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."