Corruption at Child and Adolescent Psychiatric Hospitals

I have been discussing the huge rise in diagnoses of pediatric bipolar disorder spurred on by Harvard psychiatrist Joseph Biederman and many others (not to mention the huge rise in diagnoses of bipolar disorder in adults), for a long time in this blog. While there are rare children who present with bipolar disorder, they are few and far between, and they are obviously psychotic. Most children getting the diagnosis now don’t even come close.

Not only have the big pharmaceutical companies benefitted from this, but it has also been a big financial boon for the for-profit psychiatric hospitals that have child and adolescent units, and the corrupt child psychiatrists who admit patients into them.

Of course, critics of psychiatry seem to think that it is only psychiatrists who are subject to greed, corruption, and excess. Not people running investment and banking firms, "alternative" medicine websites, auto repair shops, oil companies, or the for-profit prison system prosecuting a racist and phony war on drugs. Not even Congressmen! Just psychiatrists. 

Wolf of Wall Street, anyone? Nope. It's just the Wolf of Roxbury Drive (also known as Couch Canyon in Beverly Hills).

Anyway, the following graphic displays the incredible upsurge in hospital admissions for this alleged disorder between 1997 and 2010.

Unfortunately, fraudulent practices in child and adolescent psychiatric units are nothing new. Only the phony diagnoses have changed. In the 1980’s and 1990’s, adolescents with behavioral disturbances were kept in hospitals run by National Medical Enterprises (NME) (now Tenet), Charter (now Magellan), and some others for months at a time – until their insurance benefits ran out. They were then abruptly discharged.

Then, as now, parents were assured that their parenting, chaotic lifestyles, and/or marital problems had nothing at all to do with the behavior problems their children were having. After all, if the hospitals told the truth, parents might take their children out of the hospital in protest. 

Back then, the hospital said the culprit behind what we used to call juvenile delinquency was obviously heavy metal music!

I’m not kidding.

The hospital chains were eventually prosecuted by the United States Justice Department for billing fraud and abuse, as well as for making false diagnoses and even for false imprisonment. This is why the firms reorganized and changed their names.  

So they needed a new way to make money fraudulently, and the Biedermans of the world were happy to oblige them with false diagnoses of bipolar disorder and of course ADHD - or both.

One of my former trainees, now a colleague, told an interesting personal anecdote about a hospital with an adolescent unit, although this concerned a young adult patient with borderline personality disorder (BPD). The doctor planned a brief hospitalization for the girl in order to stabilize her, and - following the way I trained him - soon told her he was going to discharge her. Hospitalization tends to make patients with BPD worse rather than better if they are kept there longer than just briefly.

The hospital literally went behind his back and spoke with the girls parents. They told them that they were concerned that my colleague’s discharge plan was premature and was going to harm their daughter!

As soon as my colleague found out about this, he resigned from the hospital staff. I trained him well.

Of course, being an ethical psychiatrist can get you into trouble. The child and adolescent psychiatry department at the University of Tennessee Health Sciences Center, when I first came there in 1992, was heavily into "structural" family therapy and not just drugging children. It's leader, David Pruitt, had been trained by the family systems therapy pioneer Salvador Minuchin himself. 

Many years later, the department opened a new psychiatric ward at LeBonheur Children's Hospital. Only trouble was, our department's philosophy was to only hospitalize children who actually needed to be in the hospital. There were not enough patients to make the unit a viable concern, so the hospital closed it. So now, children who actually need inpatient care are completely at the mercy of the private chains.

Here are some news stories about the NME scandal:

 From Answers.com

The trouble began in 1991 when the Texas attorney general sued NME for alleged overbilling practices at its psychiatric facilities in that state. Allegations of wrongdoing were compounded that year, as individual patients began to accuse NME of having held them in psychiatric facilities against their will, only releasing them when their insurance coverage was exhausted. 

Eventually, more than 130 patient suits would be filed. Further, in the summer of 1992, 19 insurance companies, including Metropolitan Life, Aetna, Prudential, and Mutual of Omaha--some of the biggest providers in the country--filed suit accusing NME of an elaborate program of insurance fraud, beginning as early as 1988, whereby NME admitted tens of thousands of patients who did not need inpatient care, paying illegal kickbacks to referring physicians, fabricating trumped-up diagnoses, and charging exorbitant fees to treat them. At its peak, the cost of the fraud was estimated at $750 million.

 In August 1993, 600 FBI and other federal agents raided NME's headquarters and 11 of its psychiatric facilities, seizing hundreds of documents as part of an investigation into possible criminal misconduct. To his credit, Barbakow insisted on full cooperation with the investigations.

The scandals significantly damaged NME's finances as well as its reputation, as operating profits from the psychiatric division fell from $234 million in 1991 to just $3 million in 1993. As for the cost of putting the past behind, by the end of 1993 settlements with only a few of the insurance companies in question had already topped $125 million. Moreover, after spending nearly $65 million in legal fees, NME pled guilty to felony federal charges in 1994 and agreed to pay $379 million to the Justice Department and the Department of Health and Human Services, the largest settlement in history between the U.S. government and a healthcare provider.

From Uow:

In its first incarnation during the 1980s and 1990s the company was called National Medical Enterprises (NME). It was involved in a massive scandal defrauding Medicare by buying patients for up to US $2000 each from anyone who could persuade them to come to hospital. The company had contracts with bounty hunters and even pleaded guilty to kidnapping a patients. It bought patients from Canada.

Vast numbers, many of them children did not need hospital admission. The company lied to them and kept them in hospital for the full duration of their insurance all the time providing them with vast amounts of unneeded treatment. All of this was signed for by doctors. The company eventually pleaded guilty to criminal practices in 1994, was forced to sell its specialty hospitals where the fraud occurred, entered into a variety of integrity and compliance agreements and paid in the region of US $1 billion in settlements and compensation to patients

From Business Week  9/12/93:  

On Aug. 26, 600 FBI and other federal agents swooped down on NME's Santa Monica (Calif.) headquarters and 11 of its psychiatric facilities, seizing hundreds of documents. The government hasn't filed charges against NME, but sources close to the investigation say the FBI raid follows a two-year probe into possible criminal misconduct, including widespread overbilling and fraudulent diagnoses to extend patients' hospital stays.

"GOLDEN RULES." Insurers claimed that NME's top management instructed hospital administrators to adopt "intake" goals designed to lure patients into NME hospitals for lengthy and unnecessary treatments. Although the Justice Dept. isn't elaborating, sources say the government is investigating possible illegal marketing and billing practices that are the crux of lawsuits filed last year against NME by 19 insurers, including Prudential, Aetna, and Travelers.

In one internal NME document called "Intake Focus Golden Rules," which was obtained by insurers, hospital administrators declared: "Intake is our most important system--nothing else matters if we don't do that well." To that end, hospital staffers were urged in the document to admit fully half of all patients who came in for an evaluation. Barbakow, a board member since December, 1990, says the document was put out by lower-level managers. NME says it was later recalled when headquarters learned of its existence.

The FBI has also been interviewing former NME patients who are suing the company for false imprisonment. Robert Andrews, a Fort Worth lawyer who is handling 68 such cases, claims NME guide manuals instructed staffers to "push the pain" by convincing parents that if their kids weren't admitted, they might commit suicide. NME says the manual hasn't been used in years.

Dawn McClary is one plaintiff. McClary, now 20, says she spent 20 months from December, 1987, to July, 1989, at NME's Brookhaven Hospital in Dallas after quarreling with her parents about staying out late. After a three-week evaluation, McClary alleges, she was misdiagnosed with a borderline personality disorder and strapped to a wheelchair or her bed for days at a time. McClary's parents were advised she should stay at Brookhaven for five years. But when her insurance policy refused to continue payments, McClary says she was finally released. Total cost to her insurer: $298,000. NME says it's barred by law from discussing patient treatment.

Drug Company Financed Biederman on a Tear

In their continuing effort to label every acting-out child with bipolar disorder, Harvard doctor Joseph Biederman and his band of colleagues are now trying to add a THIRD disorder into the mix along with "comorbid" ADHD. 

According to a new journal article in the Journal of Clinical Psychiatry, "30% of the bipolar probands with bipolar I disorder met criteria for autism spectrum disorder." 

All the more reason to give autistic kids dangerous brand-named meds that don't do anything except drug them into oblivion, I guess. 

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.

Biederman and Colleagues Finally Get.... a Slap on the Wrist.

From the July 2 Boston Globe (http://www.boston.com/lifestyle/health/articles/2011/07/02/three_harvard_psychiatrists_are_sanctioned_over_consulting_fees/):

"Concluding a three-year investigation, Massachusetts General Hospital and Harvard Medical School sanctioned renowned child psychiatrist Dr. Joseph Biederman and two colleagues after finding they violated conflict of interest rules...

Joseph Biederman

...They did not specify the nature of the violations. But in 2008, Senator Charles Grassley, an Iowa Republican, accused the three doctors of accepting millions of dollars in consulting fees from drug makers from 2000 to 2007, and of failing for years to report much of the income to university officials...

...They said the institutions imposed remedial actions, requiring them to refrain from all paid industry-sponsored outside activities for one year, with an additional two-year monitoring period during which they must obtain approval before engaging in paid activities. They were also required to undergo unspecified additional training and suffer 'a delay of consideration for promotion or advancement...’'

...“It’s hard for me to make that judgment, but this all sounds like a little slap on the wrist,’’ said Dr. Jerome Kassirer, a Tufts University School of Medicine professor and outspoken critic of close ties between the drug industry and physicians. He pointed out that Biederman is a full professor at Harvard Medical School, so it’s unclear how a delay in promotion or advancement would affect him. Also, Biederman severed his industry ties soon after Mass. General and Harvard began their separate but coordinated investigations...

...Biederman is the country’s most prominent advocate of diagnosing bipolar disorder in children, even in those under age 6, and using antipsychotic drugs to treat many of them."

Really, in my opionion, these people should be in jail for perpertrating scientific fraud and for launching the trend of inappropriately drugging children who are merely acting out.

Debunking De Biederman

Joseph Biederman, the Harvard guru who advocates for the use of antipsychotic medication on children, is a psychiatrist who almost single-handedly started the current craze of psychiatrists and primary care doctors diagnosing acting-out children as having bipolar disorder.  I discussed in previous posts some of the issues involved both in Dr. Biederman's behavior and in the diagnosis of "pediatric bipolar disorder," particularly in my post of March 9, 2010, Recipe for Producing Frequent Temper Tantrums in Children.



Dr. Joseph Biederman

Dr. Biederman argued that the symptoms of bipolar disorder in children are very different from those of adult bipolar disorder.  In particular, he said that manic or depressed mood episodes, required by the DSM to last for a minimum of four to seven days in adults for mania and two weeks for bipolar depression, could last for mere minutes in children. Symptoms of bipolar disorder seen in children but not in adults, he opined, included temper tantrums and "explosive irritability."  Not that he had any clear scientific evidence connecting such symptoms to adult bipolar disorder. I'm guessing he just pulled these ideas out of his butt.

Tantrums, rage, emotional instabilty, low frustration tolerance and the like are all symptoms of borderline personality disorder in adults.  These types of symptoms fall under the rubric of affective instability or mood dysregulation, also called neuroticism by personality theorists. 

Individuals high on this variable get depressed, anxious, or angry quite easily and take much longer to calm down than average person. Patients with borderline personality disorder are frequently misdiagnosed as bipolar in the world of today's psychiatry (see my post of April 7, 2010, Borderline or Bipolar?).

Is similar diagnostic bungling being seen today with out of control children who exhibit affective instability?  Well, according to a new review of all of the existing studies in the February 2011 edition of the American Journal of Psychiatry by Ellen Leibenluft, the anwer is quite clearly yes.

From the abstract: "An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood.

Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups."

In the absence of validated biological laboratory tests for a psychiatric disorder, the time course of symptoms, clustering of the symptoms in close family members, and differences in brain physiology and mental abilities on various mental tasks are the most important indirect ways of assessing whether two similar appearing psychiatric syndromes have something important in common. In each of these ways, comparing short-term affective instability to the longer term symptoms seen in bipolar disorder shows that the phenomena are not the same thing.

It is also important to note that irritability is a criterion for at least six different psychiatric diagnoses in children (manic episode, oppositional defiant disorder, generalized anxiety disorder, dysthymic disorder, posttraumatic stress disorder, and major depressive episode).

Of course, not even Leibenluft discusses the possibility that -  just maybe - affective instability in children is reactive to a chaotic family environment.  Interestingly, in an interview in the January 21, 2011 Psychiatric News, she was quoted as saying, "The phrase we commonly hear from parents is that they have to 'walk on eggshells.'"

 

Translation: the kids in these families are determining what the adults do or say, not the other way around.  A situation in which parents seem to be afraid of their own children is very bad for children, who tend to badly need to be taken care of and given limits by their adult caretakers - despite the kids' protestations to the contrary.  There is very strong evidence from the attachment literature that such situations actually create affective instability in children.

So what might Biederman's answer be to this new data?  Amazingly, according the Leibenluft, Biederman's research group and some other groups maintain that it is "nonetheless reasonable to apply a bipolar diagnosis to children with such a clinical presentation. One important argument for this position is that children with severe nonepisodic irritability manifest severe mood symptoms and are as severely impaired as those with classic bipolar disorder, but without a diagnosis of bipolar disorder their access to the mental health services they need might be limited."  (p.129-130).

Wow. In other words, we should label kids who actually have behavior problems as having bipolar disorder, so instead of doing family therapy, we can treat them with sedating drugs that have not been approved as safe or efficacious in children, and which have a lot of potentially extremely serious toxic side effects (metabolic syndrome) in people including death. 

An amazing display of sick, twisted phony logic worthy of Ann Coulter.

(See a great review of the issues involved in the case of a child named Rebecca Riley who died at the hands of parents who were trying to bilk the psychiatric disability system.  It also shows how easy it is to fool some psychiatrists).

An Unpleasant Diversion

Statistics using the term drug diversion usually refer to the sum of the amount of prescription drugs being abused by the person to whom the drug was prescribed and the amount of drugs being sold to or given to other people. So, what class of prescription drugs do you think is most frequently "diverted" for non-medical uses? Opiate narcotics like Oxycontin, Vicoden, and Percodan? How about sleeping pills and tranquilizers like Xanax and Ambien?

Not even close! Far and away the most commonly diverted prescription drugs are stimulants like Ritalin, Adderall, and Concerta - drugs that are prescribed for ADHD. According to a study in the Journal of Clinical Psychiatry, about 60% of students with a prescription for ADHD medication shared or sold the medication for non-medical use. Other studies have quoted somewhat lower figures (22-50%), but comparably, people who deal in their oxycontin prescriptions are complete pikers!

Stimulants, a class of drugs which also includes street drugs like cocaine and methamphetamine, are well known to be performancing enhancing drugs. They not only help kids with attention problems concentrate and focus, they help anyone concentrate and focus. And with them, you can stay up all night and study. On college campuses across the country, they are known as academic steroids.

They are so commonly used in colleges by students and faculty alike to get a leg up on the competition that the satirical newspaper the Onion recently reported that Harvard awarded an honorary degree to Adderall ("In its 14 years of availability by prescription, Adderall has had a profound and wide-reaching effect on the works of countless academics, contributing to an estimated 3.2 million research papers and blazing the trail for the several thousand grants, fellowships, and high-grade point averages that followed."). (http://www.theonion.com/articles/adderall-receives-honorary-degree-from-harvard,17527/).

When was the last time you heard a news story about the horrors of illegal Valium abuse? Even if you have, which would make you a rare bird, compare that to how many news stories you have heard about the horrors of meth and cocaine abuse.

The FDA classifies stimulants and narcotics in the same category - Schedule II. (Only illegal drugs like Heroin are Schedule I). By comparison, benzodiazepines like Valium and Xanax are schedule IV - which means they are considered to have far less abuse potential. Instructive in this regards is the fact that calls to poison control centers regarding stimulant abuse rose 76% between 1998 and 2005, paralleling an increase in prescriptions for ADHD (Setlik and others, Pediatrics, 124 (3), pp.875-880, 2009).

Joseph Biederman, the Harvard Guru of using psychiatric drugs on Children, was active in ADHD research before he was pushing the diagnosis of childhood bipolar disorder. He published a paper that purported to show that kids who were prescribed stimulants were no more likely than anyone else to abuse drugs as adults. Maybe he should have talked to the kids' older siblings. Besides, if you get your drugs of abuse by prescription, you are still using the drugs. As if people in Methadone maintenance programs are not still opiate addicts. I wonder if Biederman's study was compromised by all that drug company money he's accepted over the years?

And how are kids on stimulants doing in school? One study showed that they gained about three more months in school over kids who were diagnosed with ADHD but were not given stimulants. How impressive. A little tutoring would have probably worked just as well. Other studies show that those who were given stimulants continued to have just as many problems in their adult personal life as those who were not treated. And they're shorter as well. Really.

Recipe for producing frequent tantrums in children

Joseph Biederman is the Harvard Psychiatrist who has been pushing the diagnosis of "pediatric bipolar disorder." He also advocates the use of potentially toxic brand-named antipsychotic and mood stabilizing drugs for children who display symptoms of this alleged condition, because Lithium tends to not work in this population. That could be because these children are not bipolar to begin with. According to the New York Times, drug companies paid Dr. Biederman at least $1.6 million in consulting fees from 2000 to 2007, but for years he did not report much of this income to university officials, according to information given Congressional investigators.

Biederman argues against the use of any duration criteria for manic or depressive episodes in these so-called bipolar children. In the current DSM, hypomania - a mild form of mania - must be present constantly for at least four days, and a full-blown manic episode has to last seven. Although these time lengths are obviously arbitrary, they were put in the DSM so psychiatrists would not label normal mood reactivity as being due to bipolar disorder.

Biederman argues that mood swings in bipolar children can last just a few minutes and rapidly alternate. He further argues that pediatric bipolar disorder is unlike adult mania and is manifested by the key symptoms of temper tantrums and “explosive irritability.” There is no credible scientific evidence that such behavior is related to bipolar disorder. He just MADE THIS UP.

The folks writing the DSM-V are somewhat concerned about the widespread adoption of this ridiculous idea by doctors who only dispense drugs and do no psychotherapy, so they decided they might come up with a whole new mental disorder, discussed in an earlier post, called "temper dysregulation disorder."

Actually, children do not have to have any biogenetic disorder in order to display frequent temper tantrums. We used to call such behavior acting out.

There is a well-known recipe that parents can use to produce this behavior in nearly any child. Just follow the following steps:

1. Start with one parent who constantly tells a child to do or not to do something, but always caves in so the child always disobeys and always does whatever he or she wants to do.

2. Add in the other parent yelling and screaming at the child about this, but still allowing the child to do whatever he or she wants to do.

3. Stir up the mix by having the parents criticize one another’s parenting in front of the child and blame one another for the child’s behavior.

To make a child with borderline personality disorder, follow these additional steps:

1. Add parents who start blaming the child in addition to each other for all of the family problems, but still let the child always get his or her way.

2. Have the whole family invalidate what the child says and does as much as possible.

3. Have parents vascillate between hostile overinvolvement and hostile underinvolvement.

Optional: If a severe case is desired: add in neglect and/or physical and/or sexual abuse of the child.

One has to keep in mind that if parents who usually act this way somehow listen to advice and stop it, the child’s behavior will get worse before it gets better. Furthermore, if the parents occasionally lapse back in to old habits, the child’s misbehavior will continue on even longer before it stops.

This is due to something behaviorists call a variable intermittent reinforcement schedule. The child will keep testing the parents to see if they will revert to prior practices.