Sunday, June 17, 2007

Backlash against psychiatric diagnoses of bipolar disorder in children

To present a 'balanced viewpoint' newspapers have a tradition of presenting 'both sides of the story'. So I suppose The Boston Globe has to say 'something' nice about their local psychiatric Doctor Strangelove who is promoting the diagnosing Bipolar disorder in very young children. The good doctor dismisses most critics, saying that they cannot match his scientific credentials, and implying anyone who disagrees with him is a fool. Good logical and scientific arguments (note our sarcasm). The Globe does report some of the facts surrounding the deaths that have resulted from this kind of diagnosis.

But there are various ways of presenting the story for a 'balanced viewpoint' depending on what impression you want to create. Stories read differently on the internet than they do on the front page of a newspaper.

In this case the first couple paragraphs were on the front page of the paper, and you had to go inside to see the real info. Thus a casual reader would not have seen much of anything, and would have received an impression of an embattled doctor fighting for modern science or something. But read inside, and you get the actual dirt. This is all a matter of editorial design, what makes it on the front page, and what is pushed into the body of the paper. Thus my original comments about the Globe putting a positive spin on the story. They tried to lessen the local impact, even if the article had some dirt in it. It gave them something to say when the poor doctor called the newspaper to complain.


Update: The Boston Globe now has a editorial on the subject, a no holds barred cautious and conservative assessment of the situation, trying hard not to say much of anything that would get them heavily criticized while advocating for a more careful approach. A fine waste of ink, indeed

Here is the original news item:


As seen in this report, emphasis added. See also this typical reaction.
No one has done more to convince Americans that even small children can suffer the dangerous mood swings of bipolar disorder than Dr. Joseph Biederman of Massachusetts General Hospital.

From his perch as one of the world's most influential child psychiatrists, Biederman has spread far and wide his conviction that the emotional roller coaster of bipolar disorder can start "from the moment the child opened his eyes" at birth. Psychiatrists used to regard bipolar disorder as a disease that begins in young adulthood, but now some diagnose it in children scarcely out of diapers, treating them with powerful antipsychotic medications based on Biederman's work.

"We need to treat these children. They are in a desperate state," Biederman said in an interview, producing a video clip of a tearful mother describing the way her preschool daughter assaulted her before the child began treatment for bipolar disorder. The chief of pediatric psychopharmacology at Mass. General, he compares his work to scientific break throughs of the past such as the first vaccinations against disease.

But the death in December of a 4-year-old Hull girl from an overdose of drugs prescribed to treat bipolar disorder and attention deficit hyperactivity disorder has triggered a growing backlash against Biederman and his followers. Rebecca Riley's parents have been charged with deliberately giving the child overdoses of Clonidine, a medication sometimes used to calm aggressive children. Still, many wondered why a girl so young was being treated in the first place with Clonidine and two other psychiatric drugs, including one not approved for children's use. Riley's psychiatrist has said she was influenced by the work of Biederman and his protege, Dr. Janet Wozniak.

"They are by far the leading lights in terms of providing leadership in the treatment of children who have disorders such as bipolar," said J. W. Carney Jr., lawyer for Dr. Kayoko Kifuji, a Tufts-New England Medical Center psychiatrist who temporarily gave up her medical license after Riley died on Dec. 13, 2006. "Dr. Kifuji subscribes to the views of the Mass. General team."

Part of the criticism of Biederman speaks to a deeper issue in psychiatry: the extensive financial ties between the drug industry and researchers. Biederman has received research funding from 15 drug companies and serves as a paid speaker or adviser to seven of them, including Eli Lilly & Co. and Janssen Pharmaceuticals, which make the multi billion-dollar antipsychotic drugs Zyprexa and Risperdal, respectively. Though not much money was earmarked for bipolar research, critics say the resources help him advance his aggressive drug treatment philosophy.

Numerous psychiatrists say Riley's overdose suggests that bipolar disorder is becoming a psychiatric fad, leaving thousands of children on risky medications based on symptoms such as chronic irritability and aggressiveness that could have other causes. Riley's father, for example, had only recently returned to the home after being accused of child abuse, according to police. Since the girl's death, state officials have stepped up a review of the 8,343 children taking the latest antipsychotic medications under the Medicaid program for conditions including bipolar disorder, to be sure the treatment is appropriate.


Psychiatrists too often prescribe these medications, which carry side effects such as weight gain and heart disease risk, without addressing problems in the children's lives, said Dr. Gordon Harper, director of child and adolescent services at the state Department of Mental Health. He likened the approach to "tuning the piano while the subway is going by."

Aggressive treatment

Biederman's critics chide him for not speaking out against misuses of a diagnosis that he has helped inspire. Among leading authorities on bipolar disorder, the Mass. General team has proposed the most aggressive treatment for the broadest group of children, they say, and Biederman should take responsibility when treatment goes wrong. At a conference on bipolar disorder at Pittsburgh's Point Park University last weekend, one speaker, Dr. Lawrence Diller, a California behavioral pediatrician, contended that Biederman bears some blame for Riley's death.

"I find Biederman and his group to be morally responsible in part," said Diller, whose popular book, "Running on Ritalin," accused psychiatrists of over treating another childhood condition, attention deficit hyperactivity disorder. "He didn't write the prescription, but he provided all the, quote, scientific justification to address a public health issue by drugging little kids."

Biederman rejects the idea that Riley's death is a cautionary tale, accusing critics of exploiting a tragedy to fan fears about psychiatry, a profession that has long faced prejudice. "The fact that she had XY drug or XY treatment is irrelevant to what happened. . . . If this child had the same outcome from treatment for asthma or seizures, we wouldn't have this frenzy," said Biederman in an interview at Mass. General's Cambridge mental health clinic.

Though Biederman acknowledges that distinguishing bipolar disorder from ordinary crankiness and flights of fancy in young children is challenging, he insists there is no ambiguity in the patients at his practice. "People have to wait a long time to see me or my colleagues. . . . It's not that somebody comes to me after their child has a temper tantrum. They do things for years that are dangerous. These are things that profoundly affect the child," said Biederman, putting them at risk of academic failure or even suicide.

Biederman dismisses most critics, saying that they cannot match his scientific credentials as co author of 30 scientific papers a year and director of a major research program at the psychiatry department that is top-ranked in the "US News & World Report" ratings.

The critics "are not on the same level. We are not debating as to whether [a critic] likes brownies and I like hot dogs. In medicine and science, not all opinions are created equal," said Biederman, a native of Czechoslovakia who came to Mass. General in 1979 after medical training in Argentina and Israel. He now lives in Brookline.

[...]

A surge in diagnoses

Biederman's work helped fuel a surge in the number of children diagnosed with bipolar disorder over the past 15 years. A national study of community hospitals found that the percentage of mentally ill children diagnosed as bipolar quadrupled from 1990 to 2000.

[...]

Dr. Steven Hyman, who was then director of the mental health institute and is now provost at Harvard University, said he remains very concerned about the growing use of "big gun" antipsychotic drugs such as Zyprexa, Risperdal, and Seroquel on children. In the Massachusetts Medicaid program, the number of people under 18 receiving at least one of the "atypical antipsychotic" drugs rose from 6,943 in 2002 to 9,123 in 2005, a 31 percent jump, before declining to 8,343 in 2006. Hyman says that none of the drugs has the approval of the Food and Drug Administration for use in bipolar children, and doctors prescribe them based on their individual judgment.

"We don't know the first thing about safety and efficacy of these drugs even by themselves in these young ages, let alone when they are mixed together," said Hyman.

Rebecca Riley's treatment


Kifuji was careful in treating Rebecca Riley, meeting the child six times before diagnosing bipolar disorder, according to Carney. Based on the child's behavior and family history, Kifuji prescribed three drugs to the 3-year-old child, including the antipsychotic medication Seroquel and Clonidine, a high blood pressure medicine that is often prescribed to calm aggressive children. Last year, Clonidine was prescribed to 1,195 children under age 7 served by the Massachusetts Medicaid program, including Riley.

Police charge that her parents, Carolyn and Michael Riley , repeatedly convinced Kifuji to give them extra Clonidine, ultimately accumulating dozens of extra pills that they used to control the little girl. Long before the child finally died on the floor beside her parents' bed, the police report said, teachers and school nurses noticed that she had become lethargic like a "floppy doll" on a nurse's lap.


Carney said his client, who is not practicing while the investigation continues, did nothing wrong in writing the prescriptions for the girl. Although some were shocked that the child was taking so much medication, Carney said Kifuji was practicing mainstream psychiatry for a very troubled child. He observed that Biederman's "research and teaching validates Dr. Kifuji's work with patients."
A couple of comments:
Biederman dismisses most critics, saying that they cannot match his scientific credentials

All of which says that he claims the mantel of authority. The arrogance is appalling. It is almost as bad as saying me must wage unrelenting war to have peace, and the only freedom is in slavery. It takes a real expert to screw up lives efficiently.

Kifuji was careful in treating Rebecca Riley, meeting the child six times before diagnosing bipolar disorder, according to Carney.

In this case the father is also a sex predator, and he was the one determining how many pills to give the poor child each night. In this case the child's misbehavior and upset was probably a sane reaction to possibly crazy parent, which the shrink did not pick up on in the first place.

No comments: