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Old 11-21-2008, 04:44 PM   #106
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Tough Choices for Tough Children

by Judith Warner (columnist)
New York Times, Nov. 20

It was disturbing to read in The Times this week that the “atypical” antipsychotic Risperdal, a tranquilizing whopper of a drug with serious, sometimes deadly side effects, is now being widely prescribed to children with attention deficit hyperactivity disorder. This despite the fact that Risperdal, which is used in children mostly to treat bipolar disorder, isn’t approved for ADHD, and apparently doesn’t work for treating it at all.

So why, according to new Food and Drug Administration data on doctors’ prescribing practices, were 16% of the pediatric users of Risperdal over the past three years children with ADHD? The simple answer is to point fingers at the drug companies, whose aggressive efforts to promote off-label use of this problematic new class of drugs have resulted in a spate of lawsuits, including one recently filed by the Arkansas attorney general that accuses Risperdal’s manufacturer, Johnson & Johnson, of having “engaged in a direct, illegal, nationwide program of promotion of the use of Risperdal for non-medically necessary uses”—like the treatment of ADHD.

But I think the truth is more complicated than that. I think that what’s happening is that children with big problems are being given big, bad drugs because no one really knows what to do with them. The biggest controversy in the controversial field of psychiatry these days (“the only field where the doctors are more stigmatized than the illness,” as Thomas R. Insel, the director of the National Institute of Mental Health, described it to me last week) is the issue of pediatric bipolar disorder, which many child psychiatrists now say is being grossly overdiagnosed, with a spike in incidence that dovetails suspiciously well with the introduction of atypical antipsychotics in the early and mid-1990s. At the heart of that controversy—the human heart, you might say—is a group of children who are really difficult: chronically irritable, extremely aggressive, prone to explosive outbursts and out-of-control rages.

Many doctors, influenced by the work of Dr. Joseph Biederman at Harvard Medical School (whose ties to industry were detailed in The Times in June), say these symptoms are signs of mania, and call these children bipolar. Others label them with “extreme ADHD” or Oppositional Defiant Disorder or “severe mood dysregulation,” a diagnosis that’s been proposed by Dr. Ellen Leibenluft, chief of the section on Bipolar Spectrum Disorders in the Mood and Anxiety Disorders Program at the National Institute of Mental Health. For the past five years, Dr. Leibenluft has been tracking 100 children she believes have severe mood dysregulation, studying the course of their illness and the outcome of their treatment. 60% percent of these children were diagnosed with bipolar disorder—mistakenly, she believes—before she met them. 90% percent of them meet the criteria for diagnoses of ADHD or ODD 60% suffer from serious anxiety. 25% had an episode of major depression before they turned 12. “The severely mood dysregulated children are as sick as the bipolar children. They’re severely impaired,” she told me this week. “You can see easily why people would feel you need to use medication. But what medication? We don’t have the data to see what medication because we don’t yet know how to think about these children diagnostically.”

It may well be these kinds of children—these diagnostic orphans — who, at least in part, are showing up now as the “ADHD” patients being treated with Risperdal. The issue of what to call these children is a hot one and will heat up further in the near future as discussions take place over whether a new or changed diagnostic category for them should be put in the DSM-V, the long-awaited updated version of the American Psychiatric Association’s diagnostic manual. And it isn’t just a matter of semantics. Category change could mean treatment change. Children who are diagnosed as bipolar, even if they have attention issues, anxiety or depression, often aren’t treated with stimulants (the first-line treatment for ADHD) or antidepressants, because some prominent child psychiatrists have argued that they make bipolar children much worse. So physicians who suspect children are bipolar instead try the much more powerful atypicals, which have much more serious side effects. But severe mood dysregulated children wouldn’t necessarily have to go the atypical route. And there is also data to indicate a real role for non-drug therapy. In other words, thinking hard about these kids—instead of merely moralizing about them and their psychotropic drug use—may well lead to a situation in which atypical use can be greatly reduced.

This will not satisfy the critics of today’s biological psychiatry for whom no drug use is good drug use, nor the critics of today’s culture of parenting who are sure that all the aggression, irritability and out-of-control behavior that psychiatrists call mental illness is actually nothing more than a state of “toddlerhood in perpetuity” caused by ineffective parenting practices, as the conservative family psychologist and writer John Rosemond and his coauthor have asserted in his new book, The Diseasing of America’s Children. It won’t solve the problem of the drug companies’ predatory marketing practices, or of thought leaders in psychiatry renting out their minds for the sake of fancy vacations and top-flight meals. But the fact that efforts are being made, in a concerted way, to figure out what lies behind the scary-sounding statistics about drugs like Risperdal argues, I think, for hope. After a period in which drug companies have had way too much power in determining how children with psychiatric issues are treated, the pendulum may be swinging back.

(Incidentally, Risperdal, like Ritalin, is in the opinion of many doctors also routinely overprescribed to elderly people in nursing homes, to keep them "cooperative." I've gone back and forth with my mother's social worker and psychiatrist--who's never even seen her; she just 'diagnoses' over the phone with input from nurses--about this and other medications they keep putting her on, altering her dose of etc., without even notifying me. )

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Old 11-21-2008, 05:00 PM   #107
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they put my grandmother on ritalin for depression when she was in the nursing home.

it appeared to have worked.

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