Map of life expectancy at birth from Global Education Project.

Monday, March 10, 2008

You don't have to take it from me

Barbara Burke in the new JAMA reviews Bipolar Children: Cutting Edge Controversy, Insights, and Research, Edited by Sharna Olfman. Unfortunately, it's subscription only, but I'll give you a fair-use quote:

IN EUROPE AND ACROSS THE GLOBE, MANIC DEPRESSION IS rarely diagnosed in the pediatric population. In the United States, on the other hand, the American Academy of Child and Adolescent Psychiatry (AACAP) suggests that it may exist in up to 13% of children.1 Prescriptions of sedating drugs (anticonvulsants, -agonists, and atypical antipsychotics) have increased up to 3-fold in the last decade.2 Both of these anomalous trends, poorly substantiated by quality research, have occurred during a time of dramatic economic change in the health care industry. Meanwhile, US children appear to be getting less mentally healthy, not more, with diagnoses of “mood disorders” and “pediatric bipolar” (PBD) topping the list. This is clearly crazy, but where does the madness lie? In the children, the prescribers, or society as a whole?

In this provocative, highly readable book, psychologist Sharna Olfman . . . presents 9 essays that collectively answer “all of the above,” with generally good success. In her introductory chapter, Olfman places the blame on the close ties between academic medicine and the pharmaceutical industry and on dwindling societal support for families. She highlights the weakness in the concept of PBD promoted by the AACAP, noting there is no proven continuity between PBD (especially PBD not otherwise specified, or “subsyndromal PBD”) and adult manic depression, strongly suggesting that children with this diagnosis have some other emotional disturbance. Olfman also points out that the current biomedical model of mental illness in children, which relies on symptom checklists to diagnose mental illness, is inadequate: While it pays lip service to psychosocial context, in practice it eliminates from diagnosis and treatment such factors as parent-child relations, history of maltreatment and loss, current and past stressors—in fact, all those external factors known to cause natural, reactive disturbance in children. Finally, Olfman points out that the practice of reducing children’s natural reactions to stress by treating them with medications is practically mandated by current economic forces in health care, especially managed care models of treatment. Soaring rates of prescriptions of anticonvulsants and atypical antipsychotics have delivered enormous profits to the pharmaceutical manufacturers in the absence of long-term follow up studies demonstrating their safety in children and despite the fact that these drugs have serious, known adverse effects, including toxicity and metabolic disturbances.

Like I just told you. Unfortunately, psychiatry is so deep in the tank to the drug companies that the idea that we should be slapping millions of kids with disease labels and drugging them, because they have trouble sitting still and shutting up in school, or they have temper tantrums or sulk or won't eat their carrots, is heavily promoted by leading academics, notably Joseph Biederman of Mass. General Hospital and Harvard Medical School, and the people who resist this movement are derided in all the higher circles of the psychiatric establishment as cranks.

When children show signs of emotional distress, there's usually a reason for it, and that reason is not bad chemicals. Somebody needs to ask what it is, and solve the problem.

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