Washington state health care professionals who treat children are bracing as a new commission launched by President Donald Trump's administration takes aim at psychiatric drugs.

Last Thursday, an executive order from the White House established a new "Make America Healthy Again Commission," chaired by Health and Human Services Secretary Robert F. Kennedy Jr. The executive order focuses on the health of American children and calls for "drastically lowering chronic disease rates and ending childhood chronic disease."

The order has sparked a swirl of concern over youth access to medications that treat depression, anxiety and ADHD. Part of it is angled at examining prescribing practices for SSRIs, antipsychotics and stimulants — drugs that can have side effects but are also critical for many who have struggled to curb debilitating anxiety and thoughts of suicide or harming themselves.

Several Washington physicians say they agree with the premise of monitoring prescribing practices — there are indeed legitimate concerns about overprescribing, several said — but a federal order could get in the way of trusting relationships between physicians and patients and their families.

"Any parent who has a child who is struggling with depression or anxiety or psychosis, it's a scary place to be. And there's a lot of harm that goes with having untreated illness," said Dr. Lelach Rave, interim executive director of the Washington Chapter of the American Academy of Pediatrics. "Not that you discount the risks of medications because they're real as well, but there is real risk with disease."

The Seattle Times spoke with Washington medical professionals about the new commission, what it could mean for Washington kids and their families and what safeguards are already in place to prevent overprescribing.

What have Trump and RFK Jr. proposed?

Concern spread quickly on social media over the weekend about whether the Trump administration was planning to restrict all access to psychiatric medications. As of now, the executive order focuses specifically on medication for children, not adults, and to start, calls for the submission of a report rather than any specific action.

By 100 days after the date of the order, the new commission is required to submit an initial report including an assessment of "the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs." Eighty days later, the commission is required to submit a strategy with recommendations for the federal government.

It's clear any changes to prescribing practices would have a huge impact: For example, the order cites medication for attention deficit disorder and attention deficit hyperactivity disorder as an example. Over 3.4 million children are on medication for ADD or ADHD, the order said.

What medications are mentioned, and how do they work?

Selective serotonin reuptake inhibitors are a class of antidepressant drugs commonly prescribed to treat depression and anxiety. Common SSRIs include Prozac (fluoxetine), Zoloft (sertraline) and Lexapro (escitalopram). The drugs work by increasing the brain's levels of serotonin, a neurotransmitter that regulates mood and other body functions.

Antipsychotics are prescribed to treat mood disorders including schizophrenia and bipolar disorder. These drugs change the balance of neurotransmitters in the brain, including dopamine and serotonin, to prevent psychosis, a collection of symptoms including hallucinations and delusions that cause a disconnect from reality.

Stimulants such as Adderall and Ritalin are commonly prescribed for people with ADD and ADHD. These drugs promote attention and impulse control by increasing the levels of neurotransmitters including dopamine and norepinephrine.

The executive order also mentions mood stabilizers and weight-loss drugs.

What's at stake for kids who can't access needed medications?

The impact of such an order on children and adolescents could be significant, especially as the youth mental health crisis has escalated over the past few years.

Summer Starr, the interim director of Washington's National Alliance on Mental Illness chapter, said the order raises concerns about mental health parity, which requires insurers to cover mental health treatment as broadly as physical health.

"You'd never deny someone cancer treatment. There isn't the same level of stigma for that," Starr said. "We're trying to destigmatize mental health, and this just adds another layer of that."

Starr also said delaying treatment for children and teens can make it more difficult to help them recover later on.

"I do know that the earlier people are able to get the support that is needed for mental health recovery, the better that process is for them," she said.

The youth mental health crisis has played out in emergency rooms, residential treatment centers and on the streets — particularly after the pandemic started. During the years after schools closed, many more kids and teens with serious psychiatric conditions sought inpatient psychiatric treatment. Rates of life-threatening eating disorders rose, as did emergency responses to kids and teens overdosing on deadly drugs like fentanyl. The Centers for Disease Control and Prevention reported that visits to emergency departments for self-harm and psychological concerns increased after the pandemic began.

Data from Washington's Healthy Youth Survey shows that while mental health outcomes among 10th graders are improving, more than half of teens surveyed in 2023 still reported anxiety or inability to stop worrying, and 30% reported persistent depressive feelings. Nearly 15% reported contemplating suicide.

What authority does RFK Jr. have over medication access?

Kennedy's authority to carry out some of his promises is not clear-cut. The secretary of the Department of Health and Human Services oversees federal health policy across 13 divisions, including the Substance Abuse and Mental Health Services Administration. He also oversees the Food and Drug Administration, meaning he has the authority to regulate medical drugs and devices.

Kathleen Sebelius, the former HHS secretary under Barack Obama, said in an NPR interview that the primary job of the secretary is to write rules and regulations that implement laws passed by Congress, not to create new laws. But she said the office does hold administrative power, such as redefining terms under various laws.

Companies can also sue the health department over regulations, which could slow down or stop actions by the agency, Sebelius told NPR.

It's still not entirely clear what Kennedy's proposal could look like in practice. But his plans to fire hundreds of employees from federal agencies under his purview, such as the FDA, could significantly slow down research and regulation of medications.

Starr, the NAMI Washington director, said the organization's legislative team is weighing its options, and may need to advocate for local legislative protections if the federal order does affect access to medications.

What has RFK Jr. said about mental health medications?

During his presidential campaign, Kennedy called people who take antidepressants and ADHD medications "addicts" and suggested they should go to rural "wellness farms" to stop taking their medications.

In a podcast appearance, Kennedy linked the use of antidepressants to the rise of school shootings — a rumor debunked by research. When asked about that claim in his Senate confirmation hearing, Kennedy said "It should be studied along with other potential culprits."

In the hearing, he also said "I know people, including members of my family, who've had a much worse time getting off of SSRIs than people have getting off heroin."

Unlike heroin and other opioids, SSRIs aren't habit forming, but some people who suddenly stop taking these medications experience physical symptoms, including restlessness and anxiety, nausea, dizziness, sleepiness, or flu-like symptoms. Experts recommend lowering SSRI doses in partnership with a health care provider.

How many Washingtonians take psychiatric medications?

It's difficult to know how many Washingtonians take psychiatric medications for mental health symptoms because there's no single database that documents the number of prescriptions written or who actually takes drugs they're prescribed.

The state does publish aggregated data on annual pharmacy claims; 2023 data suggests several antidepressant and anti-anxiety medications including Zoloft, Lexapro and Cymbalta were among the top 25 drugs prescribed among all age groups in Washington.

Nationally, about 1 in 5 children and teens are estimated to have a mental health condition. About 8% of kids ages 5-17 take psychiatric medications, according to 2021 data from the National Center for Health Statistics. A slightly higher percentage of boys were reported to have taken psychiatric medications than girls.

What oversight and guidelines are in place now in terms of prescribing to kids?

Prescription drugs for mental health conditions — how they're approved, who gets them and what doses are dispensed — are governed by at least three entities.

The FDA has a rigorous drug approval process that involves rounds and rounds of clinical trials. Once a drug is approved in adults, the FDA might later approve it for use in kids, as has happened with Zoloft, Prozac and several other antidepressants, anti-anxiety medications and drugs for neurodevelopmental conditions like ADHD.

Not all mental health medications have been formally approved for kids, though. Some physicians may prescribe such drugs "off label," when they have reason to think a child or teen could benefit from taking it.

A host of professional organizations — the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association — are tasked with developing prescribing recommendations. Experts in these organizations are well versed in the academic literature and create guidelines for dosing and when prescribers should consider certain medications, said Dr. Larry Wissow, professor of psychiatry at the University of Washington School of Medicine.

Finally, commercial and public insurers have their own "formularies" — lists of pharmaceutical drugs they'll pay for. These lists are often the deciding factor in whether someone gets one drug over another.

Washington is one of several states that closely monitors use of psychiatric medications in children, said Dr. Robert Hilt, professor of psychiatry at UW Medicine and director of the Partnership Access Line. PAL, for instance, is a longstanding state partnership with Seattle Children's and supports independent medication reviews.

When a prescription for psychotropic drugs or a combination of medications falls outside standard guidelines, it gets flagged by the state and sent to PAL for a second opinion. Physicians who have questions about medications or need help with treatment planning can also call the PAL hotline and speak with a child psychiatrist.

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