Say Hello to Temper Dysregulation Disorder with Dysphoria

The buzz around the new version of the DSM is already starting. The draft version is now online and it features a new condition with the ungainly moniker of "Temper Dysregulation Disorder with Dysphoria." That's a friggin' mouthful, so let's try T-Triple D for short. WTF is this disorder? Well, according to my first look, it closely resembles the bad-behavin' kids who have been labeled as bipolar for the last few years. The symptoms are below, and can also be found on the official DSM-V website:

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.

2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

3. The responses are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, three or more times per week.

C. Mood between temper outbursts:

1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).

2. The negative mood is observable by others (e.g., parents, teachers, peers).

D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.

F. Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

I've not given this a lot of thought yet. The committee that examined the topic has some discussion of T-Triple D/bipolar here and here. The committee takes a couple of digs at the the child bipolar diagnosis. So if this new disorder is adopted, we're going to have yet another name for children who behave badly. Fortunately, the criteria appear to require much worse behavior than what has been passing for "bipolar" according to some child psychiatrists. The diagnostic threshold is higher and should theoretically lead to fewer kids being unnecessarily diagnosed. But even if the current criteria are adopted without any changes - look for a movement to diagnose "subthreshold" cases of T-DDD, as untreated subthreshold T-DDD will be found to cause untold psychological and physical damages across the world. Damages that can only be mitigated through aggressive treatment using [insert name of latest patented tranquilizer here]. So whatever antipsychotics or "mood stabilizers" are hot in 2013 when the DSM-V is released... they will be the "cure" for T-DDD or bipolar or whatever the hell we decide to label kids with behavior problems.

That's my first impression. This is definitely going to be a hot-button topic. There is apparently some mechanism to send comments to the DSM-V folks, since this is only a draft version - feel free to comment here or send your ideas to the DSM-V posse.

Key Opinion Leader With A Very Short Fuse

Psychiatrist Joe "Short Fuse" Biederman of Harvard University is really in hot water now. The sordid details can be seen in a fantastic article by Gardiner Harris of the New York Times. Here's just one snippet:

In a November 1999 e-mail message, John Bruins, a Johnson & Johnson marketing executive, begs his supervisors to approve a $3,000 check to Dr. Biederman as payment for a lecture he gave at the University of Connecticut. “Dr. Biederman is not someone to jerk around,” Mr. Bruins wrote. “He is a very proud national figure in child psych and has a very short fuse.” Mr. Bruins wrote that Dr. Biederman was furious after Johnson & Johnson rejected a request that Dr. Biederman had made for a $280,000 research grant. “I have never seen someone so angry,” Mr. Bruins wrote. “Since that time, our business became non-existant (sic) within his area of control.”

Mr. Bruins concluded that unless Dr. Biederman received a check soon, “I am truly afraid of the consequences.”

A series of documents described the goals behind establishing the Johnson & Johnson Center for the study of pediatric psychopathology, where Dr. Biederman serves as chief. A 2002 annual report for the center said its research must satisfy three criteria: improve psychiatric care for children, have high standards and “move forward the commercial goals of J.& J.,” court documents said.

And from Bloomberg,

Biederman “approached Janssen multiple times to propose the creation of a Janssen-MGH center,” according to an e-mail from a J&J executive. The center would “generate and disseminate data supporting the use” of Risperdal in children, the e-mail said. Pediatric use was approved by U.S. regulators in August 2007.

Wow. And the plot sickens, er, thickens from there. Normally, being caught with one's hands this deep into the cookie jar would lead me to write a much more blistering piece, but the day job shows no signs of abating in its workload. Fortunately, Philip Dawdy is rolling with the story at Furious Seasons (1, 2).

Let's see if Biederman's defenders can defend him in another op-ed as they did a few months ago. Or maybe we can leave Joe to defend himself. Here's what he said a few months ago when facing criticism:

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.

Nope, most of his critics cannot match his credentials of apparently shaking down hundreds of thousands of dollars from Johnson & Johnson. But maybe I just like brownies and he likes hot dogs. Another key opinion leader whose reputation is deservedly shot to shreds. Nemeroff, Biederman, and the list goes on.

The Latest on Kiddie Bipolar

A recent study in the Archives of General Psychiatry claimed that kiddie bipolar tends to become adult bipolar. I have read the study and have a few comments. First, the authors' main findings:

• Children diagnosed with bipolar went on to have a manic episode 44% of the time.

Let's look at the study sample. Seven to 16 year olds who were experiencing a manic or mixed episode. At 8-year follow up, 54 kids had reached at least age 18. So we're talking about 24 of 54 kids who went on to experience a manic episode as adults. Not exactly a huge sample. As time moves along, there will likely be more kids from this study who experience manic episodes as adults, so it is very much possible that when all 115 kids originally enrolled in this study hit, say, age 30, more than half of them will have experienced a manic episode as adults.

The argument then goes that we must treat child bipolar early and intensely in order to prevent these kids from going on to develop bipolar disorder as adults. So, were these kids receiving treatment? Definitely. These kids received whatever treatment was offered in the community, which doubtlessly included stimulants, mood stabilizers, antidepressants, and antipsychotics. On many occasions, they were probably undergoing some serious polypharmacy driven out of desperation rather than any sort of reasonable evidence base.

So did the treatments work? 88% of people who had an original manic or mixed episode recovered, but 73% of these kids then had a relapse afterward. And if nearly half went on to experience mania as adults, doesn't that mean that treatment was not exactly working very well? At this point, the authors have not reported what treatments were used, but I am willing to bet that the polypharmacy I mentioned above was often in place and that very few of these kiddos weren't receiving regular psychopharmaceutical treatment.

Bipolar was not the only problem facing these kids. 94% had an ADHD diagnosis at some point during the 8-year followup and a similar number had some sort of disruptive behavior disorder diagnosis. So it's not just bipolar. As I've been saying for a while now, bipolar is just the name du jour for kids whose behavior is really, really bad. We used to call it ADHD or conduct disorder and now it's ADHD, conduct disorder, and bipolar disorder just abbreviated as "bipolar," driven by the market reality that there are quite profitable drugs used to oh-so-successfully treat kiddie bipolar. But it seems they can't be working that well if 73% of these kids who recover from an episode end up relapsing.

I would love to write more about how bipolar was diagnosed in these kids, but I've not been able to land a copy of the measure used to make bipolar diagnoses in the study. The authors state that they only counted episodes that met DSM-IV criteria; if I ever find time, I might look at this more closely.

And note that we don't know what happened to the youngest kids in the study (those who started at ages 7 or 8) because none of them were adults at the end of this study. This study did not include anyone younger than 7, so the rash of 4 year olds being diagnosed as bipolar is left unexamined.

Bottom Line: Assuming that the diagnoses were valid, this study makes me think that:

• Kids who show really bad behavioral and emotional problems often become adults with major psychological problems. Not exactly earth-shatteringly surprising.
  
• Treatments for child/adolescent bipolar are not working very well.
  
  

Furious Seasons also has a number of concerns about the study.

Bipolar Overawareness Week: New York Times Magazine Edition

Jennifer Egan has a roughly 29,000 word piece in the New York Times magazine regarding child bipolar disorder. OK, maybe it just seemed that long. As is apparently required for such articles, there is a very lengthy story about an allegedly bipolar child that constitutes much of the article. I'll not be focusing on that. Instead, I'll be looking at how the article discusses the controversy surrounding the diagnosis. Quotes from the article followed by my comments follow:

The Diagnostic and Statistical Manual of Mental Disorders (the current edition is referred to as D.S.M.-IV) describes bipolar disorder as a condition whose average age of onset is 20, but virtually all the leaders in the field now say they believe it exists in children too.

Well, then. I found two psychiatrists whose opinion appears to differ. Jon McClellan seems to disagree that bipolar exists in young children, as does David Healy. I could probably find others without much difficulty. Maybe they are not "leaders in the field?" But ok, let's say that it does exist in young kids. I'll grant Jennifer Egan that most agree that bipolar exists in adolescents (but toddlers???), though at what rate is a matter of debate. And more importantly, who gives a rat's behind what people think? Um, maybe we should be more concerned about what the actual science has to say about it. And in that regard, there are some serious unanswered questions, as I've described before.

1. Does child bipolar really exist in substantial quantity?
2. Does treatment help kids with this "disorder"?

But to be fair to Egan, maybe I took the last quote out of context, because she adds a somewhat more balanced view by stating that:

Many clinicians say the illness looks significantly different in children than in adults, but the question of how it differs, or what diagnostic terms like “grandiosity,” “elevated mood” or “flight of ideas” (all potential symptoms of adult bipolar disorder) even mean when you’re talking about kids, leaves room for interpretation. For example, it’s normal for children to pretend that they are superheroes, or believe that they can run faster than cars, whereas in an adult, these convictions would be signs of grandiosity. Equally unclear is whether a child who is identified as having a bipolar disorder will grow up to be a bipolar adult. Work on the D.S.M.-V is under way, and discussions have begun on how to address the issue of bipolar children.

As Ellen Leibenluft, who runs the pediatric bipolar-research program at the National Institute of Mental Health, told me, “There definitely will be — and needs to be — more description of what bipolar disorder looks like in children, how one diagnoses it and some of the challenges.”

OK, that's better. But in general, the article focuses on the proponents of the child bipolar paradigm rather than those who raise concerns. And Egan discounts a big study in a pretty odd way...

A study last fall measured a fortyfold increase in the number of doctor visits between 1994 and 2003 by children and adolescents said to have bipolar disorder, and the number has likely risen further. Most doctors I spoke with found the “fortyfold increase” misleading, since the number of bipolar kids at the beginning of the study was virtually zero and by the end of the study amounted to fewer than 7 percent of all mental-health disorders identified in children.

Huh? So it's misleading to say that for every one treatment visit for bipolar in 1994, there were 40 in 2003? No, that's exactly what the study found. Let's try an analogy. The rate of suicide among kids and teens, on an absolute scale, is very low. Very few children and adolescents actually commit suicide. So if the suicide rate went up by a factor of 40 in the next 10 years, would we then say, "Well, that's misleading because suicide was very rare in 2008, when the study began?" That makes no sense whatsoever. And to say, hey bipolar is now only 7% of kids diagnosed with mental disorders, so it's no big deal -- ??? What treatments do you think these kids get? Play therapy and lollipops? Uh, try antipsychotics, often in combination with anticonvulsants, antidepressants, and who knows what else? If you think this is all based on science, go take a spin over to Pubmed and see what you can find. What, there's no evidence that carpet bombing developing brains with a wide variety of psych drugs is effective for "bipolar"? Count me as shocked, shocked, that medications would be prescribed so widely in the absence of supporting evidence. Sure, maybe if you provide highly tranquilizing medications, they mellow out bad behavior a bit in the short-term. Is that an effective long-term solution? And at what cost?

In Leibenluft’s studies at the National Institute of Mental Health, only 20 percent of children identified with bipolar disorder are found to meet the strict criteria for the disease. Breck Borcherding, a pediatric psychiatrist in private practice in the Washington area, said: “Every time one of my kids goes into the hospital, they come out with a bipolar diagnosis. It’s very frustrating.”

OK, so a study that finds that bipolar diagnoses have shot through the roof is "misleading," but at the same time, other Egan then discusses research suggests that bipolar is being misdiagnosed at a high clip. Am I the only one who is confused?

Then there is “The Bipolar Child,” a successful book published by the psychiatrist Demitri Papolos and his wife, Janice, in 1999, and referred to by more than one parent I spoke to as a “bible.” The Papoloses’ description of pediatric bipolar disorder was amassed partly by using responses to an online questionnaire filled out by hundreds of parents on an electronic mailing list, who said they believed their children were bipolar (and who often had strong family histories of the disease). The Papoloses’ diagnostic criteria include some idiosyncratic items — a severe craving for carbohydrates, for example — that are found nowhere in D.S.M.-IV. Nevertheless, many parents walk into doctors’ offices having already read “The Bipolar Child” and concluded that their children are bipolar. Because doctors rely heavily on parental reports when diagnosing disorders in children, these “prediagnoses” may have an impact on the outcome.

Well, if that isn't the most airtight method for a study that I've ever heard. Put up an online questionnaire, have people who insist that their kids are bipolar fill it out, then use whatever these parents say as criteria for the disorder. And... severe craving for carbs? Nope, I've never ever seen a kid who really, really wants candy before. But if I do see such behavior, I'll turn on my bipolar radar; I'll be keeping my eyes peeled at the candy store.

And of course, there are pressures and blandishments from the pharmaceutical industry, which stands to profit mightily from the expensive drugs — often used in combination — that are prescribed for bipolar illness, despite the fact that very few of these drugs have been approved for use in children.

You mean like the part where key opinion leaders sign on for Big Bucks to give talks for psych drugs in treating kiddie bipolar? No, you won't find discussion of that anywhere in the article. Because we are making progress in understanding the biological disease of bipolar disorder and how to treat it. Progress is slow but everything is headed in the right direction -- the time-honored narrative of the academic-pharmaceutical complex always making progress in mental health. There is a sentence dedicated to discussing the influence of Big Pharma. One. Off-label marketing of antipsychotics for kids is never mentioned, despite Otsuka/Bristol Myers Squibb settling a federal lawsuit for pimping Abilify for kids. I suppose mentioning such shenanigans might poke a bit of a hole in the idea that we are making perpetual progress.

And here comes the hammer. Sure, bipolar might be overdiagnosed, but of course the biggest problem is the undertreatment of bipolar kids:

For all the possible overdiagnosing of pediatric bipolar disorder, however, many in the field also say that a lot of truly bipolar children who could benefit from therapy are falling through the cracks. This is a critical issue; studies clearly show that the longer bipolar disorder goes untreated, the worse a person’s long-term prognosis.

If you are so into "studies clearly showing" things, then maybe you could point to studies that clearly show benefits of treating bipolar disorder in children. I'm waiting. In fact, I've been waiting for years. As the rate of drugging kids for bipolar has increased drastically, the research showing treatment benefits is... where? And if you're telling me that kids behaving very badly, which seems to be fit roughly 100% of kids who wind up diagnosed with bipolar disorder, are not getting treatment, I think you aren't paying attention. Desperate parents want a solution, and whether the diagnosis is opposition defiant disorder, conduct disorder, ADHD, autism, pervasive developmental disorder, WTF NOS, or bipolar, I'm pretty sure that these kids are getting treated in droves. But maybe I'm wrong.

Gabrielle Carlson, the director of child and adolescent psychiatry at the Stony Brook University School of Medicine, has studied childhood mania for many years and says bipolar disorder is uncommon in children under 10, revealing itself in the same discrete episodes of mania and depression that we see in bipolar adults — not in chronic irritability. According to Carlson, a large group of aggressive and explosive children, who in fact are “diagnostically homeless,” are being relabeled as bipolar, which is a development she says is unhelpful both to the children and the field. “Diagnostically it ends up being a very important consideration of what the kid really has,” she told me. “If he really has A.D.H.D. and it’s not mania, then you give him medication for his A.D.H.D. You also give him behavior modification.” One patient she saw that day, who was thought to have bipolar disorder, actually had autism, she said. “If you say, ‘Hey, his problem is bipolar disorder,’ then you’re not going to treat his language disorder, you’re not going to give the social-skills treatment he needs,” she said. Problematic conditions in a child’s home life are also less likely to be addressed if the child’s behavioral issues are attributed to bipolar disorder, Carlson said. “Many people, when they hear bipolar disorder, their brain slams shut.”

After including quotes from Janet Wozniak of the ever-present Harvard bipolar child team, it was nice to see comments from someone who has a bit more skepticism. A harsher critic could have been included in the story, but was not. No, I'm not going to quote Wozniak because you already know what she said, which is that we discovered that bipolar disorder in kids is way, way, way, way, more common than previously thought.

The most basic question about bipolar kids remains a mystery: Will they grow up to be bipolar adults?

No, four of the most basic questions are, in no particular order:

1. How many of these kids labeled as bipolar have been misdiagnosed?
2. What are the benefits and risks of treatment, in the short-term and in the long-term?
3. What happens if we try nonmedical interventions aimed at changing discipline strategies, proving more structure at home, etc.
4. Is child bipolar at least partially a medical term for bad behavior? And where does the bad behavior stem from? Could social problems have anything to do with it? Think of things like poverty, absent parenting, violent TV programming and video games, vastly unequal income distribution, gangs, unemployment/underemployment, and the list goes on... In other words, our society ain't exactly ideal and some of these problems will impact mental health. Isn't throwing pills (or even therapy) at these problems a little shortsighted? This ain't the place to discuss how to improve society; I'm just saying that many of these problems discussed on the site probably arise from more than just intrapsychic issues or troubles with an alleged (not proven) "chemical imbalance." Do you think there is a reason, for example, that foster kids are so frequently on antipsychotics? As written by The Last Psychiatrist: "A 20% increase in therapy visits will be interpreted by psychiatry as a 20% increase in depression and anxiety. It will say depression has a prevalence of X, it will say it is underdiagnosed and undertreated, etc. And it will creep into the social consciousness that these are pre-existing diseases with triggers, not the consequences of external events. Society needs that illusion, it needs that lie, because it has created unrealistic expectations in people and no way of fulfilling them."

Think my question 4 is a little weird, that it's wild speculation? Well, if you want some wild speculation that exceeds mine, try a few slices from the NYT mag piece:

Some studies suggest that bipolar disorder may actually be on the rise among young people. One intriguing hypothesis involves a genetic phenomenon known as “anticipation,” in which genes become more concentrated over generations, bringing a stronger form and earlier onset of an illness with each successive generation. Another theory is “assortative mating,” in which a more mobile and fluid society, like ours, enables the coupling of people whose mutual attraction might be partly due to a shared genetic disposition to something like bipolar disorder, thus concentrating the genetic load in their offspring.

Yeah. That's the ticket. We've had how many thousands of generations of human existence and now, suddenly, bipolar is becoming more concentrated in kids. Intriguing hypothesis? Wouldn't such a trend be gradual, not sudden? Same story with "assortative mating" -- is it just now that bipolar folks would choose to mate with each other? Presumably, this would have happened throughout human existence, so pulling this kind of thing out of a hat now makes absolutely no sense. But there's an answer to that -- we're living in a "more mobile and fluid society." So now that we're "mobile," bipolar folks breed with bipolar folks, but before cars and planes, they couldn't breed with each other. Huh?

Kiki Chang, director of the pediatric bipolar-disorders program at Stanford, has embraced the kindling theory. “We are interested in looking at medication not just to treat and prevent future episodes, but also to get in early and — this is the controversial part — to prevent the manic episode,” he told me. “Once you’ve had a manic episode, you’ve already crossed the threshold, you’ve jumped off the bridge: it’s done. The chances that you’re going to have another episode are extremely high.”

Oh boy. Preventive psychopharmacology. If you are a hyper kid, we'll give you antipsychotics because they might keep you from becoming bipolar later. Trust us, your son is fine in our hands, ma'am.

Also see Furious Seasons' take on the matter. And give him some $$$ to help with his fundraiser. If you ever wanted to give me money, don't. Pass it his way.

FDA Gives Thumbs Up To Kiddie Bipolar: Is KOL Syndrome Next?

Philip Dawdy at Furious Seasons noted that the FDA has officially approved the existence of child bipolar disorder. Prior to it being included in the DSM, and with considerable controversy in the professional community, the FDA jumps on board. Nice. Thanks to Philip for chasing down the FDA's official view.

A few questions for consideration by the FDA (and others) that I mentioned a few months ago:

1. Does child bipolar really exist in substantial quantity?
2. Does treatment help kids with this "disorder"?
3. Why would a leading "expert" in child "bipolar disorder" say that up to 75% of children who are "bipolar" become suicidal without citing any supporting evidence?

Joe Biederman must be proud -- the FDA will now help him and his posse save countless lives through the administration of treatments (like, say, Seroquel) for "child bipolar" that lack any sort of substantive evidence base. But who cares -- even without professional consensus or any sort of official word from the FDA, the treatment of child bipolar has already flown the coop in a big way. Realistically, I suppose that the FDA's view is irrelevant -- drug marketers and key opinion leaders wield more influence than anyone at FDA when it comes to how physicians view psychiatric diagnoses.

KOL Syndrome: On a related note, perhaps the FDA (or the DSM-V committee) can approve KOL Syndrome as a disorder. That would be Key Opinion Leader Syndrome. For case examples, please see here, here, here, here, here, and here. The prevalence of KOL Syndrome seems to be increasing and seems related to the widespread adoption of irrational prescribing as well as information laundering. Symptoms include:

• Providing false "education" to physicians as a service to your corporate clients
• Calling one or more of one's own articles "commercial pieces of crap," then recanting
  
• Hiding blatant conflicts of interest
  
• Writing misleading review articles that falsely tout the efficacy of one or more drugs,
• Magically converting results that show a product is a dud into results showing that a product is safe and effective
• Making a boatload of money through ties to various drug or medical device companies, then claiming that such corporate ties have absolutely no influence on your professional judgment
• As an author, calling a study's results positive, then calling these same results negative a few years later without noticing the contradiction.
• Giving tasty sound bites in press releases about the wonders of various medications in one's capacity as an "independent" scientist
  

Back to kiddie bipolar: Do some adolescents have bipolar disorder? Sure. Five-year-olds? That's where I start getting suspicious...

Also see an excellent post from John Grohol at Psych Central on youth bipolar and some of the logical problems regarding how its treatment is advocated. And Furious Seasons also notes that the FDA database raises questions about two of the drugs touted as safe and effective for kiddie bipolar.

Say It Ain't So Joe

It appears that Joe Biederman, King of Child Bipolar, has been caught with his hands in the cookie jar. More specifically, the New York Times and Bloomberg have noted that Biederman has received a great deal of pharma cash (like at least $1.6 million dollars from 2000-2007) and has not been very forthcoming about such funds. How was such undercover money revealed? Courtesy of Charles Grassley, the Iowa Republican Senator whose prior investigation unearthed a similar situation impacting another Bipolar Child Key Opinion Leader, Melissa DelBello from the University of Cincinnati.

Here's one example, from Gardiner Harris and Benedict Carey at the New York Times:

In one example, Dr. Biederman reported no income from Johnson & Johnson for 2001 in a disclosure report filed with the university. When asked to check again, he said he received $3,500. But Johnson & Johnson told Mr. Grassley that it paid him $58,169 in 2001, Mr. Grassley found.

So Biederman is supposed to report outside income to the university, but he didn't. Then, his amended reports were in some instances a wild underestimate of his outside income. So how well is the "honor system" working out for conflicts of interest, anyway? To be fair, Biederman is not alone -- two other Harvard psychiatrists (Timothy Wilens and Thomas Spencer) had similar reporting problems. Indeed, there is nothing to say that Biederman's conflicts of interest are any more noteworthy than those of other "stars" in the academic psychiatry universe.

Worry not, Biederman is still interested in saving lives. He is recruiting 4 to 6 year olds with "bipolar disorder" for a Seroquel trial.

For some reason, I thought Biederman's prior comments were worth repeating here. From the Boston Globe:

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.

You tell 'em, Joe! I suppose those who dare critique his conflicts of interest are "not on the same level" as him. Some say that we shouldn't be concerned about conflicts of interest, that we should just look at the quality of a person's work, regardless of financial conflicts. Well, Biederman is the undisputed King of Bipolar in kids, and I'm still awaiting any impressive outcome dataon the "bipolar" kids being treated with antipsychotics. Especially the young kids. 4 year olds on Seroquel -- I'm glad I'm not on Joe's level. Are we better off now that the diagnosis of bipolar has run rampant in kids?

Also see and Furious Seasons and Pharmalot.

Update: Also read the Carlat Psychiatry Blog post on the topic.

The Bipolar Child Strikes Again

Newsweek has a lengthy story on bipolar children. Well, really, it's about one child and his family. After reading it, there is no doubt that something is very much wrong with the child (Max) profiled in the story. The story is interesting in how it portrays bipolar disorder in kids. A few things I noticed follow.

1. Max's problems are described by the journalist as "incurable" and as "a life sentence." It is true that the kid is likely in for a life of trouble. But stating that such difficulties are a certainty for the rest of his life? That's a little too certain and it's not based on any evidence. Show me one study that indicates that 100% of children like Max will always have a high level of psychological difficulties and essentially be unable to function independently.

2. The biology of child bipolar disorder is discussed as if we have a very firm grasp on the concept, then one major limitation is noted quite briefly.

Scientists now know that bipolar children have too much activity in a part of the brain called the amygdala, which regulates emotions, and not enough in the prefrontal cortex, the seat of rational thought. "They get so emotional that they can't think," says Mani Pavuluri, a child psychiatrist at the University of Illinois at Chicago. More than the rest of us, a bipolar child perceives the world as a dramatic and dangerous place. If he is shown a picture of a neutral face, he may see it as angry. Show him one that really is angry, and his prefrontal cortex will shut down while his amygdala lights up like a firecracker. The typical result: a fury that feeds on itself. Neurological research has its limits, though, and bipolar disorder still cannot be identified based on brain scans.

So dedicate space to how far science has progressed then quickly note that, by the way, these biological findings are useless in making a diagnosis. That's a rather important limitation.

3. How are all of the medications working out for Max?

By 7½, Max was on so many different drugs that Frazier and his parents could no longer tell if they were helping or hurting him. He was suffering from tics, blinking his eyes, clearing his throat and "pulling his clothes like he wanted to get out of his skin," says Richie. In February 2005, under Frazier's supervision, the Blakes took Max off all his meds. With the chemicals out of his system, Max was not the same child he had been at 2. He was worse. Bipolar disorder often gets more serious with age. The brain also reacts to some drugs by remodeling itself, and its dopamine receptors end up naked and sensitive. When the drugs are removed, it's a shock. Off his meds, Max became delusional and paranoid. He imagined Amy was poisoning him and refused to eat anything she cooked. He talked about death constantly and slept little more than two hours a night. Within a month Frazier had put him back on medication, but with a caveat: she wanted to place him in a short-term bed in a child psych ward.

But wait, there's more...

At 10, he has been on 38 different psychoactive drugs. The meds have serious side effects. They have made Max gain weight, and because he's still growing, they frequently need to be changed. The Blakes are aware that many people think their child—any child—should not be on so many drugs. They aren't always happy about it either. But to some degree, they have made their peace with medication.

Yes, you read that correctly -- he's been on thirty-eight psychiatric meds and he's 10 years old. Gee, I wonder if such a heavy regimen of medication is healthy for the developing brain?

4. More on "the bipolar brain"

The bipolar brain tries to compensate for its weak prefrontal cortex by roping in other areas to help; these areas may now become dysfunctional, too. Child psychiatrists thus face an enormous practical challenge: they often can't treat one disorder without affecting another one. "It's like a balloon where you push on one side and the other side pops out," says Wozniak, the MGH psychiatrist who helped define childhood bipolar disorder. With kids like Max, she adds, parents often have to settle for "just having one part of the symptoms reduced."

Um, okay. The bipolar brain "ropes in" other, unspecified brain areas to help the weakling prefrontal cortex and then these areas become dysfunctional too. I'm not a neuroscientist, but I think this explanation is strange at best.

5. Get ready for MANIA

During a recent appointment at Frazier's office, he went into full-fledged mania. Laughing wildly, he rolled on the floor, then crawled over to his parents and grabbed an empty medication bottle, yelling, "Drugs! I've got drugs! It's child safety!" Richie grabbed it back, Max screamed, Richie threw the bottle across the room, as if playing fetch. Max squealed and dove for it, then began to sing into the neck of the bottle: "Booorn to be wiiiiild …" Amy rolled her eyes: "Two kids." And then: "It's hard not to laugh."

It was. And it was hard to look at Max, who has borne so much, and remember that the grin on his face was not a sign of childish goofiness but a symptom of an illness.

Laughing, yelling, rolling on the floor -- it's definitely a manic episode. They probably should have given him a fat injection of Risperdal Consta to calm him down. Oh, and smiling is a symptom of mania as well. Gosh, I am learning sooooooooooo much about bipolar disorder from this article. I can't wait until the DSM-V comes out, at which point we'll discover that we're all bipolar.

Sarcasm aside for a moment, I am not making light of the situation faced by Max and his family. I can understand the sense of desperation felt by the parents and, to some extent, by the treating physicians. The story just rubbed me the wrong way a few times. The story's author was able to find some psychiatrists who were on the bipolar bandwagon, but she was somehow just not quite able to track down the unnamed critics of the bipolar child paradigm that she briefly mentioned in her story. So the bipolar advocates are given names and are quoted, while the nameless critics are essentially a footnote in her story.

I've also written previously about the tangled web of child bipolar disorder.

Hat Tip: Furious Seasons.

Key Opinion Leader Is Unfairly Disparaged

Or so she said. I've written about key opinion leader, University of Cincinnati child psychiatrist Melissa DelBello a few times (here, here, and here). One key point was she was quoted as saying "Trust me. I don't make much" in regards to income received from AstraZeneca for giving favorable talks for its antipsychotic drug Seroquel. I had missed that in 2007, she claimed she was misquoted in an interesting piece on Inside Higher Ed:

[University of Cincinnati spokesperspon] Puff said that DelBello’s comment in May that she did not “make much” money from drug companies had actually come in response to the reporter’s question “about how much money she was given for making a single, individual presentation. Her comment was misrepresented and then repeated by Sen. Grassley.” Added DelBello: “I was and have been misquoted by the NYT.” (The Times reporter, Gardiner Harris, could not be reached Sunday to respond to the suggestion that he had misrepresented DelBello’s comment.)

Puff also said that “the implication of what Sen. Grassley said was that she was disingenuous in what she was paid. She has been completely open in disclosing her payments. She’s made complete disclosures to the university and its IRB. Furthermore, she’s made full disclosure to the Senate Finance Committee.... Additionally, Dr. DelBello has disclosed her funding at all speaking engagements and she’s disclosed in the patient consents of her studies.”

I wonder if she has made disclosures about her company (MSZ Associates) that Senator's Grassley's investigation claims was set up for "personal financial reasons"and well-funded by AstraZeneca. Also, does the above mean that DelBello disclosed that she has personally received hundreds of thousands of dollars from AstraZeneca and other sources in the consent forms for her studies? I have to admit I'm pretty skeptical about that, but I could be wrong. As far as full disclosure to the Senate, Grassley's most recent findings seem to contradict this claim. Hey, maybe Grassley is just making things up, so either DelBello is being unfairly persecuted or her story is simply not adding up.

Why am I making such a big deal about this? Well, such a gigantic hidden conflict of interest doesn't exactly engender my faith, and DelBello is a person who can take at least responsibility for the widespread treatment of children with antipsychotic medications. Due to her research findings that some claim support the use of antipsychotics in kids and her many marketing speeches for AstraZeneca and others, the landscape for badly behaving children is changing, and likely not for the better (1, 2, 3).

Pharmalot reports that the University of Cincinnati is unresponsive to his requests for comment. Perhaps they're going for the time-honored tradition of remaining in silence under the belief that this publicity cannot possibly last much longer.

Bipolar Child Key Opinion Leader: I Get Money

As reported on the Wall Street Journal Health Blog, Dr. Melissa DelBello's tight financial ties to AstraZeneca are again under scrutiny. This should come as no surprise to my readers, as I noted in March that, in 2003-2004, DelBello had been the recipient of $180,000 from AstraZeneca (makers of Seroquel). I gleaned this information from results of an investigation by Senator Charles Grassley. The WSJ Health Blog noted that Grassley's investigation has continued, revealing that:

DelBello, who also has received NIH grants, also reported $100,000 in outside income between 2005 and 2007. But when Grassley asked AstraZeneca directly, the total value of its payments to DelBello during those three years came to $238,000.

So she claimed initially that she received $100k from 2005-2007, but she actually pulled in $238k from a single company and who knows how much from other outside entities. In fact, it is clear that DelBello has received funding from several other corporate interests. To quote her disclosure from a continuing medical education exercise:

Dr. DelBello has disclosed the following relevant financial relationships: AstraZeneca, Bristol-Myers Squibb, Eli Lilly, and Pfizer: Consultant; AstraZeneca, GlaxoSmithKline, Pfizer: Speakers’ Bureau; and Abbott Laboratories, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Johnson and Johnson, Pfizer, and Shire: Research Support Recipient.

But wait, there's more! According to Grassley's investigation, DelBello has also established a company for "personal financial purposes." The company is called MSZ Associates and AstraZeneca put $60,000 in the coffers of the company. The address of MSZ Associates, according to Grassley, is the University of Cincinnati Department of Psychiatry (where DelBello works).

Again, as I've said earlier, I don't know Dr. DelBello, but from this information, I do indeed feel comfortable nominating her for a Golden Goblet Award. For background, read here and here. PharmaGossip's interesting visual representation of the situation can be seen here.

This is how one sets out to become a key opinion leader. DelBello quite likely has a mortgage and bills to pay, but is this confluence of commercial and academic interests really the best we can do for our patients?

Being a key opinion leader has one pleasant side effect: You Gets Mad Money.

(Warning: Video contains adult language)

"Not Much Money," KOLs, and Child Bipolar Disorder

Intro. A few months ago, I wrote about key opinion leaders (KOLs) in psychiatry arguing that we shouldn't be making such a big deal about their payments from drug companies. After all, they were just receiving chump change. At the time, my motivation was spurred by a great piece in the New York Times on the issue of physicians receiving payments from drug companies. Physicians are often paid to become "key opinion leaders," aka salespeople. Often possessing academic positions, these KOLs give speeches to fellow physicians in which they extol the virtues of a drug in exchange for cash. Of course, physicians might be leery if a sales representative was discussing the latest wonder drug, so using an "independent" physician uses a basic marketing trick, the third-party technique, in order to give the marketing message a veneer of credibility. For the past few years, KOLs have been lighting up the upscale restaurant scene across the nation, discussing the benefits of atypical antipsychotic (er, broad spectrum psychotropic) treatment for a wide variety of ills. From schizophrenia to bipolar disorder to anxiety to well, pretty much anything you can imagine, antipsychotics are the treatment du jour.

"I don't make much." One KOL in the wonderful world of atypicals has been Melissa DelBello. In particular, her specialty is children with bipolar disorder. I've previously stated my beef with the child bipolar paradigm and I'll discuss a couple of my contentions a bit later in the post. DelBello has been involved in research regarding the treatment of child bipolar disorder (not saying I necessarily agree with the term; just using it because she used it). As a KOL, DelBello has given talks supported by AstraZeneca, manufacturer of Seroquel. As for her reimbursement for such talks, she said "Trust me. I don't make much."

Here is what a little investigation from Senator Charles Grassley uncovered regarding DelBello's definition of "not much" money.

Here is where it gets interesting. After Dr. DelBello released her study, Astra Zeneca began hiring her to give several sponsored talks. Another doctor told The New York Times he was persuaded to start prescribing drugs [Page: S10722] such as Seroquel after listening to Dr. DelBello. But when the reporter from the New York Times asked Dr. DelBello how much money she got from Astra Zeneca, she told the paper: ``Trust me. I don't make much.''

Well, I decided to find out how much, and I went directly to the University of Cincinnati who, by the way, has been extremely cooperative, helpful, and responsive. Soon I figured out just how much ``not that much'' money is. Dr. DelBello's study, which helped put Seroquel on the map, was published in 2002. That next year, she got more money than she has ever received from the pharmaceutical companies--at least that is what the documents that I have say.

In 2003, Astra Zeneca alone paid her a little over $100,000 for lectures, consulting fees, travel expenses, and service on advisory boards. In 2004, Astra Zeneca paid her over $80,000 for the same services.

So, if I have this correct, $180k over two years is "not much money." Hey, this is quite similar to a response from another moonlighting entrepreneur with a license to practice medicine. To quote from the New York Times...

The psychiatrist receiving the most from drug companies was Dr. Annette M. Smick, who lives outside Rochester, Minn., and was paid more than $689,000 by drug makers from 1998 to 2004. At one point Dr. Smick was doing so many sponsored talks that “it was hard for me to find time to see patients in my clinical practice,” she said.

“I was providing an educational benefit, and I like teaching,” Dr. Smick said.

Right. The companies provide you with the slides and the key marketing points, and you call yourself an "educator." Um, doesn't that actually make you a marketer? And the clincher: Who has time for patients in clinical practice when you are off stumping for the hot drug of the week?

The KOL-Pharma Marriage: For all I know, Dr. DelBello is a great human being. I disagree with her a great deal on the child bipolar thing, but there are certainly many very bright and reasonable people who see things differently than myself. Personally, I have difficulty seeing the child bipolar bandwagon as anything other than a massive campaign to re-brand a broad spectrum of unruly behavior under one heading that can be used to call out for antipsychotic treatment. Researchers in the area of child bipolar perceive that scientific progress is being made because they have "discovered" a condition that affects millions of youth. Big Pharma loves it because, conveniently, they can treat this newfound condition with their cash cow atypical antipsychotics. And the marriage between child bipolar researchers and Big Pharma becomes even tighter through the well-paying speaking gigs in which KOLs pimp atypicals as the treatment for child bipolar, a condition that was considered quite rare until KOLs and Pharma "educated" us about this "neglected and undertreated serious medical condition."

Taking large payments then writing them off as "not much" just adds another brick to the wall of conflicted interests that dominates medicine these days. The physician-marketer (aka KOL) can perhaps take great pride in the rate of treatment for child bipolar expanding by perhaps 4000% of late. In fact, the spread of atypical antipsychotics for children, the elderly, and everyone else is such good news that I think KOLs should be up for some sort of marketing award. Go Team Seroquel! Viva Zyprexa! Rock on Geodon Crew! Gimme an I-N-V-E-G-A! Pimp that Abilify!

Believe it or not, I'm not against industry-academic collaboration. But I am against industry-academic corruption. When there are no checks and balances on a system, one should not be surprised when it is subverted by a combination of power and money. When academics turn into industry spokespeople, or become information launderers, or become medal winners in the conflict of interest department, why on Earth should we simply trust them as if they had no skin in the game?

Welfare Queens on Fiapta Demand Confidential Peer Reviews

I've been very neglectful in linking to a number of very interesting stories by my compadres in the blogging world. So here is a limited attempt to catch up:

• Pfizer wants to pry confidential peer reviews away from the New England Journal of Medicine. This is utterly ridiculous. Pfizer is facing a pile of lawsuits and is hoping that a peer reviewer might have said something nice about their products Bextra or Celebrex in a peer review, which they could then try to use as a legal defense. This reeks of desperation.
  
• PharmaGossip notes that AstraZeneca is out a cool $215 million for Medicaid drug price fraud in Alabama. Sheesh, and to hear certain politicians and talk show hosts decry the so-called "welfare queens" -- it would appear that AstraZeneca is the real welfare queen!
• Aubrey Blumsohn has a fine sarcastic bit on Fred Hassan. Meanwhile, the British Medical Journal advertising watch continues.
• Philip Dawdy lays down the smack on Judith Warner from the New York Times regarding overmedicated kids.
  
• And ex-GSK CEO Jean-Pierre Garnier is now officially delusional. He can't stand that his company is being judged by those meanies in the media, who seem to just ignore the science which proclaims that all GSK products are wonderful. Don't worry, Garnier is still a hero. .
• Atypical Antipsychotics notes that (whoopee), Vanda Pharmaceuticals has finally submitted its application for iloperidone. The best part is that, apparently drunker than a skunk, Vanda opted to name the drug "Fiapta", which is possibly the lamest name yet for a prescription drug. I've thought previously that this drug looks like a flop, and we'll see if I'm right... Note that an article published in 1995 stated that clinical trials for iloperidone were underway. It is now 2008 and I cannot find a single published clinical trial on the drug. Does that seem strange to anyone else?
  
• Daniel Carlat notes how Lilly concocted an article to put a smiley face on Cymbalta.
• The heparin/Chinese pigs/who needs supervision/high CEO pay with little accountability/yuck story is at Health Care Renewal. It's not a fun read, which is why you should check it out.
• Pharma Giles places his usual brand of sarcasm onto the new FDA guidelines that would allow drug companies to engage in off-label promotion under the guise of science.
  

Next week, expect a post on the ceaseless marketing of Effexor in which researchers (and "editorial assistants") used a combination of a very small advantage for Effexor over other drugs in combination with a "soft" endpoint to make the case that Effexor is so advantageous as to improve public health.

Mandatory Mental Health Screening for Massachusetts Medicaid Kids

As reported initially by the Boston Globe, then covered by the AHRP Blog and Furious Seasons, Massachusetts has implemented a mental health screening process for its children on Medicaid. It would make sense that if mental health is to be examined, one would look for symptoms of mental illness. To assist in the process, one of eight questionnaires is to be used by doctors to identify mental health issues. Here are some of the issues mentioned on one of the mental health screenings:

• Complains of aches and pains
• Is less interested in school
• Is absent from school
• Refuses to share
• Blames others for his or her troubles
• Teases others
• Does not understand other people's feelings
• Does not show feelings
• Gets hurt frequently
• Wants to be with you [the parent] more than before

There are a few others that seem iffy, but I think the above are the worst offenders. So what? Apparently, it may be a sign of some yet to be defined mental illness that a child would want to be with mommy more often, refuse to share toys with a sibling, and not show interest in school. 'Cuz kids should show little interest in their mothers, school is pretty exciting, and most kids love letting their brother share their coolest toy.

Yes, I understand that any of the above could possibly be linked to a mental health issue. If I counted right, there were 35 of these issues listed on the questionnaire. Who is going to spend time going over each of these 35 issues? Nobody. It would seem that if we are going to screen kids for mental health problems, we might want to stick with the more important issues rather than a kid who does not like to share toys.

It is certainly a good idea for doctors to pay attention to the mental health of their patients. However, I'm not sure that this sort of overly inclusive checklist of potential issues is going help much.

Mental Health Problems: An Epidemic? There is the black undercurrent of labeling developmentally relatively normal behavior as indicative of a mental disorder and sticking the kids on all sorts of psychotropic meds that (in many cases) have little data to support their use.

But there is more to it than drugs. It's our culture. We've come to accept that there is an epidemic of autism, depression, anxiety, ADHD, bipolar disorder, and who knows what's next in our kids. While the drug industry certainly played a role in these developments, it says something about our culture that we are readily willing to buy into the idea that mental illness has spread like a plague throughout American society. Have we bought into these disorders hook, line, and sinker because:

• It abdicates parents of any responsibility for their children's behavior
• It lets kids off the hook for their behavior (I couldn't help it -- I have ADHD)
• It adds yet more drama to the teen years (Gina is, like, so moody. I bet she is, like, bipolar)
• It seems so scientific. We uncover yet more diagnoses with each edition of the DSM and we then think that we have a better understanding of human behavior.
  

I'm not claiming that these are especially deep thoughts, but there is something about the interaction of science, marketing, and American culture that seems to have gone awry here.

Bipolar Explosion, Spot-On Parody, and Other Highlights

A number of great posts have emerged across the wonderful world of health blogs as of late.

In particular, check out the following on bipolar disorder, which must be spreading like wildfire these days:

• David Healy and Joanna LeNoury have a new paper on the influx of bipolar disorder cases. Consider it required reading. Key opinion leaders, Big Pharma, astroturf patient support groups, Brandon and the Bipolar Bear, and more. Read it now. Furious Seasons has some choice excerpts
  
• Furious Seasons has a whale of a post on living with "bipolar disorder." As a very bright and thoughtful man who has been diagnosed with bipolar for decades, and has lived through many an interesting experience, his discussion of bipolar is quite timely and fits nicely into the present mania of diagnosing bipolar every time somebody does not respond well to antidepressants.
• The name of the post says it all: Is early-onset bipolar disorder simply normal childhood? Read it at Psych Central. I can't resist taking one choice quote from the post (quote from psychologist John Rosemond):
  
• In their book and in the May 2007 issue of their newsletter, available through their website, the Papoloses recommend against using the word “no” with a bipolar child “because it will trigger a meltdown.” When they were toddlers, my children often suffered wild seizures at the sound of “no.”

On the topic of disease mongering, the best parody I've yet seen may have just been penned by the incredible Pharma Giles. The Pharma Giles take on the Montel Williams fiasco is also a great laugh.

The Scientific Misconduct blog has a post on the conflict between integrity and money, which somehow just keeps rearing its head on this site and others.

Mind Hacks notes an example of poor journalism regarding an alleged cure for Alzheimer's.

Peter Rost, ever the excellent self-promoter (meant as a compliment), has a website promoting his expertise as a pharmaceutical marketing consultant and expert witness. After tracking his work for a while, I am convinced -- I'd certainly hire him.

The Carlat Psychiatry Blog is just on-fire all around. No need to single out a particular post.

Pharmalot points out that Wyeth just got slapped by the FDA for a highly misleading ad about Effexor. Read the FDA letter -- this ad is well beyond a little bit misleading.

Zyprexa for Youth: What Marketing Plans?

As reported on Bloomberg, Pharmalot and Furious Seasons, an FDA official has overruled FDA reviewers to put Zyprexa on track for approval for treating adolescent schizophrenia and bipolar disorder.

Lilly claims it has no plans for a major marketing campaign. Yet given the glut of atypical antipsychotics, their frequent use among kids already, and the concerns associated with Zyprexa's side effects, Lilly will have to market aggressively in order to win scripts. Bloomberg also reported that Abilify and Seroquel may win FDA approval for the youth market before long and with Risperdal going generic soon, Lilly will either have to market their drug like hell (i.e., Operation Restore Confidence Part Two?) or accept a minor piece of the market. But perhaps they don't care - maybe the studies were just an attempt to generate good publicity and to extend the patent for six months, which was estimated to be worth a billion dollars in itself.

Child Bipolar: Youth Gone Wild?

This one has been covered by many other outlets (Furious Seasons, Washington Post, Psych Central, etc.) and I have admittedly little to add. A recent study in the Archives of General Psychiatry found that diagnosis of child bipolar disorder has increased 4000% No, that is no misprint. Here's a quote from the article:

While the diagnosis of bipolar disorder in adults increased nearly 2-fold during the 10-year study period, the diagnosis of bipolar disorder in youth increased approximately 40-fold during this period

This is the change from 1994 to 2003. A 40-fold increase in child bipolar diagnoses. I advise all readers to check out the limitations of the study pointed out at Psych Central. Even with some caveats, the results can be accurately described as stunning.

Well, Joe Beiderman (1, 2), are you happy about this development? Perhaps the child bipolar crew at Mass General can write another op-ed and defend how work by Biederman and friends has helped to push "awareness" (or is it misdiagnosis?) of child bipolar disorder.

In the meantime, is it the Youth Gone Wild or the Treatment of Youth Gone Wild?

Antipsychotics for Kids Update

I posted hastily earlier regarding a story in the Edmonton Journal on a survey of Canadian child psychiatrists. The article previously cited was based on a paper in the June issue of the Canadian Journal of Psychiatry. This survey investigated the frequency of prescription of newer antipsychotic medications for patients under 18 years of age.

As part of the survey, psychiatrists were asked for which disorders they prescribed atypical antipsychotic medications. Among those who prescribed atypicals (Risperdal, Zyprexa, Seroquel, etc.), here's the percentage who reported prescribing them for various conditions

• 81.8% bipolar (Go Team Biederman?)
• 30% depression
• 25.9% eating disorders
  
• 51.2% ADHD
• 74.7% poor frustration tolerance
• 35.9% insomnia
• 89.4% pervasive developmental disorder
• 51.2% oppositional defiant disorder
• 59.4% conduct disorder

The list goes on, but the above interested me the most. Apparently, the child bipolar paradigm is winning favor in Canada (as it obviously is here in the U.S.), and there are a variety of (how do I say this nicely?) not well-supported prescribing practices occurring. I'd add a rant, but the numbers speak for themselves. It's not clear precisely how often the medications are being prescribed, but it is clear they are fairly common. The survey further noted that 12% of these prescriptions were for children under age nine. Read the full-text of the study here.

Good News for Biederman?

To quote from a report in the Edmonton Journal [all emphases added]…

Ninety-four per cent of 176 child psychiatrists in Canada surveyed are prescribing powerful drugs known as atypical antipsychotics for a variety of disorders and symptoms, including anxiety, attention-deficit hyperactivity disorder and "poor frustration tolerance."

While most prescriptions were for children 13 and older, a "surprising" number were for the very young: 12 per cent of all prescriptions were for children aged eight or under, including three-year-olds.

None of the drugs has been officially approved for use in children. Risperidone (brand name Respirdal) was the most commonly prescribed atypical antipsychotic to children, followed by olanzapine (Zyprexa) and quetiapine (Seroquel).

Later, the reporter writes (providing no supportive evidence)

Atypical anti-psychotics are considered a significant improvement over older antipsychotics that were used in both adults and children.

Apparently the reporter never heard of CATIE, CuTLASS, or some of the other trials to recently compare newer and older antipsychotic meds. Oh, and if a kid has “poor frustration tolerance,” I suppose that means he/she is bipolar? Better ask Joe Biederman.

Hat Tip: Pharmalot

Child Bipolar Wars Continue

As reported on Furious Seasons, it looks like Joe Biederman is getting attacked by psychiatrist Lawrence Diller, who goes pretty far in his accusations. I’m glad someone in psychiatry is questioning the child bipolar frenzy, though I don't necessarily agree with Diller entirely.

On a somewhat different note, Daniel Carlat urges caution before jumping on the Biederman Bashing Free-For-All. If Carlat’s writing is always going to contain as much sarcasm as appears in his most recent Biederman post, I’ll be one happy guy. One snippet: “The study [in which Biederman played a key role] was not even funded by industry, which is impressive for a department in which psychiatrists can barely find the water fountain without industry support. [my emphasis]”

Let the games continue…

My Opinion Matters More Than Yours

Over at Furious Seasons, Philip Dawdy has a long and highly recommended post on the latest in the child bipolar wars. It is regarding the recent Boston Globe interview with Dr. Joe Biederman, who clearly believes that child bipolar is relatively common and undertreated. Background on child bipolar here and here. I'm in firm disagreement with Biederman, but am more than willing to change my position should the science start to improve.

What really concerned me was how Biederman discussed his critics in the Globe article:

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.

I really hope he was taken out of context and that he didn't get all braggy about his 30 papers per year and about the US News rating of his department. Just because you've published 30 papers per year does not mean you're right about child bipolar. Indeed, despite publishing a mountain of research, some questions still loom large...

1. Does child bipolar really exist in substantial quantity?
2. Does treatment help kids with this "disorder"?
3. Why would a leading "expert" in child "bipolar disorder" say that up to 75% of children who are "bipolar" become suicidal without citing any supporting evidence?

True, all opinions are not created equal in science -- but the idea that child bipolar is a hugely underdiagnosed and undermedicated condition is not backed by consistent data. It would seem that Biederman is confusing quantity (e.g., publishes a boatload of papers) with quality of evidence. Again, please see my above questions. If they can be answered sufficiently, then I'll be glad to jump on the child bipolar bandwagon.

Now, does this mean I'm "not on his level" because I have the audacity to ask questions and point out gaping holes in the so-called evidence base regarding this purported disorder? I suppose his opinion is more valid because he has published more articles than his critics? I'm really hoping that Biederman was quoted out of context, but if he was not, he looks pretty arrogant.