Director’s Blog: NIMHBy Thomas InselJune 6, 2014A recent symposium at the Carter Center featured a report by the Centers for Disease Control and Prevention [CDC] that as many as 10,000 toddlers may be receiving psychostimulant medication, like methylphenidate [Ritalin]. The media reports of this, like many past reports, decried the overmedication of children. The numbers are notable. The latest estimate from the National Center for Health Statistics reports that 7.5 percent of U.S. children between ages 6 and 17 were taking medication for “emotional or behavioral difficulties” in 2011-2012. The CDC reports a five-fold increase in the number of children under 18 on psychostimulants from 1988-1994 to 2007–2010, with the most recent rate of 4.2 percent. The same report estimates that 1.3 percent of children are on antidepressants. The rate of antipsychotic prescriptions for children has increased six-fold over this same period, according to a study of office visits within the National Ambulatory Medical Care Survey. In children under age 5, psychotropic prescription rates peaked at 1.45 percent in 2002-2005 and declined to 1.00 percent from 2006-2009.
Taken together, what do these numbers mean? A common interpretation: children with behavioral or emotional problems are being overmedicated by psychiatrists too busy to provide therapy, at the request of parents too busy to provide a healthy home environment. A corollary of this interpretation is to blame schools too busy to provide recess or activities for fidgety boys. And usually the blame extends to the pharmaceutical companies that market medications in pursuit of profits.
When I read the title to this piece, I had an uncanny premonition. I knew exactly what it was going to say based only on its title and its author. And, as it turned out, I was totally correct in my fore·telling. I even knew the logic structure that the piece would follow on the road to it’s predestined conclusion. A newfound gift of prophesy? or The well worn path of monotony? The latter, I fear – so there will be no stock tips or World Series predictions. In those areas I am guaranteed to be off by a mile. As a child, I once got closest to estimating the number of jelly-beans in a jar only because of a misreading of my lousy penmanship. Claravoyancy is not in my usual bag of tricks…
While blaming psychiatrists, parents, schools, or drug companies might seem legitimate, some of the facts just don’t fit. First, most of the prescriptions for stimulant drugs and antidepressants are not from psychiatrists. In fact, outside of a few major cities, families in much of the nation have very limited access to child psychiatrists. Blaming parents is easy, but as Judith Warner argues in her book, We’ve Got Issues, most parents resist medication rather than request it. Schools in many parts of the country have reduced unstructured time, but the increase in medication is now seen in toddlers, years before children begin school. And drug companies, while frequently maligned, have reduced, not increased, their marketing budgets in the US.
If psychiatrists, parents, schools, or drug companies are not the culprit, who is? The answer is potentially more complicated and more worrisome. Is it possible that the increased use of medication is not the problem but a symptom? What if more children were struggling with severe psychiatric problems and actually the problem was not over-treatment but increased need? Surely, if we discovered more children were being treated for diabetes or immune problems, we wouldn’t blame the providers or the parents. We’d be asking what drives the increase in incidence. And, there actually are large increases in the incidence of Type I diabetes and food allergies.
There’s a piece of logic here that’s hidden behind the clouds. The topic is the massive increases in the number of children on medications, yet he is already talking about the possibility that it really means more sickness. That presumes that the treatment for mentally ill children is medications. This equation mental illness in children equals treatment with medications has actually come into being during his and his predecessor’s tenure [Stephen Hyman], and is contradicted by NIMH studies, FDA black box warnings, the debunking of the bipolar child myth, etc. His automatic jump to mental illness in children equals treatment with medications speaks more to Dr. Tom Insel’s automatic mentality than to the state of childhood mental illness. If there were a signal that mental illness in children is increasing at the rate he is about to propose, it’s not the job of the Director of the National Institute of Mental Health to be speculating about the use of medications. His job would be to mount an all out task force to look for the reasons why, rather than speculating as a way of debunking the claim that children are inappropriately overmedicated [and, by the way, children really are inappropriately overmedicated!].
Skepticism regarding increased rates of emotional and behavioral difficulties as opposed to increases in other medical disorders can be attributed in part to the absence of biomarkers or laboratory tests for psychiatric diagnosis comparable to glucose tolerance tests for diabetes or anaphylactic reactions for allergies. Absent these kinds of consistent, objective measures for mental disorders, we cannot distinguish between a true increase in the number of children affected or simply changing values or trends in diagnosis. Clearly context matters. What one parent might consider hyperactivity, another parent might consider healthy exuberance. What physicians once called attention deficit hyperactivity disorder [ADHD], often now elicits a diagnosis of childhood bipolar disorder, leading to a 40-fold increase in prevalence from 1994-1995 to 2002-2003.
No question, in a field without biomarkers, there is a risk of over-diagnosis. No question, subjective diagnosis could invite unnecessary treatment and over-medication. But what if the increased use of medication reflected more children with severe developmental problems and more families in crisis? What if the bigger problem is not over-medication but under-treatment? Hearing that 7.5 percent of children are on medication [4.2 percent on psychostimulants] seems stunning, but knowing that 11 percent of children have a diagnosis of ADHD raises a possibility of under-treatment.
Notice that the maxim "11 percent of children have a diagnosis of ADHD" is presented as a simple truth. It would be nice to hear about where his simple truth came from [unreferenced in his article]. And his comment, "What if the bigger problem is not over-medication but under-treatment?" betrays his monotonous equation that mental illness in children equals treatment with medications. I know of no hypothesis that medication in childhood mental illness is anything more than symptomatic. For all of Dr. Insel’s sermonizing about clinical neuroscience, he reduces child mental health treatment to symptomatic therapy. Is that what the National Institute of Mental Health is for? I don’t think so.
In fact, evidence from nationally representative surveys of youth in the U.S. challenges recent concerns regarding widespread overmedication and misuse of medications, at least in adolescents. Among those with current mental disorders, only 14.2 percent of youth reported psychotropic medication use, and the majority who had been prescribed medications had a mental disorder with severe consequences, functional impairment, suicidality, or associated behavioral or developmental difficulties. In light of the evidence that about 1 in every 12 youth suffer from a severe developmental, behavioral or emotional disorder, under-treatment remains a serious problem.
Of course, the problem may be both over-treatment and under-treatment. It is possible that children with issues that would be resolved by psychotherapy alone are receiving medication. It seems very likely, given the data in adolescents, that many who would benefit from medication and psychotherapy are receiving neither intervention. It is also worth considering that the rates of childhood mental disorders could be stable, but that more children are getting the treatment they need and, for many, detection and intervention is at an early age. If it is your child suffering acutely from anxiety, autism, anorexia, or depression, the problem is certainly not over-treatment. The CDC report showed that parents of more than one-half of those children who used a prescribed medication for emotional or behavioral difficulties had reported that this medication helped the child "a lot.” What I hear from families in crisis is lack of access, poor quality care, and a desperate need for answers. In the media reports on over-medicating children, this perspective is missing. The possibility that there is a real increase in the number of children suffering with severe emotional problems, just as there is a real increase in the number of children with diabetes and food allergies, is not even considered. Shouldn’t we be asking why so many children, at younger ages, are being seen for emotional and behavioral problems?
Actually, "Dr. Insel, Shouldn’t you be asking why so many children, at younger ages, are being seen for emotional and behavioral problems? Your agency is in charge of asking and answering these questions rather than bringing them up to defend the position that the current use of psychoactive medications in children is rational."
It’s funny. I don’t really see Tom Insel as a cause of what happened in psychiatry, but rather a product. He was something of a whiz kid finishing college at 17. He went straight from residency [1976-1979] to the NIMH and was in some kind of lab somewhere until becoming an administrator in 1994 [and ever since]. He has championed the neuroscience version of psychiatry since it came into view, and never wavered. He has never practiced psychiatry, or for that matter, any kind of medicine. From the dates, I would guess he did psychiatry training during the years when an internship in general medicine wasn’t required, though I don’t know that. He has moved from theory to theory about how brain disease causes mental illness, and in that he has never wavered either. He has micromanaged the directions of the NIMH rather than following some balanced sampling generated from the scientific community at large.
Whether benignly motivated or not, it’s time for him to go somewhere else – get bumped upstairs, lead some foundation, take an academic post. He’s particularly ill equipped to lead the NIMH in an era when PHARMA is no longer supporting psychiatric research. His tenure has been characterized by big clinical trials initiated by his predecessor and a variety of initiatives that haven’t been particularly productive. This blog post is an example of his now tired and predictable thinking, cheerleading about the global burden of mental illness leading to the same old conclusions. Director of the National Institute of Mental Health is not his pulpit anymore…
UPDATE: I spoke too soon. This paragraph is from his next blog about the BRAIN:
"What Freeman Dyson said about the importance of tools for new directions in science is critically important for NIMH. Biomarkers, new therapies, and preventive strategies for brain disorders, especially for the “connectopathies” that we call mental disorders, will require better tools. NIMH will be co-leading the BRAIN Initiative with our sister institute, the National Institute for Neurological Disorders and Stroke (NINDS). Whether you are a scientist working on synapses or a family member challenged by a mental disorder, the BRAIN Initiative represents a bold commitment by the NIH, offering hope for the development of better tools to enhance our understanding of the brain in health and disease."
"connectopathies"!? "chemical imbalances" was easier to say…
There’s so much illogic in Insel’s statement. Since he asserts psychiatrists are not responsible for the huge increase in drugging children, does he really think PCPs are doing a good job of diagnosing and treating their psychiatric disorders?
The estimable Dr. Claudia M. Gold, the “Child in Mind” psychiatrist, responds with good sense to Insel here http://www.boston.com/lifestyle/health/childinmind/2014/06/insel_of_nimh_misses_the_mark.html
I second that link to Claudia’s site. She points out the depth of the problem of uncared-for children that Dr. Insel actually amplifies by his monocular reductionism on matters brain [which we don’t understand] and denying psychosocial issues [which we do understand but choose to ignore].
The next head of NIMH should be a CLINICIAN-researcher. Or maybe simply a CLINICIAN surrounded by a host of researchers as support. We need someone who has been in the trenches with “dis-eased” people and their families. Someone who understands what a psychological, intrapsychic fire fight is, someone who has real experience with the internal politics of the mind (or “brain” if you prefer), not someone who is an academic bureaucrat with experience solely in external politics.