Assuming Facts Not in Evidence: ADHD and Pediatric Bipolar Disorder

As I discuss in my book, How Dysfunctional Families Spur Mental Disorders, one marketing technique used by big Pharma to mislead physicians is the engineering of a journey of ideas that have never been proven into the clinical lore as if they were established facts.  So-called experts who are paid off by drug companies make presentations at continuing medical education conferences or write "review" articles for medical newspapers or throwaway journals in which they mention these so-called "facts."

They do tend to use conditional language, like "[such and such diagnosis] may be made in cases that do not meet the established DSM criteria, or that "[such and such] drug appears to have efficacy."  And they almost always throw in a, "Of course, more research is needed" or something like that.

Conditional phrases are said or written as a quick aside in order to leave the speakers and writers a loophole just in case a member of the audience challenges them about overstating their case. Should this happen, the speakers are then able to point to the conditional language they used and “remind” the audience that their use of this language indicates that they are not making spurious claims.  Most of the time, however, no one in the audience will make such a challenge. The audience is left with a dangling implication (and a superficial sigh?) that the statement is an established fact. 

The non-discerning physician comes away with the “take home lesson” that the assertion is true.  Research has shown that most people only remember one or two salient points from a paper or an oral presentation anyway, and Pharma knows this very well.

A superb example of this was recently seen in the December 2011 edition of the newspaper Psychiatric Times.  The article - for which a doctor could get credit for continuing medical education - was entitled The Clinical and Treatment Implications of Co-Occurring Mania and ADHD in Youths.  It was written by Janet Wozniak, a protege of well-known pediatric bipolar and ADHD enthusiast Joseph Biederman at Harvard Medical School.

Janet Wozniak, M.D.

She writes, "A major component of the debate regarding the diagnosis of bipolar disorder rests with its high overlap with ADHD." (her reference: a paper co-written by Biederman). In truth, the real debate is whether both pediatric bipolar disorder and ADHD are being over-diagnosed in children who have plain old behavioral problems or anxiety due to family dysfunction of various sorts and/or who are just plain acting out.

She admits, "Arguably, all of the symptoms of ADHD, including inattention, impatience, disorganization, and restlessness, could be part of the mania component of bipolar disorder."  And vice versa! Since we have no lab tests, exactly how then are we able to distinguish them? Unmentioned is that all of these symptoms can be due to anxiety or acting out as well.

In her answer to this question, she brings up the fact that, according to the diagnostic manual, the DSM, "episodicity" is a definitional feature of bipolar disease.  Loosely translated, this means that a manic episode has to last for at least a week, non-stop.  She then goes on to say, "However, the documented chronicity and complex/rapid cycling of bipolar disorder in youths often renders the notion of classic episodicity as a distinguishing feature of mania functionally impracticable." So, she is saying that the DSM criterion is at the very least clinically unusable, with the strong implication that it has this idea completely wrong. 

Her view is documented, she opines.  Sounds impressive.  But I don't think she has a leg to stand on.  People who created the diagnosis of pediatric bipolar disorder are the ones who made that up, using circular reasoning in my opinion.  In fact, as I described in a previous post, the available evidence shows that unstable moods (affective instability) in children are not, in fact, related to bipolar disorder. And the whole concept of ultra rapid cycling is also highly dubious in adults, as I described in another recent post.

Of course, Wozniak adds a sentence to the end of the paragraph that implies that the jury is still out on this question, but you can safely wager that the average doc reading this will not pay attention to that caveat.  Besides, it's just not practicable to worry about such issues.

She goes on to point out that of course giving stimulants for ADHD can make mania worse - true, if the child were really manic, a rare occurrence usually involving frank psychosis - and that medications for mania have a lot of potentially toxic side effects (also true).  So if you cannot tell ADHD and bipolar disorder apart by their symptom presentation, then what is a doctor to do?

Simple.  She recommends diagnosing children with BOTH conditions!  If you treat the patient with a downer like depakote, then the stimulant won't make them hyper.  Uppers in the morning, downers in the evening, sugar at suppertime.  File this under pharmacology, insane.

She then states that one study demonstrated that children with the "combined disorder" continued to meet criteria for both mania and ADHD after discounting overlapping symptoms, which to her "suggests" (to most readers, "suggests" means that it's true) that co-morbidity is not an artifact resulting from shared diagnostic criteria.  And who did this study?  Biederman's group!

And then comes the kicker.  She states that 70 to 90 percent of pre-adolescents with bipolar disorder also have ADHD!  Imagine that.  70 -90 per cent.  Her reference for this truly unbelievable figure: another study of which both she and Biederman were co-authors.

Now, I myself often reference my own previous work in my academic papers, but most of my work involves ideas rather than alleged statistics, and I do not want to have to have repeat all of my ideas anew in each paper.  In this case, however, when a whole research group has come under suspicion like Wozniak's has, it might behoove them to quote someone who is completely independent from them and not funded by big Pharma.