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Psychiatric labels

MagazineAugust 2005 (Vol. 16 Issue 5)Psychiatric labels

The growing 'grey' population may be raking in the cash for drug companies, but look at the other end of the age spectrum and you'll also see burgeoning trade

The growing 'grey' population may be raking in the cash for drug companies, but look at the other end of the age spectrum and you'll also see burgeoning trade. The number of children diagnosed with mental disorders, including attention-deficit/hyperactivity disorder (ADHD), depression and bipolar disorder, has skyrocketed over the last few years, bolstering sales of psychotropic medications such as stimulants, antidepressants, tranquillisers and antianxiety drugs.

But is this truly an epidemic of insidious 'brain disease' sweeping across the paediatric population, leading them to act in ways that are considered 'challenging' or 'abnormal'?

The answer, as WDDTY has found out, is no. The real problem lies with the increasingly ubiquitous practice of assigning psychiatric labels, based on loose diagnostic criteria, to children - some barely out of their diapers - who show any signs of emotional upset, misbehaviour or learning difficulties.

Unreliable science
While physical disorders such as cancer or diabetes have tests that show concrete results to confirm the diagnosis, 'mental' disorders are still diagnosed largely by subjective opinion - usually that of the physician making the analysis. The popular claim that mental disorders are caused by biochemical imbalances in the brain has, so far, not been substantiated by objective scientific evidence. Asking your doctor for a test to reveal the biochemical abnormality behind your child's ADHD or manic-depressive symptoms will draw a blank stare - there are no such tests.

Yet, psychiatric disorders continue to be diagnosed as if they have a physical cause, and are classified according to standardised criteria. However, these medical models of 'abnormality' are little more than simple checklists of behavioural quirks and anomalies - and notoriously un-reliable. The subjectivity of a doctor's interpretation of the symptoms means that two psychiatrists can easily diagnose the same patient with two different disorders.

A landmark study in the early '70s by young psychology graduate David Rosenhan underscored the fallibility of the psychiatric diagnostic classification system (Science, 1973; 179: 250-8). In this experiment, eight sane people - including Rosenhan himself - attended various hospitals, complaining that they were hearing voices that repeatedly said words like 'empty', 'hollow' or 'thud'. No other aspects of their behaviour, personal history or circumstances (except their names) were changed. According to the then latest edition of the US Diagnostic and Statistical Manual of Mental Disorders (DSM-II), seven of the eight pseudopatients were diagnosed with schizophrenia and admitted to a mental institution. During their stay, they reverted back to normal behaviour, but their sanity was never once detected by staff. Even worse, the psychiatric label mistakenly slapped on them continued to stick even after their release, with all but one pseudopatient given a new diagnosis of 'schizophrenia in remission'.

Rosenhan's study shook the psychiatric profession. In response, a task force of clinicians and researchers was set up to expunge all signs of ambiguity, psychobabble and subjectivity, and to tighten diagnostic criteria by setting up strict guidelines for the duration and frequency of symptoms.

Damning definitions
However, instead of bringing more scientific credibility to psychiatry, the resulting tome - which has gone on to become the best-selling psychiatric bible and currently in its fifth major edition - seems to have done even more harm, with its ever-expanding definitions of mental disorders. The net has now been cast so wide that it's little wonder so many children are being given such diagnoses.

Take the evolution of ADHD, for example. This was introduced in the second edition of the DSM in 1968 under the guise of 'hyperkinetic reaction of childhood', and characterised by a short attention span, hyperactivity and restlessness.

In the following update (DSM-III) 12 years later, this childhood disorder was known as 'attention-deficit disorder' (ADD). Its symptoms were expanded into ADD with hyperactivity/impulse problems ('hyperactive ADD') and ADD without hyperactivity ('inattentive ADD').

When DSM-IV came out in 1994, ADD had taken on its current name of ADHD, and the disorder had proliferated into three further subtypes: ADHD, primarily inattentive; ADHD, primarily hyperactive/impulsive; and ADHD, combined type.

By the time DSM-IV had appeared in its most recent form (DSM-IV-TR), the list of symptoms for ADHD had stretched to such an extent that even typical childish behaviour such as fidgeting, answering a question before it's finished or disliking homework could be seen as having a pathological origin. The list of symptoms below is but a mere fraction of the DSM-IV entry on ADHD, and a minimum of only six items in either category (inattention or hyperactivity/impulsivity) is needed to 'fast-track' your child to an ADHD diagnosis.

* Inattention
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as homework)
Is often easily distracted by extraneous stimuli
Often has difficulty organising tasks and activities
Is often forgetful in daily activities.

* Hyperactivity/impulsivity
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Is often 'on the go' or often acts as if 'driven by motor'
Often talks excessively
Often has difficulty playing or engaging in leisure activities quietly
Often blurts out answers before questions have been completed
Often interrupts or intrudes on others (e.g. butts into conversation or games) (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [Text Revision], 4th edn, June 2000).

Indeed, it appears that the original task force's mission has not been achieved. Instead of tightening up the diagnostic criteria of mental disorders, as they had originally set out to do, the definition of ADHD, for one, has become looser and looser. Not surprisingly, the number of children diagnosed with ADHD in the US has spiked with each new revision to the Manual - escalating from a half-million cases in 1987 (when DSM-IIIR came out) to more than four million 10 years later (three years after DSM-IV was published), then jumping to six million in 2001 (a year after the arrival of the newest text revision, DSM-IV-TR).

While ADHD has received the most media attention, another disorder has also seen a surge in diagnoses among children: bipolar disorder. A serious mood disorder affecting more than two million Americans, it is characterised by cycles of depression and mania (abnormally elated thoughts such as euphoria and a loss of inhibitions). Usually diagnosed in adolescence or early adulthood, if left untreated, it can lead to a high risk of suicide.

Diagnoses of paediatric bipolar disorder were rare up until the last 10 years. Then, in 1999, the controversial book The Bipolar Child, by New York psychiatrist Demitri Papolos, was published. According to The Washington Post, one of the book's most contentious features is a list of over three-dozen symptoms commonly seen in bipolar children. These include silliness, separation anxiety, night terrors, carbohydrate cravings, fidgeting, extreme bossiness, bedwetting, lying, social anxiety and difficulty getting up in the morning ('Going to Extremes', The Washington Post, 15 February 2005). Supporters of the book believe it has helped parents to identify their child's behavioural symptoms as those of a recognised mental disorder and, hence, helps them make sense of the situation. Once an appropriate medical label has been tagged onto the child, there is then the hope of treatment.

Bipolar explosion
The appeal of psychiatric labelling is understandable. Parents do not wish to see their children suffer, so even if the treatment offered is not one they would like to hear, they hang on to it in the desperate belief that these powerful drugs can help their child recover from their illness - just like an aspirin can take away a headache.

Because of the potentially greater risk of suicide if bipolar disorder is left undiagnosed and untreated, there is increasing pressure towards early detection of the disorder so as to 'nip it in the bud' through timely intervention. In addition, some studies into childhood bipolar disorder have also suggested a possible genetic component (Bipolar Disord, 2004: 6: 305-13; Am J Med Genet C Semin Med Genet, 2003; 123: 26-35). Combine these two fear factors and you then get a case, as revealed in The Washington Post (see above), where an 18-month-old baby can be diagnosed with bipolar disorder and treated with lithium because she screamed continually and has a bipolar mother.

The management of bipolar disorder is yet another troubling issue. Children diagnosed with bipolar disorder often take several classes of drugs all at the same time to control mood shifts and alleviate depression. One anxious parent, rightly voicing her worries on a health Q&A website (pediatrics.about.com/ od/weeklyquestion/a/04_bipolar_kids_p.htm) concerning the armoury of drugs prescribed to her five-year-old 'bipolar with ADHD' son, described his daily medication regime as:
* Antipsychotics: Risperdal 0.5 mg once a day, and Seroquel twice a day - 25 mg at midday, and 100 mg (at night)
* Mood stabilisers: Depakote 125 mg three times a day
* Stimulants: Ritalin 5 mg (at 6.00 am) and Concerta 36 mg (at 8.00 am)
* Other drugs: Strattera 25 mg, a non-stimulant for ADHD, and asthmatic medications (Singulair and albuterol).

Such a menu of drugs would be alarming for anyone, but of greater concern is the fact that this is just one of the many cases where pharmaceutical cocktails are unreservedly being fed into a young developing body.

More harm than good
If these children really do have a mental illness and these drugs can effectively ease the psychological suffering and improve their quality of life, then there may well be an argument for their use. However, this is not the case.

Several studies have shown that treating depression in youths with antidepressants is only modestly effective, and many will still experience symptoms (Arch Gen Psychiatry, 1997; 54: 1031-7; J Psychosoc Nurs Ment Health Serv, 1998; 36: 12-9). Then, there are the much-publicised selective serotonin reuptake inhibitors (SSRIs), which have been linked to an increased risk of suicidal behaviour among users.

Mounting evidence of the adverse effects of ADHD drugs has also been increasingly highlighted in the media. In addition to Ritalin's reputation for suppressing growth and inducing muscle tics, the newer selective norepinephrine reuptake inhibitor Strattera (atomoxetine) has been linked to decreased appetite, drowsiness and fatigue in children (Pediatrics, 2004; 114: e1-8). Older patients taking the drug have reported side-effects such as dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating, burning sensations during urination, sexual problems and heart palpitations (Drugs, 2004; 64: 205-22).

Children diagnosed with bipolar disorder also have to contend with a cornucopia of side-effects.

Antipsychotic drugs such as risperidone (Risperdal), prescribed for schizophrenia and mania associated with bipolar disorder, are frequently associated with significant weight gain (and the adverse consequences of that), drowsiness, drooling and hyperprolactinaemia (excess production of the hormone prolactin), which can cause ovulation and menstrual disorders in girls, and sexual dysfunction in boys (J Child Adolesc Psychopharmacol, 2004; 14: 372-94; J Child Adolesc Psychopharmacol, 2002; 12: 337-45; J Child Adolesc Psychopharmacol, 2001; 11: 435-40).

The mood stabiliser Depakote (divalproex), supposedly designed to keep those mood swings in check, has been linked to a number of life-threatening cases of pancreatitis (inflammation of the pancreas, with severe pain and debilitating illness) in both children and adults (www.fda.gov/medwatch/safety/2000/depako.htm).

While it cannot be denied that mental illness does afflict children, and that its significant impact on both the children and those around them cannot be dismissed, the soaring figures need to addressed. Too many children are falling victim to a labelling system that is increasingly based on what has been termed 'shoddy science', and harmful drugs, with their lure of a quick-fix solution, have become the first port of call.

Unless this situation is taken in hand, this sweeping epidemic of medicalising behavioural problems of otherwise healthy children will only serve to fatten Big Pharma's wallet.


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