If All the Docs are Doing it, is it not Malpractice?

Part of the legal definition of malpractice includes the idea that the treatment provided falls below the accepted standard of practice in the medical community.  In other words, it must be shown that the practitioner was acting in a manner which was contrary to the generally accepted standard operating procedures that are currently being widely used by other physicians in the city in which the doctor practices.

For a malpractice case to be successfully pursued in court, the treatment must also be shown to be negligent and of course result in some quantifiable harm to the patient. But what happens if certain harmful procedures were being widely performed by almost all of the other doctors in the community? Even if the harms are predictable and significant, is a doctor protected from liability just because "everybody's doing it?"

Many mothers back in my day used to answer their kids' protestations that "other kids get to do it!" with, "If everyone jumped off a bridge, would you do it too?" I can't speak for others, but mindlessly following the herd was not something that was encouraged in my family system.

I do not know off hand what the answer is to the question above. Perhaps some malpractice attorney who happens to read this might write in with the answer. The reason I thought of this question was something I recently read in the psychopharmacology (psych drug) newsletter Biological Therapies in Psychiatry (July 2014) about how often kids are monitored for side effects when they are prescribed psychiatric medications.

Regular readers of this blog know that I think that the diagnosis of pediatric bipolar disorder is in the vast majority of cases a scam, and that prescribing antipsychotic drugs to children to control their behavior is a reprehensible activity. Kids should not be sedated into being less affected by family dysfunction.   

That would be bad enough, but what is worse is that antipsychotic drugs have potentially dangerous side effects. Particularly with the newer, "atypical" antipsychotics, there is a significant risk of causing weight gain, type II diabetes, and high cholesterol. These risks may be higher in children and adolescents than they are in adults.

If a patient is psychotic, the benefits of these medications generally outweigh the risks, especially if the patient is monitored for the emergence of these side effects. And there are few other options. (Sometimes one drug in a class will do it in a given patient, but not another drug in the same class). If patients are not psychotic, and very few kids are, the benefits decidedly do not outweigh the risks.

At the very least, the doctor should take blood tests periodically to see if these side effects are developing. You would think that doing that would be the standard community practice.

Well, if you thought that you would be wrong. 

In a retrospective study by Delate and others (JAMA Pediatrics, 2014 May 5) of pediatric patients started on an atypical antipsychotic within the Kaiser Permanente system HMO in Colorado, the authors found that only 1 patient out of 1023 received the full recommended panel of baseline and follow-up blood monitoring!

That's right; you read correctly. 1 out of over 1000, or one tenth of one percent. Of course we don't know if kids in other health plans are being treated this negligently, but I would not be surprised.

So if almost all of the doctors in a community are making little kids jump off bridges, does this mean that they are not going to be held liable if they are sued for malpractice?

Your Child’s Behavior Still a Problem after Treatment with One Drug? Try Two

Back in 2010, I wrote about all the strange and bizzaro combinations of psychiatric drugs some of my adult patients had been put on by other psychiatrists who had seen them before me. These combinations, in addition to being excessive, often made no sense from the standpoint of what these drugs did in the central nervous system. 

Uppers and downers and bears, oh my.

In the biz, this is known by some as malignant polypharmacy.

Sometimes polypharmacy is medically necessary because of disorders which co-occur in certain patients (comorbidity), like patients who have both real bipolar disorder and panic disorder. However, a lot of times new drugs from different classes are added merely because the first class of drugs used just did not do the job. And IMO, the most common reason the first class of drugs fails is that the drugs were never indicated for the patient’s underlying condition in the first place.

By now this practice has unfortunately spread to the lucrative field of drugging children, where the use of more than one class of psychiatric drugs is becoming more and more common. I have written about how the use of psych drugs in kids is, in general, often higher in children who have been subjected to a lot of stress and trauma, such as children in foster care (9/20/10, 12/2/11). To me, this fact strongly implies that behavior problems and reactions to stress are being misdiagnosed as mental illnesses.

Higher prescription drug usage also seems to be inflicted more often on poor children, who have much less access to good and more comprehensive psychiatric treatment (read: family therapy), and whose underpaid doctors may give them short shrift.

In the United States, poor children are insured under Medicaid, the U.S. Government’s medical plan for the poor. Medicaid pays psychiatrists quite poorly, so most of them do not accept it. It is especially crappy at covering family therapy.

So, it is hardly a surprise that a recent study of children on Medicaid showed the following results, as reported by the American Psychiatric Association’s newspaper, Psychiatric News, on 6/26/14:

Use of second-generation antipsychotics (SGAs) concurrently with other psychotropic medications in children in the Medicaid program has increased over the last few years, according to a report published online in the Journal of American Academy of Child and Adolescent Psychiatry.

Researchers at Children’s Hospital of Philadelphia used data from the Medicaid program to estimate the probability and duration of concurrent SGA use with different psychotropic medication classes over time and to examine concurrent SGAs in relation to clinical and demographic characteristics. Their analysis showed that while SGA use overall increased by 22%, about 85% of such use occurred concurrently with use of other psychotropic medications. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. The concurrent SGA use occurred for long durations (69%-89% of annual medication days).

The explanations for this phenomenon advanced by the senior author, as reported by the story, were very telling:

David Rubin, M.D., co-director of the Policy Lab at Children's Hospital of Philadelphia. “In all likelihood, the use of the antipsychotics illustrates the great challenge clinicians are having when responding to disruptive and challenging behaviors in youth that don't neatly fit common diagnostic categories. In a society that often doesn't offer other services to respond to these behaviors, we should not be surprised how quickly the use of antipsychotics has grown.”

So, he is almost declaring outright that antipsychotic drugs are being given to children not for mental illnesses, but for disruptive behavior! If stimulants are involved, most of these children are undoubtedly being diagnosed with ADHD. So, if other drugs are being added, it looks as if stimulants may not be working all that well for this problem in a significant number of cases. And yet, doctors and drug companies and even the National Institute on Drug Abuse go on and on waxing eloquently about how impressively effective they are!

And when they are not working, then doctors are apparently adding a drug meant for the almost non-existent condition of pediatric bipolar disorder. I guess these kids have two mental illnesses. Maybe three. Yeah, right.

There is no evidence from clinical trials that the combination of these two drugs is efficacious for anything, nor is there a physiological rationale for combining them. And SGA’s are potentially very toxic, especially in children. And they still do a terrible job of even sedating acting-out kids.

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. 

Pills Are Not for Pre-Schoolers by Marilyn Wedge: The Crucial Questions That Most of Today’s Child Psychiatrists Never Ask

The theme of this blog, as well as of my last book, How Dysfunctional Families Spur Mental Disorders, is that family systems issues have been disappearing from psychiatry in favor of a disease model for everything by a combination of greedy pharmaceutical and managed care insurance companies, naïve and corrupt experts, twisted science, and desperate parents who want to believe that their children have a brain disease to avoid an overwhelming sense of guilt.

I’ve also written about some of the family systems ideas that are being neglected. But the question many readers may still have is: What do systems-oriented family therapists actually do? In an excellent new book, Pills Are Not for Pre-Schoolers: a Drug Free Approach to Troubled Kids, author and therapist Marilyn Wedge shows, with a series of excellent case examples, what can be done.  She demonstrates brilliantly how kids who might be labeled with serious mental illnesses (that they do not actually have) are, in fact, responding to trouble at home.

Marilyn Wedge

Some of the key points that she illustrates are:

• If a child acts violently angry, the purpose of this behavior is to deflect the anger that one parent is experiencing against the other. Violence is, therefore, usually a sign of parental discord. 
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• Kids hear and understand much more than we think. 

• A child will do anything to make his or her parents stop arguing.
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• Kids act out parental feelings that the parent can’t express. 
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• Young adults that refuse to grow up and move out are doing so in order to covertly give their parents who are not getting along a reason to stay together. 
• 
  
• A parent’s obsession with a child is often a substitute for intimacy in the parents’ marriage.         
• 
  
• The pain of one family member always affects all other family members.  
• 
  
• Sibling squabbles can reflect parental discord.

She explains how family and home problems become far less likely to be addressed once a child is called bipolar or ADHD. (Magazines – and some advice columnists - are at present labeling any sharp change in mood as a symptom of bipolar disorder).

Of course, even parents who are very much against the use of psychiatric medications are often very sensitive to the question of whether or not they are somehow to blame for the problems of their child.  So if a mental health professional does not know how to handle this sort of parental guilt, and furthermore does not even know what questions to ask to find out if there is any family discord, they are not going to hear about family problem - as I pointed out in a previous post, Don't Ask, Don't Tell.

Wedge shows clearly how this trap can be avoided.

A lot of child psychiatrists these days are so focused on “symptoms” that they miss the forest for the trees. They do not even try to find out what is going on behind the scenes, and they seem to have lost all understanding of what constitutes normal child reactions to family stress.  A clear case of "Don't Ask, Don't Tell."

Wedge discusses some very simple and very crucial questions mental health professionals need to ask both “problem” children and their parents that can often lead to a torrent of new information.

It is often necessary to interview children without parents in the room and vice versa.  Simple but potentially fruitful questions for children include:

• Who are you worried about more, your mother or your father? 
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• What makes you scared at night? 
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• What would things be like at home if you did not have this problem?

Questions to ask various family members, alone in combination:

• What was happening in the life of the family when the symptom began? 
• 
  
• What is the SECOND biggest problem in this family? 
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• Where and when does the problem NOT occur?  What is happening when the symptom is NOT?

The author goes on to illustrate several family psychotherapy techniques for inducing behavior change in family behavior, in clear and easily-understood language. Most of  these techniques come from a subschool of family systems therapy called strategic family therapy, whose originators include Jay Haley, his wife Chloe Madanes, and Mara Selvini Palazzoli.

My only quibbles with the book are minor.  She may promise a little bit more than systems therapists can deliver. Like many family systems therapists before her, the family members who populate her case examples all seem to be either highly motivated to follow her instructions, or if not, can easily be handled using with a few well-timed paradoxical therapy interventions.  She says she often cures a problem within seven sessions. While this can be the case, often it is not.  

Old habits are hard to break.  The TV show Supernanny clearly shows how almost all of the family members she sees revert to old behavior once the Supernanny leaves.  She leaves and comes back on purpose to deal with this phenomenon.

While the behavior of the children in her examples may be extreme, most of them come from families that have many strengths. I often see a much more disturbed set of patients: parents (I do not treat children and teens) who have almost no personal or family resources on which they can draw, and/or have significant personality problems themselves. The author also clearly states that none of the children in her case examples were abused or neglected.  I do not know how much experience she has with these other types of populations, but clearly they are far more difficult to treat, and there are a lot of them out there.

All in all, however, I highly recommend this book for those parents who actually want to solve their children’s problems, not just cover them up with drugs.

The Big Lie and Pharmaceutical Marketing

Joseph Goebbels

The “big lie” is a propaganda technique in which a falsehood is repeated so often and in so many different ways that people come to believe that it is true.  The term is generally credited to master Nazi propagandist Joseph Goebbels.  According to Wikipedia, he wrote the following paragraph in an article dated 12 January 1941, 16 years after Hitler's first use of the phrase "big lie," titled "Aus Churchills Lügenfabrik" and translated "From Churchill’s Lie Factory." It was published in Die Zeit ohne Beispiel.

The essential English leadership secret does not depend on particular intelligence. Rather, it depends on a remarkably stupid thick-headedness. The English follow the principle that when one lies, one should lie big, and stick to it. They keep up their lies, even at the risk of looking ridiculous.

The technique has become commonplace in all sorts of marketing and is particularly rampant in Pharmaceutical Company marketing.  It is part and parcel of the process of turning facts that have never been established into established facts, as I wrote about in my post of January 31, 2012.

I of course need to make the following disclaimer for any reader who is logic-challenged:  Just because someone uses a propaganda technique invented by the Nazis does not make them a Nazi. I am not calling anyone in the pharmaceutical industry a Nazi, so don’t write me a letter.

I have already done several posts on how drug companies have turned irritability, temper tantrums, affective reactivity and other very normal behaviors and emotions in children into symptoms of mania (or ADHD, or both).  In this post I will add one more, to show how often this nonsense is repeated over and over again in poorly designed and misleading journal articles, complete with plausible deniability, and then reported uncritically in the medical press.

One way to propagate a lie about the effectiveness of pharmaceuticals is through the publication of studies in which subjects fill out self-report tests or are subjected to symptom rating scales based on their immediate presentation at the time they are seen. The results of symptom ratings scales are tabulated uncritically and produced in a journal article-  as if the results of the tests prove something.  I discussed some of the issues involved in symptom rating scales in my previous posts, Counting Symptoms That Don't Count, and A Stupid Study and an Even Stupider Headline.

A journal article called Age Group Differences in Bipolar Mania by Safer, Zito, and Safer was published online in the journal Comprehensive Psychiatry on June 12, 2012.  As reflected in the title of the journal article, the psychiatric press dutifully but incorrectly wrote that the conclusion of the article was that symptoms of bipolar are different in children and adolescents with mania than they are in adults.   

The study seemed to say that aggression, irritability and motor activity were more prominent symptoms in pre-teens than teens.  Adolescents had more aggression and irritability than adults, while adults showed more grandiosity and hypersexuality.  Proof positive that the symptoms said to be more common in teens and pre-teens were actually symptoms of bipolar disorder?  

If you only read the news reports or superficially glossed over the abstract of the actual article, you might think so.

Yet in actuality this was yet another repetition of the same old big lie technique.  Looking at the abstract of the article more closely, the conclusion was a little different: that the results of a symptom rating instrument, the Young Rating Mania Scale (YMRS), showed this, not a complete and comprehensive diagnostic evaluation of the subjects in question: "In age-grouped YMRS item assessments of bipolar mania, anger dyscontrol was most prominent for youth, whereas disordered thought content was paramount for adults." 


Notice how the authors cannot be accused of lying, since this is in fact what their study actually showed.  The "take home message," however, is that this means that these symptoms are in fact valid symptoms of bipolar disorder in kids.


So let's take a closer look at the study and the YMRS.  The study was based on a review of the literature describing several other studies, and the other studies that were chosen for review were "... studies reporting age group differences in total YMRS scores that included individual baseline item scores."  So this study reviewed other studies that used what I will soon show is a highly suspect test. 

Symptom rating instruments like the YMRS are meant for two purposes: 


1. To be screen out patients who for sure do NOT have the diagnosis and make sure that anyone who might have the diagnosis is included for evaluation. In other words, the tests are designed to have a lot of false positives, that is, people who score positively on the test but do not in fact, have the disorder.


The authors of this review clearly know that the YMRS is a screening instrument:  "These outpatient studies required a minimum YMRS total baseline score of 20 for inclusion and achieved total baseline YMRS scores of 28 to 33 indicating at least moderate manic symptoms [20,22,23,25]. In these clinical trials sponsored by industry, trained raters did the YMRS item scoring at baseline. The subjects who met full research criteria for mania were subsequently randomized into placebo and medication treatment groups."


2.  To measure changes in symptoms over time in patients who have already been diagnosed correctly by other means. The other means that are used usually consist of research diagnostic clinical interviews, but we have no way of knowing how well the clinical interviews were done - particularly whether the duration and pervasiveness criteria of the symptoms were applied correctly, since this is frequently not done by drug company shills. 


But even using a symptom rating scale to measure changes in symptoms is frought with difficulty, particularly in the case of the YMRS, which completely ignores the issue of symptom pervasiveness and duration.


The problem with tests that ask patients to rate their own symptoms was described succinctly by one patient, who purportedly said about a psychiatrist who used a self report question as the entire basis for prescribing drugs, "The question is always the same. He asks me, ‘On a scale of 1 to 10, rate your mood.’ I answer, but you know, in 6 hours I might have a different answer.”   


Many of these rating scales uses what is called a Likert Scale.  Likert Scales generally ask a patient or a researcher to rate the severity of a given symptom on a 4 to 7 point scale.  A big issue with Likert Scales in self-report instruments is that when they ask whether a symptom is mild or severe is that they do not indicate the answer to the question, compared to what?  Compared to a patient with a clinical disorder, or compared to the symptoms as they have been experienced by the patients themselves?  When someone is very sad but has never been clinically depressed, he might rate the sadness as severe.  Having perhaps never seen another person with a severe clinical depression, he has no external reference point that would distinguish a normal mood from a highly abnormal mood.


Now for the YMRS. The YMRS asks a clinician to rate the patient's symptom based on what the patient looks like or says at the time of the interview. Let's look at item number 5 on the YMRS scale, irritibility.  The interviewer is asked to rate it on a 5 point scale based on observations during administration of the test.  0 = absent, 1 = subjectively increased, 2 = irritable at times dring the interview, or recent episodes of anger or annoyance on the ward, 3 = frequently irritable during the interview: short, curt throughout, and 4 = hostile, uncooperative, interview impossible.


Notice that there is no requirement than an effort be made to find out why the patient presents with irritability during the interview.  It just assumes that it is due to the underlying mania.  But how long has it been going on?  Just today?  How do we know the patient is not acting irritable because he had been having a really bad day, or because the interviewer was perceived as condescending? We don't.  


Or take item #6, rate and amount of speech.  Manic patients have what we called pressured speech - they talk and talk and no one can get a word in edgewise.  This is present regardless of external circumstances.  If a patient exhibits very fast speech in the YMRS interview, on the other hand, the symptom could conceivably be present because the patient is in a big hurry to leave on that particular day, but characterologically likes to make sure the doctor gets a very precise answer with all its myriad details to any question.  


Without this additional information, the answers to the questions are meaningless!  In children, aggression and irritability have hundreds of potential causes besides their supposedly being symptoms of bipolar disorder.


But the mantra that they are indeed symptoms of bipolar disorder in children is once again subtly repeated.  Over and over and over again: the big lie technique in operation.

Childhood Bipolar Disorder: The View From Abroad

Is Pediatric Bipolar Disorder (PBD) a “culture-bound syndrome” of the USA?

The following is a guest post from Dr. Peter Parry, an Australian psychiatrist and senior lecturer at the University of Queensland, who is a co-conspirator of mine in the fight against the pernicious practice of psychiatrists and pediatricians diagnosing acting-out children as having the major psychiatric disorder bipolar disorder (manic depressive illness).

A “culture-bound syndrome” [http://rjg42.tripod.com/culturebound_syndromes.htm]  in psychiatry is used to describe psychiatric disorders that generally occur in exotic indigenous communities and developing countries due to cultural factors.  Examples include “Koro” - a disorder of group hypochondriasis that occurs in epidemics in parts of south-east Asia where men start to believe that their penises are shrinking into their abdomens; “Dhat” - a disorder in India associated with anxiety and fatigue in men related to fear of losing too much semen; “Bebainan” - a disorder where young women from Balinese nobility, who in everyday life must behave with extreme politeness and be very demure, vent their anger in seemingly irrational brief rage attacks.  The last of these can be seen to have a useful function for individuals whose emotional lives are otherwise highly socially constrained.

In a couple of blog posts on “The Geography of Pediatric Bipolar Disorder” [http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder] on Psychology Today  I concluded by posing the question: “is Pediatric Bipolar Disorder (PBD) a culture bound syndrome of the USA?”.  As I explained in the first post, PBD, despite becoming the most common diagnosis for pre-pubertal children in US inpatient units 10 years ago [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001259/], has barely rated in the rest of the world. 

This is not to say that there haven’t been a few academic research centers who have investigated PBD in places like Spain, Switzerland, the Netherlands, Brazil, India and Australia.  These research centers have usually collaborated with prominent American PBD research centers such as Prof Biederman’s center at MGH-Harvard.  In clinical practice outside the USA there have been a few isolated pediatricians and rarely child psychiatrists who have adopted the American clinical practice of diagnosing PBD in pre-pubertal children.  But the vast majority of practicing clinicians and academics in child psychiatry and pediatrics in Britain, Europe, Australia, New Zealand and to lesser extent Canada have simply not accepted PBD as a valid diagnostic entity in clinical practice.

Here in Australia, one group that seriously researched the PBD diagnostic constructs was based in Sydney.  Their follow-up research found that few cases went on to true bipolar disorder.  Prof Philip Hazell who led much of this research was quoted in the Australian media [http://www.theaustralian.com.au/news/health-science/moody-teens-wrongly-diagnosed-with-bipolar-disorder-psychiatrist/story-e6frg8y6-1226191879545] saying “There are about 10 times as many people with 'lookalike' mood dysregulation as there are people with bipolar disorder”.

Now it is true that bipolar disorder often first manifests in adolescence and early manic or hypomanic symptoms can be mistaken for extreme adolescent emotionality, risk-taking or substance abuse.  But until an unequivocal manic episode erupts it is difficult to make the diagnosis.  The “BCOS study” [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract] was a study of 240 adults mostly in their 40s with classical Bipolar-I or Schizoaffective Disorder in Melbourne and Geelong in Australia.  The BCOS study found that the diagnosis was often made years late.  The study asked the adults when their symptoms first began.  The median age of onset for the first hypomanic/manic episode was 24.1 years old.

Yes bipolar disorder is a severe mental disorder that needs to be detected earlier in life than it often is.  But it is still a disorder that doesn’t usually start until late adolescence or young adulthood.

Another study that asked middle aged adults with bipolar-disorder when they thought their first symptoms of bipolar disorder began was published in the British Journal of Psychiatry [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract].  The authors of this study were quite favorably disposed towards PBD.  The remarkable aspect of the study is the discrepancy in recall of symptom onset between the European subjects with adult bipolar disorder (Dutch and Germans) and the American subjects.

Is there something about childhood in the USA that brings on a severe psychotic mental disorder such as bipolar disorder so much earlier than in other countries?  Or is there simply an over-diagnosis fad in operation, one that colors the memory recall of childhood?  Notably the American adults in this study had features more suggestive of milder “bipolar” and more personality and substance use problems than the Europeans who had more classic euphoric manic symptoms.

A 20 year follow-up study [http://www.jaacap.com/article/S0890-8567(09)64566-4/abstract] in New Zealand (NZ) was published in the Journal of the American Academy of Child & Adolescent Psychiatry in 1991 (before the creation of the PBD phenomenon).  It was based on all inpatient admissions to the child and adolescent psychiatric ward for a catchment area of 1 million people.  In those 20 years there were 59 children under age of 18 who presented with a confirmed psychotic illness that included schizophrenia, schizoaffective disorder or mania/bipolar disorder.  Age of diagnosis was based on reports of first symptoms, not date of admission to the inpatient unit.  Of these 59 children and teenagers, only 3 were aged 12 or under at onset of symptoms.  One of these 3 children was reported to have had their first manic episode at age 9, the youngest who later turned out to have schizophrenia was aged 7 at onset of first symptoms.

The lead author of the study is now Emeritus Professor of Child & Adolescent Psychiatry in Auckland, NZ, Prof John Werry.  In a survey that I and colleagues organized of Australian and New Zealand (ANZ) child psychiatrists [http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2008.00505.x/abstract] on PBD that found high levels of skepticism (including that only 3% thought that PBD was not over-diagnosed in the USA), Prof Werry sent a hard hitting comment for public airing:

“I do not see any juvenile bipolar disorder below adolescence and I think that the American view is mostly nonsense as do many of my American colleagues.”

The second author of the NZ study was one of his “American colleagues”, Dr Jon McClellan, a child & adolescent psychiatrist who returned to the USA and is based in Seattle.  Dr McClellan was one of the very few child psychiatrists to have a dissenting article [http://www.jaacap.com/article/S0890-8567(09)61468-4/abstract] on PBD published in the Journal of the American Academy of Child & Adolescent Psychiatry.  With regard to PBD his article concluded:

“the rate of psychotropic agents being prescribed to preschoolers is skyrocketing…Labelling tantrums as a major mental illness lacks face validity and undermines credibility in our profession.”

One very prominent US psychiatrist, Prof Allen Frances who was chair of the DSM-IV task force, has called PBD a “fad” [http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005] diagnosis.

What I found when attending the American Academy of Child & Adolescent Academy (AACAP) meeting in Hawaii in 2009 is that Werry, McClellan and Frances were spot on.  Many US child psychiatrists were very troubled by the PBD diagnostic fad, the bad effects on the children and families of a spurious diagnosis and wrong treatment, and the undermining of credibility in our profession.  I received mainly supportive comments from my US colleagues when I presented my poster of our Australian and New Zealand survey showing high levels of skepticism about PBD in ANZ.  These comments helped to explain what it was about the culture of the USA that had spawned the PBD fad epidemic.

Firstly – the US health system is mainly a private insurance system and much more fragmented than the universal health cover that exists in nearly all other 30 developed nations in the OECD [http://www.oecd.org/dataoecd/24/8/49084488.pdf].  US health insurers are more likely to restrict reimbursements on the basis of diagnosis than health insurers in other countries.  Also pharmacotherapy is favored over the psychotherapies. 

At the Hawaii AACAP conference an American child psychiatrist told me that if she is seeing a boy with emotional and behavioral problems embedded in difficult family dynamics, with some insurers she has to phone the insurer in the first session and is asked to give a diagnosis. If she says she has no diagnosis at that early stage, the insurance clerk says no reimbursement. If she says the diagnosis is a “parent-child relational problem” (which is a non Axis I DSM diagnosis) she may also be told no reimbursement. If she says it is an “adjustment disorder” (an Axis I DSM diagnosis) then she may be allowed 1 or 2 sessions to fix the complex problems. But if she says it is “bipolar disorder” then ongoing sessions are likely to be reimbursed. 

This is effectively diagnosis by medically untrained health insurance clerk.  It is also an expensive system, the USA spends 17% of its GDP on health care whereas other OECD nations spend between 8% and 11%.  A lot of money goes into paying medically untrained clerks and profits to shareholders.

Secondly the pharmaceutical industry has focused its influence on medical research and public opinion more in the USA than elsewhere.  The pharmaceutical industry is globally the most profitable industry on the planet.  In 2002 the 10 Pharma companies in the Fortune 500 had greater profits than the other 490 world’s biggest companies combined.  In 2008 they averaged 18% profits whilst the rest averaged 0.9% profits in the global recession.  Pharma spend 3 times as much on marketing to the medical profession and (mainly in the USA) the public than they do on Research and Development.  The biggest market for medications, particularly psychotropics, is the USA and direct to consumer advertising (DTCA) is only legal in the USA and New Zealand (but NZ has a tiny market).  Thus the American public have been flooded with advertising of psychotropic drugs and often ads about bipolar disorder whereas the public in other nations have not (though the internet is changing this).

Another US child psychiatrist colleague told me at the ANZ child psychiatry conference in 2007 that in working as a locum in NZ he had never had parents come to see him stating their child had “such and such diagnosis” and demanding a related medication, rather they asked him what he thought.   Conversely parents invariably were fixated on a diagnosis and drug or two when they came to consult him in the USA.  He had also trained at an academic child psychiatric unit prominent in PBD research and was trained to ask himself “is it bipolar?” and diagnosed half a dozen cases of PBD, yet in NZ he’d never seen a case of PBD and had started to question his training.

The pharmaceutical industry provides considerable funding to researchers and to academics to provide “continuing medical education” (CME) to other doctors.  Internal industry documents [http://www.healthyskepticism.org/global/news/int/hsin2009-12] revealed that Pharma saw broadening of bipolar diagnoses in adults and children as useful to selling more atypical antipsychotic agents.  Such CME is a global phenomenon and has been harshly criticized [http://www.psychiatrictimes.com/display/article/10168/1570483] in recent years.  However proponents of PBD providing CME were mainly confined to the USA.

A key researcher in neuroimaging children diagnosed with PBD, Dr Mani Pavuluri, presented findings at the Hawaii AACAP meeting.  The research appeared to be of high technical quality.  The findings (overactive right amygdale, underactive right frontal lobe) were identical to findings in children who had suffered attachment trauma and abuse.  I and others in the audience asked why not call such children “affect dysregulated” rather than PBD.  Dr Pavuluri agreed that would be a more neutral term, but stated “if we don’t call them bipolar we don’t get funding for our research”.  Such a dependence on a presumed result favored by funders reverses the scientific process.

Also at the AACAP Hawaii conference I asked Dr Melissa DelBello about attachment trauma in her group’s research, the interchange was recorded by Dr. David Allen on this blog here [http://davidmallenmd.blogspot.com.au/2010/04/attachment-latest-dirty-word-in.html].

I did an extensive review [http://cdn.intechopen.com/pdfs/29393/InTech-Paediatric_bipolar_disorder_are_attachment_and_trauma_factors_considered_.pdf ] of the PBD literature for exploration of attachment, trauma and abuse as possible contextual factors and found that the PBD literature was extremely lacking in consideration of these very obvious markers of distress in childhood. 

Why this is so is a very interesting question.  Denial and repression of trauma is a feature of humanity, be it at individual, family or societal levels.  Whether this is more the case in the USA is unlikely but it is possible that American parents have been more indoctrinated with the neurobiological paradigm for children’s behavioral problems and this helps them avoid “parent blaming”.  As an aside, I find it helpful to discuss with parents how parenting in modern societies is incredibly difficult compared to how parenting evolved in small hunter-gatherer ancestor tribes. 

But other modern societies have similar epidemics to the US PBD epidemic.  Instead of PBD in Europe, Canada and Australasia there is a tendency to also over-diagnose autistic spectrum disorders and ADHD as ways of overlooking more complicated attachment, trauma, family dynamic, learning difficulties, bullying and other contextual problems.  To a great extent I think the simplistic checklist approach to diagnosis fostered since DSM-III plays a role in this [http://www.clinicalpsychiatrynews.com/views/commentaries/single-article/diagnostic-labels-and-kids-a-call-for-context/5783d363fe823984bafbef98b0ffaa75.html]

According to DSM-IV: “Not all (culture-bound syndromes) are considered pathological in their society of origin, and may be seen as "idioms of distress”, a way of communicating distress in a way which is culturally understood and, to varying degrees, accepted.”  Thus for a society that has been “educated” to see mental, emotional and behavioral problems as based in neurochemistry fixable with medications, where “parent blaming” is considered unsociable, where health insurers value pharmacotherapy over more talking therapies and insurance clerks request more serious diagnoses from clinicians before reimbursing sessions, and where funding of research comes largely from pharmaceutical companies – to diagnose the moodiness and rages of distressed toddlers, preschoolers and older children as bipolar disorder has to varying degrees become accepted. 

Prescribing polypharmacy psychotropic cocktails to toddlers can be seen as the ultimate in a Huxleyan “brave new world”, the ultimate end point of “Pharmageddon” [http://www.socialaudit.org.uk/60700716.htm].  The recent book by Dr David Healy expands on how we arrived at such a point [http://www.ucpress.edu/book.php?isbn=9780520270985].  PBD can also be seen as an emblematic diagnosis for an era of “mindless psychiatry” [http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826].

The US is not alone to suffer from these factors, but it seems to suffer more than other jurisdictions and hence PBD can be seen as a culture bound syndrome of the USA.  That is not to say it couldn’t spread to other nations if the same predisposing factors were to arise, and ADHD and Autistic Spectrum Disorders do to some extent represent a similar phenomena outside the USA.

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.

Practice of Doping up Children to Treat Parental Anxiety Continues to Grow

I have already written several posts about the inappropriate "diagnosing" of bipolar disorder in children and the even more inappropriate use of antipsychotic medications in children.  My main point has been that, rather than having a psychiatric disorder, the vast majority of these children are just acting out.  (For those readers who have difficulty making distinctions - especially those who automatically assume that things that look vaguely alike must be identical - this opinion does NOT apply to those uncommon children who are actually psychotic or to older adolescents who are clearly and obviously manic).



So what proof can I offer?  Well, at the American Psychiatric Association Annual Meeting, John Goethe, MD (director of the Burlingame Center for Psychiatric Research and Education at Hartford Hospital’s Institute of Living), presented the results of a decade-long study of antipsychotic prescribing for children and adolescents in psychiatric hospitals.

The results? Forty-five percent of patients with such behavioral disorders as ADHD or conduct disorder were given antipsychotics and 44% of patients with post-traumatic stress disorder (PTSD) received them. The percentage for other anxiety disorders was 31%!

Forgetting for the moment that an ADHD diagnosis may just be yet another case of acting out, antipsychotic medication is not indicated for ADHD.  In adults, antipsychotic medications are not indicated nor FDA-approved for any anxiety disorder or PTSD.  Not only that, but there is not the slightest evidence from any neurobiological study that the purported mechanism of action of antipsychotic medication has anything to do with anxiety disorders or ADHD. 

And conduct disorder?  This "disorder" was formerly called juvenille delinquincy.  Acting out by any other name. Don't even get me started.

One of the predominant side effects of these medications, is however, sedation.  So one might conclude that the reason the meds seem to both the parents and incompetent doctors to "work" is that the kids quiet down because they are being doped up. (This prescribing practice does not just apply to some psychiatrists but also to many other primary care doctors as well -as to pediatricians, read Claudia Gold's blogpost, Pediatricians Prescribing Psychiatric Medication: A Dose of Reality),

But who's anxiety is really being treated here? 

I submit that it is the anxiety of the parents. Parents who have out-of-control, acting-out children are the real objects of these "treatments."  These parents covertly feel guilty when they are unable to control their children due to inconsistent, neglectful, or abusive parenting practices.  Yet they have great difficulty changing these practices for a variety of reasons - sometimes very understandable reasons.  (One of which is that their doctors make no effort to understand what is really going on in their homes, and take advantage of their insecurities). 

Nonetheless, when the kids are doped up and are therefore less trouble, the parents feel better. And they have the doctors stamp of approval that the problem resides entirely within the child, not with them.

An unsolicited plug


The use of these drugs in kids diagnosed with PTSD is particularly instructive.  Unless you are treating victims of such disasters as the recent outbreak of tornadoes in the South and Midwest, or working with victims of crime like Jaycee Dugard, the most common trauma leading to PTSD in children is child abuse.

Of course, this whole process of sedating acting-out children usually does not end with the first prescription.  For most drugs that have sedation as a side effect, the sedation gradually subsides after  a few weeks on the medication.  Then, of course, the kid starts doing what kids always do - start reverting back to their previous behavior.

The parents then drag him or her back to the incompetent doctor, who starts to take one of the following steps and then another, in no particular order:

1. Increase the dose of the medication.
2. Change to a different medication which also is not indicated for anxiety and conduct disorders.
3. Add a prescription for a second one of those medications, and then perhaps a third or a fourth.
4. Change the diagnosis to something else other than acting out, and begin the whole process all over again.

Since the kid still is not controlled after the sedative side effect subsides, another step the parents can take is to apply for social security disability for the child.  This gives the child the message that the parents think he or she is both sick and incompetent.

Readers of the blog know what I believe happens next.  The child develops a false self that only seems to be sick and incompetent.  Such children hide their abilities as they grow into adults, continue to act in ways that preclude employment, and continue on social security disability. 

When you take the time to actually get to know them, however, it seems that the only thing they can not seem to do that most people can is maintain employment.

And then Robert Whitaker thinks that the medications were the cause of the disability, just like the less-than-thorough doctors thought that the medications caused the initial improvement of the child's "mental illness" when it was just a side effect that temporarily muted acting out behavior. 

It always amazes me how much people who seem to be on opposite sides of a debate think alike.  Basing their conclusions on totally incomplete information seems to be a favorite blind spot of theirs.