. The actual patient’s consent is not legally valid. Many of the children I treat don’t have capacity to consent even if they agreed and could consent.

There comes an age and level of maturity where it is helpful to have the patient willingly involved to assist with compliance and build family trust/support. I’d want to discuss the patient’s hesitations and involve the father in care.

 

[clausewitz2]

I can see merits to both sides. Before 18 years of age, parents are in control and sign my consent forms. The actual patient’s consent is not legally valid. Many of the children I treat don’t have capacity to consent even if they agreed and could consent.

There comes an age and level of maturity where it is helpful to have the patient willingly involved to assist with compliance and build family trust/support. I’d want to discuss the patient’s hesitations and involve the father in care.

I think I like my state better. While parents can consent to treatment for kids under 18 at 14 children here get the legal right to consent to their own mental health treatment even if their parents say no. Whether that is a good idea depends on the kid, but we have all met 15 year olds who probably have more capacity and better judgement than 30 year old patients we can think of.

 

[Crayola227]

I think I like my state better. While parents can consent to treatment for kids under 18 at 14 children here get the legal right to consent to their own mental health treatment even if their parents say no. Whether that is a good idea depends on the kid, but we have all met 15 year olds who probably have more capacity and better judgement than 30 year old patients we can think of.

On the subject of the patient consenting when the family says no, how does it work if they say no and the family says yes? I hope it's clear what I'm getting at.