February 19, 2007

Pediatric Bipolar. Yeah. Okay.

Rebecca Riley is the 4 year old who died of psychiatric drug overdose-- she was on 3 of them-- supposedly with a diagnosis of bipolar disorder.  If you want the scoop from a psychiatric perspective, you should read this post from the resident blogger (no pun intended) at intueri.

But I'll add two things.  Let me be very clear: it is not unlikely a 4 year old has bipolar-- it is absolutely impossible.  This is because bipolar disorder is not a specific disease with specific pathology that one can have or not have; it is a description of symptoms that fall together.  We decide to call a group of behaviors bipolar disorder-- and meds can help them, for sure-- but this decision is completely dependent on the context of the symptoms.  Being four necessarily removes you from the appropriate context, in the same way as having bipolar symptoms during, say, a war, also excludes you from the context.  You might still have bipolar, but you can't use those symptoms during the battle as indicative of it.   If I transplant you to Brazil, and you can't read Portugese, does that make you an idiot? 

I don't mean that 4 year olds can't have psychiatric symptoms.  I'm saying  you must be more thorough, more attentive to the environment.  As soon as a person-- a kid-- is given a diagnosis, it automatically opens the flood gates for bad practice that is thought to be evidence based.  That's what makes the diagnosis so dangerous.  Instead of, "should I use Depakote in this kid?" it becomes "It's bipolar, so therefore I can use Depakote."

Secondly, we must all stop saying these drugs are not indicated for kids.  That's meaningless.  We can debate whether they should be used or not in kids, but you can't say they shouldn't be used because they're not indicated.  To quote myself (lo, the narcissism):

Thus, categorizing a medication based on an arbitrary selection of invented indications to pursue—and then restricting its use elsewhere—may not only be bad practice, it may be outright immoral.

I do not make the accusation lightly.  Consider the problem of antipsychotics for children.  It is an indisputable fact that some kids respond to antipsychotics.  They are not indicated in kids.  But don’t think for a minute there will be any new antipsychotics indicated for kids.  Who, exactly, will pursue the two  double blind, placebo controlled studies necessary to get the indication? No drug company would ever assume the massive risk of such a study-- let alone two-- in kids. 

And which parents will permit their child in an experimental protocol of a “toxic” antipsychotic?  Rich parents?  No way. The burden of testing will be undoubtedly born by the poor—and thus will come the social and racial implications of testing on poor minorities. Pharma is loathed by the public and doctors alike, and the market  for the drugs in kids is (let’s face it) is effectively already penetrated.   There will not be any new pediatric indications for psych meds.  Not in this climate.  Think this hurts Pharma?  It's the kids that suffer.

It's funny how psychiatry always tries to appeal to a higher authority (FDA, "studies", clinical guidelines, thought leaders, etc) except when it gets in trouble.  And then it's always the same refrain: "no one can tell me how to practice medicine." 


I have been ranting about t... (Below threshold)

February 19, 2007 5:26 PM | Posted by Cheryl Fuller, Ph.D.: | Reply

I have been ranting about this issue for years. Thank you!!!

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Your points are well taken.... (Below threshold)

February 19, 2007 11:11 PM | Posted by Maria: | Reply

Your points are well taken. And thank you kindly for the link; I appreciate it. :)

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but if the child has bipola... (Below threshold)

February 20, 2007 6:26 PM | Posted by Tron: | Reply

but if the child has bipolar, why wouldn't bipolar medications such as Risperidal be ok? How can you say a child is too young to have bipolar?

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Tron:it doesn't ma... (Below threshold)

February 21, 2007 9:17 AM | Posted by Duh: | Reply


it doesn't matter if a child is bipolar or not. There is NO safe, appropriate medicine for this age bracket. Period.

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We talked about this on our... (Below threshold)

February 21, 2007 5:37 PM | Posted by dinah: | Reply

We talked about this on our podcast #11. I linked to your post on the comment section of our blog.

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I have some thoughts: ... (Below threshold)

February 24, 2007 12:11 PM | Posted by Steve: | Reply

I have some thoughts:

1. Why does being 4 remove one from the context? And what context is that exactly?

2. The symptoms of bipolar disorder are not arbitrarily grouped together, right? There's reasons for the grouping.

3. Toxic drugs? Oh please, lipitor can be toxic if given at the right dose. So, what is YOUR evidence that psychotropics at normal doses are toxic? And please don't say that lithium can be toxic. Sure, it can just like all other drugs, but if a lithium level reaches toxic levels, then one hopes that the doctors lowers the dose. And what do you say to the evidence posted here: http://ssrn.com/abstract=949229 that antipsychotic drugs may stop the toxic effect of psychosis?

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That is just crazy! Doctors... (Below threshold)

February 26, 2007 10:17 AM | Posted by gregf: | Reply

That is just crazy! Doctors are trying to say mental health problems way to early now day. Let the child grow up some before they start doing that shit!

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My 19 year old daughter, wh... (Below threshold)

February 26, 2007 10:12 PM | Posted by ckennedy: | Reply

My 19 year old daughter, who fits the definition of bipolar disorder after having had many depressive episodes, frequent rapid cycling, and several manic episodes, one lasting five days, began exhibiting symptoms when she was 2 1/2 years old. I promise you we were not looking for such a diagnosis and explored all alternatives until a severe episode when she was 11. I don't know anything about the tragic case in your post but you should have some idea that psychiatric disorders do appear earlier than previously thought and are just different, symptom- and behavior-wise, in very young children.

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You are a trolling blogger.... (Below threshold)

February 28, 2007 8:35 AM | Posted by flavoriffle: | Reply

You are a trolling blogger. Embellishing and ranting in a masturbatory fashion. Setting up straw men and then pretending to decide a meaningless argument. If you are the last psychiatrist, shoot yourself, and let the species become extinct with a shred of dignity. Indeed you have none.

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To address Dinah's points:<... (Below threshold)

February 28, 2007 5:43 PM | Posted by Admin: | Reply

To address Dinah's points:

The entire problem of pediatric bipolar-- maybe even psychiatry in general-- is that psychiatrists are allowed to say this:

"Oh, I FIGURED OUT he's an undiagnosed bipolar, and THEREFORE I can give him Lamictal."

An arbitrary diagnostic label allows a treatment algorithm to kick in, in the absence of any rigor to the diagnosis or treatment.

Your point #2: The symptoms _are_ arbitrarily-- not randomly-- grouped together. We decide we are going to call the following collection of symptoms bipolar. Fine. So if I see the _same_ collection in someone else, I can apply that same label.

But what do you do if a person has only some of these behaviors/symptoms? Is it still bipolar?

The only way that answer could be "yes" is if there was something else to the diagnosis of "bipolar" that would allow us to know it was bipolar, even in the absence of the symptoms.

For example, cancer is cancer even if there is no weight loss, no nausea, no lethargy, etc. But if the person never gets manic, for example, how can it be bipolar?

So it's not that the kid isn't bipolar, or at least on his way to becoming bipolar in adulthood-- it's that the diagnosis frees the doctor from having to do any serious social work.

I know everyone (doctors) are going to disagree with me-- they're going to say that doctors don't automatically prescribe based on the diagnosis.

Toxic drugs: I simply meant they had heavy side effects. It's all risk/reward. Can anyone tell me how giving Depakote/Risperdal/Concerta to a 4 year old, WITHOUT HAVING FIRST DONE THE "SOCIAL WORK" is rigorous?

Yes, antipsychotics (and lithium) probably are neuroprotective, for two reasons.

gregf: I think I addressed your comment in this comment. Of course kids can manifest psychiatric symptoms early. What I am on about is how psychiatrists (and parents, too) sometimes (often?) use the diagnosis as a way of getting out of the harder work.

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I am an elementary school t... (Below threshold)

March 4, 2007 3:28 PM | Posted by Psyfie: | Reply

I am an elementary school teacher in Texas. This year, four children in my school entered PRE-KINDERGARTEN diagnosed with Bipolar Disorder. Each has prescriptions for Depakote, Risperdal, and two are taking additional medication for ADHD. This is very scary stuff.

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I completely agree with the... (Below threshold)

April 10, 2007 1:09 AM | Posted by Common Reader: | Reply

I completely agree with the good doctor.

The question people need to be asking is how we have a system where a family that clearly needs services and oversight can take its most vulnerable member into a psychiatrist's office and all that happens is they walk out with a prescription for that member.

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I am a child psychiatrist i... (Below threshold)

May 31, 2007 5:06 PM | Posted by james freeman: | Reply

I am a child psychiatrist in georgia. In my opinion, many psychiatrists who work with children are not that bright and are quite lazy, with their primary interest being in money rather than their patients. It takes time to look at the entire child and her/his environs, background and the other complexities that lend themselves to a child's disordered behavior, mood, and thinking. It is quick and easy to see all irritable youths as bipolar and throw medications at them. One can make a good living doing this. Then again, so can any whore. Which is, I fear, what many of my fellow psychiatrists have become. Oh well. This too will pass.

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Thanks for the nice article... (Below threshold)

October 7, 2007 5:04 PM | Posted by patrick: | Reply

Thanks for the nice article. Really interesting. I found similiar content on this website Bipolar Disorder. Keep the good job!

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