Map of life expectancy at birth from Global Education Project.

Monday, May 15, 2006

And I have more to say about this . . .

Like most psychiatric diseases, bipolar disorder is diagnosed based on a set of behavioral symptoms. Nobody knows what the underlying biological process or abnormality is in BPD, or for that matter whether there is only one -- in other words, whether it is really one disease. (In the past, doctors thought that schizophrenia and tertiary syphillis were one disease. They still don't know whether what we call schizophrenia is one disease, but it probably isn't.)

The basic description of bipolar disorder is cycling from periods of what looks like clinical depression to periods of unusual self-confidence and exuberance which can pass over into an irrational state called mania in which self-confidence turns into grandiosity, racing thoughts become divorced from reality, and assertiveness may turn into aggressiveness. Some people stop short of the extreme manic state. The milder form, called hypomania, may actually be desirable -- a period of creativity and joy.

Well, four and five year old children are like this naturally. One moment they are calm and quiet, then they are exuberant and creative, then they have a tantrum, then they sulk. In their exuberant, creative phases they indulge in fantasies which they seem fully to believe. In their tantrums, it is impossible to reason with them.

In school, children are required to spend long periods quietly focusing on tasks which are often not very interesting. They are required to speak only when they have permission. They may play energetically only during brief, specified periods. Most children do not like to do these things, and some simply will not. In the old days, when children didn't conform, their teachers would smack them on the back of the hand with a ruler, beat them on the buttocks with a rod or a paddle, or make them sit in the corner wearing a bizarre, humiliating hat. Parents usually demanded comparable conformity at home, and used similar measures to enforce it.

I presume these methods were at least somewhat effective, or they would not have been so widely used for so long, but clearly they had pernicious secondary effects, as we say. Nowadays they are out of favor. When children fail to conform their behavior to the demands of adults, we label them as diseased and drug them. Reasonable people may disagree as to whether and under what circumstances this is appropriate, but there is very widespread concern that far too many children are being drugged and that it ought to be a last, desperate resort.

Like physical violence against unruly children, the drugs have side effects. The most widely prescribed are amphetamines, which are among the most dangerous of addictive drugs and can even produce psychotic states. For children diagnosed with bipolar disorder, as I wrote below, lithium and Depakote are the common prescriptions. These drugs also have side effects.

But anti-psychotics are another matter entirely. These drugs are so toxic that even desperately ill adults often cannot take them. They are associated with severe weight gain, hyperglycemia and diabetes, and hypercholesterolemia and heart disease. They can cause severe neurological complications, damage the liver and kidneys, and cuase a life-threatening metabolic disorder. The "clinical trial" for quetiapine in 4 and 5 year olds is a "phase IV" trial which is supposed to test the safety of the drug in a new population. There is no need for such a trial. We already know the answer. The drug is not safe. It is not safe in adults, albeit it is sometimes the lesser evil. To give it to children, whose brains are still developing and whose liver enzyme systems are underdeveloped; children who are not physically ill but whose behavior is troublesome, who may or may not have some completely unknown neurological abnormality, is grotesque. The purpose of this is for a drug company to try to sell more pills and make more money.

That's my opinion.

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