1 Boring Old Man

^{ABSTRACT: Insofar as children who have outbursts frequent and severe enough to warrant this diagnosis may live in stressful households and have other conditions such as attention-deficit disorder, depressive or anxiety disorders, or learning and language disorders, focusing solely on medication risks overlooking problems that require nonpharmacologic solutions. And although psychiatrists attempt to make relatively fine discriminations among the clusters of symptoms used to identify psychiatric disorders, the pharmacologic tools available for treating those symptoms are often blunt.}

^{In February, the American Psychiatric Association released draft revisions for the next iteration of its diagnostic manual (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-V]). One of the draft’s most talked-about features is a new diagnostic category for children: temper dysregulation disorder with dysphoria (TDD). The addition has been praised by some as a verdict on one of the hottest questions in child psychiatry: Is the dramatic increase in the number of children with a diagnosis of bipolar disorder appropriate? The answer appears to be no…}

^{As Thomas Insel, director of the National Institute of Mental Health, put it, "The unfortunate reality is that current medications help too few people to get better and very few people to get well." … the American Academy of Child and Adolescent Psychiatry described evidence for their efficacy in children as "sparse at best"…}

^{The good news is that the addition of TDD to the psychiatric manual may lend some clarity to the debate about the most appropriate diagnostic home for some deeply troubled children. The bad news is that our understanding of the nature of these children’s heterogeneous disturbances is in its infancy. The risk-benefit ratios of the medications used to treat severe outbursts have not been established. And though effective nonpharmacologic treatments are being developed, it’s probable that too few children will receive these interventions. Troubled children, regardless of their diagnostic label, deserve better.}

^{The Perspective article by Parens et al. misleads, misinforms, and is missing relevant facts. The authors imply that the increase in the diagnosis of pediatric bipolar disorder was due to a cabal of child psychiatrists rather than the increase in published, peer-reviewed research.}

^{They argue that “no existing DSM [Diagnostic and Statistical Manual of Mental Disorders] diagnosis conveys the appropriate severity” of the moods and behaviors of children “who can be explosively angry, irritable, frantically active, suicidal, or even homicidal.” An adult with these symptoms would very likely be diagnosed with bipolar disorder, and 65% of adults with bipolar disorder report an early onset of the condition. Research from multiple sites supports the validity of pediatric bipolar disorder.}

^{The authors cite “sparse” evidence supporting the efficacy of medications. Large-scale pediatric trials documenting safety and efficacy have led to Food and Drug Administration approval of two agents. They describe nonmedical treatments as “first-line,” even though few studies document the usefulness of these resource-consuming therapies; those that do consider them adjuncts to medication, not replacements…}

^{Dr. Biederman reports receiving grant support from Alza, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, McNeil, Merck, Organon, Otsuka, and Shire, lecture fees from Fundación Ramón Areces, Medice Pharmaceuticals, the Spanish Child Psychiatry Association, Janssen, McNeil, Novartis, Shire, and UCB Pharma, and consulting fees from Janssen, McNeil, Novartis, and Shire...}

But I’m on a different tack in this post. Dr. Joseph Biederman is a bully. It’s in the emails about his dealings with the pharmaceutical people. It’s in his contentious responses during his court deposition. And it’s in this retort to Parens’ article. At the time he wrote this particular nasty-gram, he was being investigated because he took a small fortune in unreported pharmaceutical payola; he had been exposed as signing off on ghost-written literature; and there is public documentation of his active participation in pharmaceutical marketing schemes.