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Sunday, April 26, 2009

The bipolar child is a purely American phenomenon

Psychology Today

"The bipolar child is a purely American phenomenon": An interview with
Philip Dawdy
By Christopher Lane, Ph.D. on April 7, 2009 - 12:17pm in Side Effects
Philip Dawdy, a prize-winning investigative journalist, has for
several years written a powerful, well-researched, and well-regarded
weblog, Furious Seasons, which focuses on American psychiatry, mental
health, and the way we think about treatment options. Given his
intensive work on the issues, I wanted to ask him several burning
questions about ADHD, bipolar disorder, and other controversies in
American psychiatry.
You've written extensively about the psychiatric diagnosis of teens
and preschoolers. How do you account for the astonishing rise in the
number of diagnoses we're seeing in these age groups, especially with
regard to ADHD and bipolar disorder?
To me, you can lay all of this squarely at the feet of the pharma
companies, which had a slew of newish drugs come online in the 80s and
90s and wanted them taken by as many humans as possibleâC"consequences
for the patients be damnedâC"and a crew of child psychiatrists at
Harvard/MGH who see deeply-flawed, ill-for-life children where other
psychiatrists might see personality disorders and issues that will
burn out over time. The pharma companies and the Harvard crew worked
hand-in-hand to bring America a generation of ADHD kids and bipolar
children, and their profound influence can be seen in the millions of
children and teens who now carry lifetime diagnoses and take gobs of
psychotropic drugs each day, often to their detriment.
That may sound extreme to some people, but it's worth noting that the
rest of the world has not embraced these diagnostic and treatment
paradigmsâC"except Britain, where there was an initial embrace of ADHD
and stimulants, but where there's now a significant backlash.
Meanwhile, in France and Italy ADHD is rarely diagnosed and it's
difficult to see where French and Italian culture have suffered as a
result. As for bipolar disorder in kids (meaning pre-teens and
younger), it's simply not an issue in the rest of the world. The
bipolar child is a purely American phenomenon, as big a metaphor of
our times as credit swaps, subprime loans, and government bailouts.
Why do you think so many more teenage and younger boys than girls are
being diagnosed with ADHD, and what does that say about our culture,
education system, parental expectations, and so on?
The data I'm familiar with pegs the boy-to-girl ADHD ratio at 3 to 1,
which is pretty dramatic. I suspect that boys get pegged with the
diagnosis more than girls do for two reasons: One, boys have always
been far more energetic and physically exuberant than girls, a point
going back through history, perhaps because they are developing their
hunter-gatherer beings. And, two, the hyperactivity piece of ADHD is
quite easy to spot and probably leads to greater pressure for kids to
be diagnosed because hyperactive boys can be disruptive, especially in
school environments.
As out there as this may sound, I think we are as a culture cheating
boys of their inherent natures and I have real questions about how
that affects their psychosocial development long-term and what it will
all mean for manhood a couple of generations down the road (I'm
concerned about comparable issues with girls as well). What's more, I
think the educational system places too much emphasis on having quiet,
compliant kidsâC"far more so than in the past. When I was a kid in the
1970s, boys were pretty much allowed to engage in all kinds of
wildness at recess in elementary school and after school, but from
what I hear that's being discouraged today. Why the change I couldn't
say, but I do know that there's been a real push in our culture to
silence outward signs of male aggressiveness, both in kids and adults.
As for parents, I think they are under a lot of self-imposed pressure
to have perfect kids with high grades who get into top universities or
they've somehow failed as parents. The ADHD drugs and the diagnosis
itself have been foisted on them as a way to have their kids better
liked among school peers and to achieve higher grades and perform
better on the many, many standardized tests kids must take these days.
What's interesting to me is that parents and our culture may well have
been sold a bill of goods here, as the recently released MTA study (a
long-term tracking study of kids through teens with ADHD, both on and
off-meds) showed that long-term treatment with stimulants didn't
appreciably improve GPAs and other test scores.
What influence do you think patent cycles exert over such diagnostic
trends? I'm thinking especially of the move to "bundle" depression
with bipolar disorder when the patents for so many SSRI
antidepressants ran out.
I think there is some influence here, even though diagnostic trends
should ideally be driven by unbiased science, independent of the needs
of pharma companies. What I've noticed over time is that, as you
suggest, there's been a great rush to get a drug approved for as many
indications as possible as it nears the end of its on-patent life,
likely because the drug companies can then market said drug directly
to the public. Certainly, that's part of what went on with Paxil and
social anxiety disorder in the late-1990s and, right now, I'm noticing
an epic push by Eli Lilly and AstraZeneca to have their atypical
antipsychotics (Zyprexa and Seroquel, respectively) approved for a
wide range of indications (including ones like depression) before the
drugs go off-patent in a few years.
Perhaps the most egregious example of a pharma company trying to
influence diagnostic trends came in 2002 when Eli Lilly launched a
massive sales campaign to convince PCPs that patients walking into
their offices complaining of depression actually had bipolar disorder
type 2 instead, and that Zyprexa was the perfect fix for that. The
results were utterly disastrous for patients, what with all the weight
gain and diabetes they experienced as a result. Interestingly, female
patients were the primary target of the campaign.
Do you think the black-box warnings that the FDA issued against
pediatric antidepressant use were effective as a deterrent?
I'm not sure they were much of a deterrent since there's been 14
percent growth in antidepressant prescriptions since 2004, according
to IMS Health. But to the degree that the black box on suicidality
gave patients and doctors important information that had long been
hidden from them by both the pharma companies and some researchers, I
think the warnings were a boon. It has at least forced people to think
long and hard about what drugs they are taking, and to pay closer
attention to side effects and any strange emotions that might arise
upon first taking the drug or changing a dosage.
Why do you think Bipolar II disorder is controversial as a diagnosis?
I may be the only writer in America who thinks BP2 is controversial
and I can hardly think of any doctors who do. For me, it's a
questionable classification and something of a cop-out by the DSM
writers for a couple of reasons: One, BP2 isn't bipolar disorder,
properly understood. There's no mania, there's no hospitalization for
mania, and there's no one running naked down the street. The most
prominent features of BP2 are depression (and that covers the vast
majority of a person's time who is diagnosed with BP2) and bursts of
energy, broadly understood. To me, that sounds a whole lot more like
depression and agitation than it does manic-depression.
Two, the minute someone gets hit with a bipolar disorder diagnosis of
any subtype, then they are faced with a profoundly bad set of social
assumptions; they get stigmatized by friends and family; and they lose
their jobs. I know of multiple cases along these lines, including one
of a sheriff's deputy in King County, Washington who was fired from
her job as soon as the brass learned she had BP2, even though she had
a stellar track record as a cop and had done nothing wrong on the job.
That hardly seems fair when we're talking about a disorder that
doesn't involve hallucinations or psychosis and has none of the
off-the-charts impulsivity of true manic-depression. While it's nice
of researchers and mental-health advocates to claim that we've got to
end this kind of stigma, in the real world that would take generations
and by then people with BP2 today will have reached the ends of their
natural lives.
Why BP2 wasn't called something else is beyond me, but the diagnosis
has sure caused a lot of unfair social damage.
Much of the rationale for medicating teens and preschoolers has to do
with arguments about early intervention. You've written that you find
such claims questionable and their underlying philosophies flawed.
Explain why.
Let me restrict this to psychosis. What you are referring to is the
prevention paradigm, or the use of psychotropics as prophylactics, all
of it trading off kindling theories of mental illnesses and disorders.
They are interesting theories, but in the real world they've not
turned out to be successful. Simply put, there is very little
long-term or short-term research to prove their validity. For example,
the PRIME study at YaleâC"which sought to identify kids at risk of
psychosis and then gave them Zyprexa to prevent psychosis from ever
arisingâC"was an epic failure and certainly raised questions about the
ethics of giving kids dangerous drugs for disorders that they, at
least in some of the cases, didn't even have.
The trouble is that the prevention paradigm is deeply seductive. If
true, psychiatry would be like cardiology where high cholesterol is
considered a risk factor for heart disease and people with high
cholesterol are given statins to prevent heart attacks. But psychosis
isn't so simple andâC"from what I've seen to dateâC"researchers have
not been able to predict with a high degree of accuracy who will
develop psychosis. That's why I find the whole thing suspect. Perhaps
I'll be warmer to researchers' claims here when they can predict
psychosis with great accuracy and replicate their findings in many
studies across different population subtypes.
As you noted on your site, the St. Petersburg Times recently reported
that in 2007 23 infants less than one-year-old were given
antipsychotics. Given all the media attention to the death of Rebecca
Riley, aged 4, from an overdose of antipsychotics (and a diagnosis of
bipolar disorder at age 2), how is it possible for psychiatrists to
continue prescribing to infants in such numbers without more
oversight?
Doctors have great powers to prescribe drugs off-label for whatever
they see fit and, to a degree, that's fine. What's gone on with
antipsychotics prescribed to infants and toddlers is simply
inexplicable to me. The drugs are known to cause huge problems in
adults, so why the heck would a doctor give them to little kids,
especially infants? It boggles my small mind.
There probably is no acceptable way to introduce oversight into this
situationâC"outside of insurance provider overviewâC"without trampling
all over doctors' traditional freedom to prescribe off-label. I'm no
fan of bans or restrictions, but this does strike me as a situation
where there needs to be a serious rethinking of what we are
doingâC"and maybe there should be a ban on the use of these drugs in
kids under, say, 6 years of age.
That said, perhaps the most effective short term fix is for parents
themselves to get educated about the problems with these drugs and to
demand a second opinion when a doctor tries to prescribe them to their
child.
Your web site Furious Seasons, which has earned you awards, includes
extensive documentation about Zyprexa. What will readers of your site
learn about the drug and its side effects?
Hopefully, they'll learn that this is a drug that causes rapid weight
gain, hyperglycemia, diabetes, lipid problems and the like in a high
percentage of patients, and that it's a drug the use of which demands
great caution. They'll also learn that Eli Lilly actively lied to
doctors and patients about problems with the drug and that the company
has had to settle almost $3 billion in lawsuits and has pleaded guilty
to a criminal misdemeanor charge in federal court for off-label
marketing of the drug for use in dementia.
One classic example: in April 2002, Japanese regulators forced Lilly
to warn doctors in Japan abut hyperglycemia and diabetes problems with
the drug, but at the time same time the company claimed in internal
documents that this did nothing to affect the safety of the drug in
the US market. Two months later, Lilly rolled out its extensive
Zyprexa marketing campaign to PCPs, which I referred to above. That is
some of the worst corporate behavior I have ever seen in my 15 years
as a reporter.
Some months ago, the government's Clinical Trials web site signaled
that the antipsychotic Seroquel was being tested for people with
public-speaking anxiety. What can and should the FDA be doing to stop
such clear signs of "mission creep" over pharmaceuticals?
I don't think the FDA has any interest in stopping this kind of
behavior, and it likely doesn't even have the regulatory authority to
do so. For instance, in the last two years the agency has approved
antipsychotics for use in pediatric bipolar disorder and in treatment
resistant depression. Neither diagnosis exists in the current edition
of the DSM, but the agency seems just fine with this situation. It
even went to great lengths to justify the diagnosis of pediatric
"mania" bandied about by some researchersâC"which amounted to little
more than agitationâC"to the point where the FDA's chief of psychiatry
products, Thomas Laughren, was actively involved in a conference where
researchers and pharma companies joined to design clinical trials of
this kiddie mania.
Likely the best solution here is for Congress to pass legislation
requiring the FDA to only approve psychiatric medications for
disorders that appear in the then-current edition of the DSM. I cannot
think of a more effective way to stop Big Pharma's making up of
disorders which they then repurpose their drugs to "treat."
Final questions: How do you keep up with all the news in pharmacology,
and what are your standard sources of information?
My sources are a mix of traditional media coverage of the field
(although that's sadly declining as newspapers fade away), as well as
original research in journals, plus items that get sent my way by my
many dedicated readers. On top of that, I've been an investigative
reporter (mostly of government and law enforcement) for a decade and I
know where to snoop. Suffice to say, I read a ton of journal articles
and reportage. It's gotten to the point where I've not read a novel or
nonfiction book outside of the mental health world in about three
years.
Philip Dawdy is the author and editor of the award-winning weblog
Furious Seasons. Christopher Lane is the author of Shyness: How Normal
Behavior Became a Sickness.

--

Yours in good health, happiness, and gratitude,

Dr. Alan C. W. Tang, DC FIAMA
Family Care Wellness & Rehab
805 Plainfield Rd, Darien, IL 60561
(630) 789-8080 http://www.FamilyCareWellness.com
Don't just manage symptoms, *FIX* the problem
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