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By Zarathustra of the Mental Nurse blog
Recently I heard something via a friend that alarmed me. An American schoolteacher commented on a 5 year old child in his class who was nodding off into his schoolwork due to being prescribed a combination of quetiapine and risperidone - two atypical antipsychotics. This was because a child psychiatrist had diagnosed him with "pediatric bipolar disorder", or PBD.
The idea of of young children having bipolar disorder runs against the traditional view that bipolar disorder emerges in somebody's teens at the very earliest. PBD isn't a recognised category in either the DSM-IV or the ICD-10, the two main classification systems for psychiatric diagnoses. Despite this, recent years have seen rapid growth in the number of children being diagnosed with PBD in the United States. Glossy websites claim that many of the children currently being diagnosed with conditons such as ADHD actually have bipolar.
Among my colleagues in Child and Adolescent Mental Health Services (CAMHS), professionals are taking sides. You know those arguments people have about ADHD? The ones where one side says, "You're drugging up our kids, you sickos!" and the other side exclaims, "These children need help, and we're giving to them!" Well, the pediatric bipolar debate is roughly similar, except with more shouting and the occasional item of hurled furniture. Some of my colleagues reckon it's the new big thing.
Others insist it's a load of cobblers dreamed up by a vocal clique of American shrinks sucking at the teat of Big Pharma. So far, the "load of cobblers" contingent appear to be be gaining ground.
British child psychiatrists tend to have a different outlook to their American counterparts, making more use of psychosocial interventions (counselling, CBT, parent training, family therapy etc) and less use of medication. Antipsychotics are used comparatively rarely, and the use of more than one antipsychotic in a single child is rarer still. For a five year old who is functioning enough to be in a mainstream classroom (as in the ancedote above) to be prescribed multiple antipsychotics is almost unheard of in Britain.
Diagnoses of PBD are also extremely rare over here. Among the kids being seen by CAMHS in my area, I can't think of a single one who was diagnosed with bipolar any younger than 13. We do, however, have a girl on our caseload who was diagnosed with ADHD in Britain and prescribed methylphenidate. The parents then took her to America where she was promptly diagnosed with PBD and prescribed mood stabilisers and antipsychotics. On their return to Britain, she was re-assessed by CAMHS, found not to have signs or symptoms of bipolar, and switched back to methylphenidate.
It's not just Britain where PBD is virtually undiagnosed. PBD diagnoses are almost exclusively an American phenomenon. Almost all of the research comes out of America too. There isn't a single published study of the prevalence of PBD in Britian. That said, I'm aware of a so far unpublished study in which 200 British children with ADHD were assessed for signs and symptoms of bipolar disorder. Of the 200, only one was felt to show evidence of PBD.
Even in America, concerns are being raised about the extent of the diagnoses. The draft of the fifth edition of the DSM contains a proposed diagnostic category of "Temper Dysregulation Disorder with Dysphoria". According to the LA Times, this has been introduced in order to reduce the number of children being diagnosed with PBD, which the authors insist is given too frequently to children who turn out not to have bipolar disorder when they grow into adulthood. It's good that they've recognised these concerns, but it seems odd that they seem to need to slap a medical label onto excessive temper tantrums in order to do so.
So, what's the truth of it? Given the recent explosion in PBD diagnoses in the States, it'll probably be a few years before we have large scale studies tracking how many of them actually develop bipolar disorder as adults. Personally, I'm strongly skeptical that PBD is anything other than a very rare illness, and I suspect that in many cases it will turn out to be a misdiagnosis of other problems. Either way, I'm of the view that we shouldn't be prescribing powerful (and dangerous) antipsychotics to small children without a clear rationale and an evidence base. Right now we don't have either.
Zarathustra
3 CommentsA guest post by Zarathustra of the Mental Nurse blog.
Before I became a mental health nurse, I spent a few years as an over-educated, unemployable humanities graduate - hey, I'm not knocking that; being an over-educated, unemployable humanities graduate can be a lot of fun.
I also had quite firm views on psychiatry. I was a huge fan of RD Laing, the radical 60s psychiatrist. I'd tell anyone who would listen that psychiatric diagnoses are a subjective construct, that drugs aren't the answer, and that the medical model of mental illness is irredeemably reductionist (yes, I was the kind of humanities graduate for whom "reductionist" is the ultimate word of abuse).
Comparing these views with what I think now, I get the impression my younger self would be rather disappointed in me. Admittedly I haven't changed my views entirely. I still think there are problems with some forms of psychiatric diagnoses, and these problems are inevitable due to their subjective nature. I still regard the psychosocial aspects of mental health as absolutely vital, and I still regard the drug reps as servants of Beelzebub.
Even so, I also now think the medical model has its merits as well as its flaws. Diagnostic categories do seem to have some usefulness and validity, and psychiatric medication can at times work wonders. The twentysomething, BA-educated version of me would shake his head in sorrow.
So, what's changed my mind on the medical model? Well, the most obvious answer would be that I went into the belly of the beast and trained as a mental health nurse. Certainly cold, hard clinical experience has had a lot to do with it. I can't swan around saying that the drugs don't work, because all too frequently they do work. Admittedly the meds work haphazardly, and sadly all too often with unpleasant side effects, but the bottom line is I've seen too many people benefit from medication to be able to dismiss those benefits.
Crucially though, the people who've most effectively challenged my previous hostility to the medical model have been patients rather than doctors.
I have a friend with bipolar disorder who's also a very intelligent, independent-minded lady. Not the sort to be brainwashed by an evil cabal of shrinks and Big Pharma. She's tried yoga, mindfulness, CBT, person-centred counselling...all of which have had some benefit, but she's also learned to her cost that, unless she takes the meds, all those benefits are immediately cancelled out. Her response to anti-psychiatry is to angrily insist, "Look, I don't have a problem in living, or a social construct, or an existential crisis. I have an illness which is called bipolar disorder, for which I take medication."
"Your diagnosis is this, and we're going to treat it like this" is an explanation that works for a lot of a people. Those people shouldn't be hectored on how they're dupes of the medico-pharmaceutical complex simply for finding the medical model helpful.
While much has been written on how psychiatric diagnosis can label and stigmatise people, you can also demean, belittle and patronise people by telling them they don't have an illness, and that it's all just a social construct/problem in living/spiritual crisis.
Of the anti-psychiatric authors, Thomas Szasz in particular writes with an unpleasant moralistic tone that reeks of, "You could just snap out of it and pull yourself together if you really wanted to."
Ultimately though, any argument about, say, "medical model" versus "psychosocial model" shouldn't be an either/or issue. It's perfectly possible to make use of diagnosis and medication while also taking into account psychological and social issues. And yes, while also being aware of the political and philosophical controversies that psychiatry generates.
Any model of psychiatry, be it medical, psychosocial, existential, social contructivist etc, describes an aspect of the truth from one particular angle. We need to be able to move between the models as and when they become useful, rather than loudly privilege one model while denouncing the others.
Speaking of models, a consultant psychiatrist I know has a fondness for saying that we follow an "ecobiopsychosocial model". I'm gagging for him to say it to me so I can quip back, "That's easy for you to say."
Zarathustra
45 CommentsMaking the news in the USA is research that indicates that mild and moderate depression are not lifted by antidepressants, which are only useful for severe depression (though the research methodology has come in for some critcism).
The research concludes that if a person experiences mild or moderate depression then medication should be just one of the options available.
This side of the pond, National Institute for Health and Clinical Excellence (NICE) guidelines already states that antidepressants should not be the first choice in treating mild depression but may be of use for people with a past history of moderate or severe depression.
Of course guidance and practice aren’t always in step and it was reported last year that prescriptions for antidepressants are on the rise and recently that GPs prescribe antidepressants even if they feel another treatment might be more beneficial as that treatment is not as readily accessible.
The government had pledged £173 million towards mental health care. The Improving Access to Psychological Therapies (IAPT) scheme is designed to combat the reliance on prescribing medication for mental distress by offering accessible alternatives. There is some uncertainty over how the scheme is faring, with reports late last year that it has experienced difficulties, including only 400 of the required 3,600 therapists trained, although IAPT disputes this figure and other aspects of the article.
With any luck headlines about the best treatment options for depression and will strengthen the government’s resolve to keep supporting a wide range of treatment options for the millions who experience depression and other mental health problems.
Bridget O'Connell, Head of Information
As I gathered information for my new book, Psychiatric Drugs: Key Issues and Service User Perspectives, I became aware of how research trials of psychiatric drugs don't reveal the whole story.
Research intended to establish whether drugs are effective compares them with placebo (dummy pills). If their effect on relieving symptoms is greater than that of placebo and they are not considered to be too harmful, then they are passed as suitable for treatment for people with the diagnosis they have been tested for.
What this process misses out is the wide variety of responses people have to psychiatric drugs, and this is what emerges so clearly from surveys such a All you need to know?, a survey by the Scottish Association for Mental Health (you can download this as a PDF).
One example from this survey was the range of responses to the drug Risperidone, prescribed to people with diagnoses such as schizophrenia. Nearly a third, 30 per cent, said they found it "very helpful" but nearly as many, 28 per cent, reported that it was "very unhelpful". Comments ranged from "I don't know what I would do without my paroxetine [an antidepressant] and risperidone" to "being forced to take risperidone had an entirely negative effect on me and made me more ill than I have ever been in my life."
I found a similar range of experience when people talked about coming off psychiatric drugs. For example, some people coming off the antidepressant venlafaxine (Efexor) experience a particularly nasty sensation which is sometimes called brain shivers. But the Mind survey, Coping with Coming Off, revealed that of thirteen people trying to come off venlafaxine only two experienced this particular effect and five found coming off the drug fairly easy.
Taking and coming off psychiatric drugs is an unpredictable business. Assumptions based on generalised data cannot be relied upon. I suggest that prescriber and patient adopt an approach of cautious experimentation. Feedback and discussion are necessary to establish if the person taking the drug is benefitting sufficiently to justify the inevitable risks. Coming off psychiatric drugs should be approached in the same spirit.
I have some hope that we are moving in this direction. Guidance from NICE, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, effectively condemns the term 'compliance' and the one-sided practice that goes with it to the history books. The recovery approach places an emphasis on what works for the person rather than treating their diagnosis.
I hope this book can play some part in bringing the experiences and views of "experts by experience" - people who have taken psychiatric drugs - into debates about their effectiveness and good practice in prescribing them.
Jim Read is author of Psychiatric Drugs: Key Issues and Service User Perspectives and Mind's report, Coping with Coming Off.
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