May 3, 2006

Are Antipsychotics Overprescribed In Kids?

According to USA Today, 2.5 million antipsychotic prescriptions a year are written for kids under 18.  The rate for privately insured kids is 6.5 in 1000-- it has to be easily ten times that for Medicaid kids.

The FDA database has 45 deaths; 6 from diabetes, the rest from CV disease, liver failure, suicide, etc. There were 41 pediatric NMS cases.

According to the article, 13% of antipsychotic prescriptions are for bipolar disorder.

So are antipsychotics being overprescribed?  The answer is yes, but not for the reasons cited in the article.

The article, indeed, all articles about pediatric psychiatry, make a special point about how these medicines are not FDA approved for kids.  This is absolutely meaningless.  FDA approval requires two double blind, placebo controlled studies.  These studies are universally taken on by the drug companies.  No drug company would ever assume the massive risk of such a study-- let a lone two-- in kids. How do you recruit the study subjects?  What parent is going to allow it?  Rich parents?  No chance.  So it will have to be Medicaid parents-- and thus will come the Tuskegee-like charges, dripping with the obvious social and racial implications of pharma testing on poor minorities. Pharma is already loathed; they're not going to take any risks for the sake of a medal from the FDA.  So there will not be any new pediatric indications for psych meds.  Not in this climate.  Think this hurts Pharma?  It's your kids that suffer.

But don't be confused by crypto-socialist hysterics who say that Pharma will do anything for a profit, including peddle drugs to kids.  Drug companies do not market these antipsychotics  for kids.  They are paranoid to a fault about doing this; they know everyone is scrutinizing them, especially lawyers.  If you are a child psychiatrist who sees no adults, reps cannot even call on you.  And if they call on you for other things, they cannot mention the use in kids.  In the past five years, it has never-- never-- happened that a rep detailed me about their use in kids.

The only two reasons these drugs are used in kids is because psychiatrists give them, and parents demand them.

First, the parents. They don't come looking for antipsychotics, specifically.  But my experience is that they are unrealistic about what is going on with their kids; in near denial about the family dynamics impacting on the kid's behavior; and virtually devoid of insight into relatively obvious, though procedurally difficult, maneuvers that could improve the situation. If your kid doesn't sleep enough, and consistently-- if your five year old doesn't nap-- you cannot tell me your kid has ADHD.  Period. Parents demand a diagnosis of bipolar disorder for their kids because it means the divorce had nothing to do with it.  They demand another medication when the first one fails to get the kid to do math homework instead of playing Xbox all day. And their kids' marijuana and alcohol abuse can't possibly have anything to do with their own marijuana and alcohol abuse.   Parents: don't flame me.  Your situation is different, I know.  I know. 

Second, psychiatrists prescribe them because of the pressure to do something, in the face of consistent failure.  They don't start with antispychotics-- they end up with them.  They prescribe them out of desperation.  This is why, in every story about a child getting sick from one of these medicines, they are, in fact, on several medicines.  First they start with Ritalin.  If Ritalin doesn't help, or there is a side effect, or they can't sleep-- then a second drug is added.  Maybe this helps, but after a while something else happens-- and another drug is added to this.  That's why psychiatry's current obssession with the detection of underdiagnosed "bipolar disorder" is so important.  This diagnosis justifies, and encourages, polypharmacy.

It is psychiatry's  ridiculously dangerous, and ultimately doomed, paradigm: if you are not doing well on a medication, you must be so sick that you require two medications.  It seems to have occurred to no one in psychiatry that failure on a medication could mean that it was the wrong medication. 

The reason this polypharmacy madness is even possible is psychiatry's obsession with diagnosis, labels-- with semiotics.

What makes a drug an antipsychotic?  Well, it treats psychosis.  Fine-- but does that exclude its efficacy for something else?  If it is later found to be efficacious in, say, depression, then what do you call it?  Is the drug an antipsychotic that's also good for depression, or an antidepressant that's also good for psychosis?

There's no value in the label "antipsychotic" or "antidepressant" except what we give it.  It's a drug that treats psychosis and depression, not an antipsychotic that treats depression (or the other way around).  If you can't see the difference, stop reading now and go back to watching American Idol.  

For example, why are antipsychotics viewed as "off label" for kids?  The word "antipsychotic" is meaningless. Antipsychotics are tested against a scale, like the Brief Psychatric Rating Scale.  But these scales measure a lot of things, like depression, and not just psychosis.

And at what point did we start making a distinction between psychosis and "dementia related psychosis?"  Or bipolar depression and regular depression?  Why do we need separate FDA approvals?  Does someone know something about the physiology of these disorders that I don't? Do we need to start approvals for "diabetes related depression?"

Saying an antipsychotic is worse than an antidepressant for depression is a valueless statement, especially in the absence of data on this question.  You are actually better off asking, "which is better for depression, blocking the serotonin transporter or blocking 5HT2a receptors?"  See?  Put this way the distinction seems less obvious.  And even that question is valueless, as there is nothing (that we know of at this time) that allows us to say what effect either pharmacologic maneuver actually has.  5HT2A blockade does what again?  Really?  Do you have any evidence for that at all?  And no more post hoc ergo propter hoc nonsense.  David Hume laughs at you.

A Simpson's reference is helpful here:

Homer: Not a bear in sight.  The Bear Patrol must be working like a
Lisa: That's spacious reasoning, Dad.
Homer: Thank you, dear.
Lisa: By your logic I could claim that this rock keeps tigers away.
Homer: Oh, how does it work?
Lisa: It doesn't work.
Homer: Uh-huh.
Lisa: It's just a stupid rock.
Homer: Uh-huh.
Lisa: But I don't see any tigers around, do you?
        [Homer thinks of this, then pulls out some money]
Homer: Lisa, I want to buy your rock.

I know.  The FDA, the Scientologists, socialists, the parents at the end of their ropes- the easy thing to do is blame Pharma.  I'm in the strange position of having to be a Pharma apologist, to be the only doctor willing to defend Pharma.  There are plenty things I don't like about the way Pharma conducts business, but I can't voice these complaints because I have to use the time countering these inane attacks.   I know what will happen if the Pharma critics get their way.

You think Pharma should have no sales contact with physicians?  Fine.  Now deal with the consequences.

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