Institute of Psychiatry organises lecture on Psychopharmacology in Child Psychiatry

Rawalpindi

Institute of Psychiatry and WHO Collaborating Centre here at Benazir Bhutto Hospital organised a lecture titled ‘Psychopharmacology in Child Psychiatry’ that experts termed as unconventional, bordering on controversial.

The session was conducted the other day by Dr. Sabooh S. Mubbashar who is a Consultant Psychiatrist and Clinical Instructor at the Yale School of Medicine and Medical Director at the Ädelbrook Behavioural and Developmental Services and at the Inpatient Unit for Dementia and Associated Co-morbidities, Sharon Hospital in the US.

The lecture was conceived and organised by Dr. Ayesha Minhas, head of the Child and Adolescent Psychiatry Department at the Institute however; unfortunately she did not attend the session because of an overlapping international commitment.

Assistant Professor of Psychiatry at the Institute Dr. Asad Nizami welcomed the audience on behalf of Head and Director of the Institute Professor Fareed A. Minhas. Professor Emeritus and founder of the Institute Professor Malik H. Mubbashar graced the occasion as chief guest while Professor Mowadat Hussain Rana, founder of Armed Forces Institute of Mental Health, was among the honourable guests.

Head of Paediatrics Department at Rawalpindi Medical College Professor Rai Asghar, Assistant Professor of Psychiatry at Jinnah Hospital Lahore Dr. Usman Hotiana and Consultant Psychiatrist at KRL hospital Dr. Anum Misbah were also among the esteemed guests. Psychologists, post-graduate residents in psychiatry and paediatrics, and house officers were also in attendance.

Dr. Sabooh Mubbashar began the session by talking about autism. He declared that autism is a multifaceted disorder, poorly understood even in the western world. He highlighted that in the label ‘Autism Spectrum Disorder’, the key-word, to the surprise of most people, is not autism but spectrum. An autistic person can exhibit severe self-harming behaviour, be completely non-verbal, and completely dependent; or he could be a Mark Zuckerberg or a Bill Gates; thus the spectrum and difficulty in diagnosing the ever-evolving disorder that is Autism. Functionality in autism can vary across this spectrum, he said.

He clarified, especially for the paediatricians in attendance, how psychiatry predominantly deals with disorders rather than diseases. A conundrum of symptoms present to the psychiatric clinic and the lack of any pathognomonic, concrete and testable sign preclude an easy diagnosis. Dr. Mubbashar did not hesitate in adding that this problem is further compounded by the fact that we are poor diagnosticians in general.

He alluded to the human tendency of labelling so as to give ourselves a greater sense of control. This leads us to pigeon-hole patients in diagnostic categories. He gave an example of a nine year old boy who in the course of his interaction with various psychiatrists had gotten labelled with multiple, often contradictory, diagnoses. He conceded that this may be due to varying presentation of symptoms, but that does not excuse ignorance or poor history taking. The eyes cannot see what the mind does not know, he reminded everyone. He symbolized this sorry state of affairs with the example of the blind men around the elephant, each labelling the elephant with whatever they got access to, disregarding the whole.

Dr. Mubbashar severely reprimanded the thought that child psychiatry is just adult psychiatry with shrunken adults. He recalled how he learnt this the hard way in the very beginning of his own fellowship.

He further elaborated on the diversity of the spectrum in autism by saying that stalkers who end up killing famous people were seen in hindsight to have been social loners. Further, to the utter surprise of most people in attendance, he ventured his theory that schizotypal and schizoid personalities were described by adult psychiatrists looking at autism in its adult form.  Alluding to the importance of a developmental psychiatry he said that he strongly felt that to be a child psychiatrist should be mandatory and adult psychiatry should be optional rather than the other way around which is how it is around the world.

The discussion then moved on to psychopharmacology. Dr. Mubbashar to the surprise of many, said that the main side effect of selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitors (SSRI’s, the class of drugs used as antidepressants) is that the symptoms get worse initially and this is something that patients should be informed about and a short-term benzodiazepine may be useful initially to attenuate this effect. He lamented the underuse of antidepressants due to its notoriety for suicidal tendencies. He said that even the most robust literature says that the threat is 1 in a 1,000, and for that if 999 patients are deprived of the benefits of the SSRI’s then that doesn’t make sense.

Professor Malik H. Mubbashar then spoke as chief guest and acknowledged the pearls of wisdom and practical tidbits given by Dr. Sabooh Mubbashar as being very impressive. He lamented how people usually refrain from giving these titbits in the scientific world that we live in. He reiterated for the audience that rather than pushing a patient to a diagnostic category try to understand the patient and his problems.  He reminded everyone to understand the western knowledge but in your own context. He concluded with a reminder to all the physicians in attendance not to sell their dignity before pharmaceutical companies.

Professor Rai Asghar also commended Dr. Mubbashar for his presentation especially the tricks of the trade, he offered. He explained further that a child is not miniature of man and the pharmacokinetics are very different in the paediatric age group; there is more fat and size of liver as per weight of child is more and the enzymes are more. Therefore the metabolism and renal clearance is greater. This is why, he said, that drugs are more meticulously measured according to weight. He also proposed that trainees from paediatrics should rotate in child psychiatry for at least two months.