Between 1996-2001, you explain, there was a fivefold increase in the use of antipsychotics (Zyprexa, Risperdal, Abilify, Seroquel, and others) in preschoolers and preteens. What role did DSM-IV play in that, with its introduction of the still-controversial category Bipolar II disorder?
The concept of juvenile bipolar disorder flies even more in the face of traditional wisdom in psychiatry than does calling Donna bipolar. As of 2008, upwards of a million children in the United States—in many cases preschoolers—are on "mood-stabilizers" for bipolar disorder, even though the condition remains unrecognized in the rest of the world.
I am not sure how much DSM-IV played a role in this switch. I think the companies would have found a way to engineer the switch even without the introduction of Bipolar II disorder in DSM-IV.
So then how much of that shift is attributable to SSRI antidepressants coming off patent while the antipsychotics were still major revenue earners?
I think this was in fact central to what happened. The antidepressants were due to come off patent whereas the anticonvulsants were older drugs that could be repatented for this purpose, and the antipsychotics—which also could be (and were) marketed as mood stabilizers—were early in their patent life.
A related point that’s worth bringing out is that the switch happened because companies weren't able to make new and more effective antidepressants. Had they been able to do so, I think they would have probably stuck with the depression model rather than made the switch to bipolar disorder.
In terms of what is happening in the US, I think we have to look at how skillfully the drug companies have exploited doctors. Doctors have wanted to help. While the drugs are available on prescription only, doctors tend to see giving a medicine as the way to go, where previously they had been much more skeptical about the benefits of drug treatments.
The drug companies have engineered a situation in which academics have become the primary spokespeople for the drugs. We see the sales rep in the corner and think we can easily resist his or her charms—but we still let them pick up the drinks tab. But it's the academics who sell the drugs. Doctors who think they are uninfluenced by company marketing listen to the voices of academic psychiatrists when these, in the case of the antidepressants or antipsychotics given to children, have talked about the data from controlled trials, and by doing so have been witting or unwitting mouthpieces for company marketing departments.
In your opinion, did the FDA's 2004 decision to add black-box warnings to SSRIs over pediatric use lead to greater off-label prescriptions and even the move toward antipsychotics, on the presumption that the latter are safer to use on children?
I think this had very little effect on the switch from depression to bipolar disorder, but what was quite striking was how quickly companies were able to use the views of the few bipolar-ologists who argued that when children become suicidal on antidepressants it's not the fault of the drug. The problem, they said, stems from a mistaken diagnosis and if we could just get the diagnosis right and put the child on mood stabilizers then there wouldn't be a problem.
There is no evidence for this viewpoint, but it was interesting to see how company support could put wind in the sails of such a perspective.
It was also interesting to see how close to delusional people could get about an idea like this. Faced with details such as even healthy volunteers becoming suicidal on an antidepressant, committed bipolar-ologists were quite ready to say that this just shows that these normal people are latently bipolar.
In this case, I think most people will see that "latent bipolarity," as a concept, is functioning a little bit like the way latent homosexuality once functioned for the Freudians. Most people will also see that the first concept is impossible. What the companies have done is hand a megaphone to the proponents of that view on bipolar disorder, which was until very recently a distinctly minority one.
And are the antipsychotics in fact safer than antidepressants?
No, they are not. The antipsychotics are as dangerous as the antidepressants. Before the introduction of the antipsychotics, the rates of suicide in schizophrenia were extremely low—they were hard to differentiate from the rest of the population. Since the introduction of the antipsychotics the rates of suicide have risen 10- or 20-fold.
Long before the antidepressants were linked with akathisia, the antipsychotics were universally recognized as causing this problem. It was also universally accepted that the akathisia they induce risked precipitating the patient into suicidality or violence.
They also cause a physical dependence. Zyprexa is among the drugs most likely to cause people to become physically dependent on it. As far as I am concerned, Zyprexa's license for supposed maintenance treatment in bipolar disorder stems from data that is in fact excellent evidence for the physical dependence it causes and the problems that can arise when the treatment is stopped.
In addition, of course, these drugs are known to cause a range of neurological syndromes, diabetes, cardiovascular problems, and other problems. It's hard to understand how blind clinicians can get to problems like these, especially in youngsters who grow obese and become diabetic right before their eyes.
But we have a field which, when faced with the obvious, instead chose to listen to Eli Lilly voices saying, "Oh no, there is no problem with Zyprexa. The psychosis is what causes diabetes—Henry Maudsley recognized that 130 years ago." Well Henry Maudsley hated patients, and saw very few of them at a time when diabetes was rare. We recently looked at admissions to the North Wales Hospital from 1875-1924, years spanning his career, and among the more than 1,200 cases admitted for serious mental illness, not one had diabetes and none went on to develop it.
We also looked at admissions to the local mental-health unit between 1994 and 2007, and in over 400 first admissions none had type 2 diabetes, but the group as a whole went on to develop diabetes at twice the national rate.
This is not surprising. What is is how the entire field swallowed the Lilly line, especially when it was so implausible to begin with. We had great difficulties getting this article published—one journal refused even to have it reviewed.
One way of raising the profile of bipolar disorder in children, you note, was to argue that they'd been misdiagnosed with ADHD. What were the implications and effects of that claim?
In the case of children with ADHD, I think what one needs to appreciate is that in most of the world until very recently (and in countries like India still), ADHD is a very rare disorder where children, usually boys, are physically very overactive. This is a condition they grow out of in their teens. Treatment with a stimulant can make a difference in cases like this. Whether treatment is always called for, however, may depend on the circumstances of the child as opposed to the nature of any supposed condition.
It is only in a world where schooling or adherence to a particular set of social norms is compulsory that a condition like ADHD becomes a disorder. There was greater scope over a century ago than there is now for children to do other things in childhood and wait until they settled down in adolescence without being treated for their condition.
What we have today is not ADHD as it was classically understood, but rather a state of affairs we have had for centuries, which is "the problem child." Today the problem child is labeled as having ADHD. But having just one label is very limiting. Child psychiatry needed another disorder—and for this reason bipolar disorder was welcome.
Not all children find stimulants suitable, and just as with the SSRIs and bipolar disorder it has become very convenient to say that the stimulants weren't causing the problem the child was experiencing; the child in fact had a different disorder and if we could just get the diagnosis correct, then everything else would fall into place.
