The Business of Medicalizing Infancy
Why the age thresholds for childhood disorders keep falling.
Posted Jun 04, 2014
“No therapeutic category is more accepting of condition branding than the field of anxiety and depression,” wrote Vince Parry a decade ago in the trade journal Medical Marketing and Media. Parry, an industry insider, called his article “The Art of Branding a Condition.” Anxiety and depression were especially susceptible to “condition branding,” he told peers, because “mental illness is rarely based on measurable physical symptoms and, therefore, is open to conceptual definition.”
The art of branding—of successfully aligning a condition with a pharmaceutical product—boiled down to three key strategies:
- elevating the importance of an existing condition
- redefining an existing condition to reduce a stigma
- developing a new condition to build recognition for an unmet market need.
Parry’s candid article was a good preview to Aaron E. Carroll’s excellent Times article yesterday, “Calling an Ordinary Health Problem a Disease Leads to Bigger Problems.” Dr. Carroll, a professor of pediatrics at Indiana University School of Medicine, exposed the consequences of Parry’s strategies—on public health, stretched healthcare budgets, and a growing picture of vastly expanding diagnostic rates in disorders whose age thresholds have been lowered for the very young, in some cases dramatically so. Justification for that course is built around a still-controversial, largely untested argument for early pharmaceutical intervention, with "early" referring to age, rather than the onset of illness. That of course permits medication to begin at ever-younger ages, and for a great many more children (increasingly, infants).
Dr. Carroll writes about the considerable downward pressure on the age threshold for childhood diagnoses of GERD (gastro-esophageal reflux disease), even though the actual disease (as distinct from its common symptoms) is “rare” among that age group. “About 50 percent of healthy infants will spit up more than twice a day," Carroll writes. “About 95 percent of them completely stop doing that without treatment. When a majority of infants have (and have always had) a set of symptoms that go away on their own, it isn’t a disease—it’s a variation of normal.”
As the age thresholds for such diseases fell, however, and the promotional campaigns took hold, “more and more babies with reflux were labeled as having a ‘disease.’ The incidence of a diagnosis of GERD in infants tripled from 2000 to 2005.” It comes as little surprise to hear from this pediatrician that “many of those babies are now being treated with drugs called proton pump inhibitors (P.P.I.s): “Between 1999 and 2004,” he writes, “the use of one child-friendly liquid form of P.P.I. increased more than 16-fold.”
Considering such a massive expansion in prescriptions over just five years, for children at that age and a great deal younger, it’s worth recalling Parry on the creation of adult GERD. The disease-condition was devised, he boasts, to accompany a massive promotional campaign for the drug ranitidine.
One of the simplest ways to overstate the gravity of a medical condition, Parry admitted, is to dazzle the public with acronyms. In the case of GERD, the public previously assumed that over-the-counter remedies would be adequate in tackling heartburn. So the marketing campaign needed to elevate … redefine … develop the rebranded condition, to persuade doctors and patients otherwise. Other acronyms and near-identical emphases were devised to promote IBS (irritable bowel syndrome), ED (erectile dysfunction), PMDD (premenstrual dysphoric disorder), and SAD (social anxiety disorder), as I showed at much greater length in Shyness: How Normal Behavior Became a Sickness.
“The bigger problem” with the massive overdiagnosis and overmedication of infant GERD, Carroll concludes, “is that the vast majority of these infants weren’t ‘sick.’ We just gave them an official diagnosis. This labeling of patients with a ‘disease’ can have significant consequences, for both people’s health and the nation’s health care budget.”
Sorry, but doctors—especially pediatricians: Whatever happened to “First, do no harm"?
References and links:
Carroll, Aaron E. “Calling an Ordinary Health Problem a Disease Leads to Bigger Problems.” New York Times: June 3, 2014.
Lane, Christopher. 2007. Shyness: How Normal Behavior Became a Sickness. New Haven: Yale University Press.
“Medicating Children: Why Controversy Still Flares over ‘Early Detection.’” Psychology Today: September 2, 2010.
“The OECD Warns on Antidepressant Overprescribing.” Psychology Today: November 22, 2013.
“Americans Are Being Aggressively Over-Diagnosed.” Psychology Today: September 20, 2011.
“Behavior Drugs Given to Four-Year-Olds Prompt Calls for Inquiry—in the UK.” Psychology Today: March 19, 2011.
“Naming an Ailment: The Case of Social Anxiety Disorder.” Psychology Today: June 11, 2012.
Parry, Vince. “The Art of Branding a Condition.” MM&M: Medical Marketing and Media (May 2003): 44-46.