With the American Academy of Child and Adolescent Psychiatry meeting in San Diego right now, I’m having something of a remembrance of things past period. Of course there’s Paxil Study 329 which stands in my mind as a paradigm for an infamous era, along with a other less well known Clinical Trials suggesting that the SSRIs are effective and safe in the treatment of adolescent depression [ie more Wagner et al…]. It remains a major unresolved question in my mind why the Journal of the American Academy of Child and Adolescent Psychiatry is still unwilling to retract Paxil® Study 329, or for that matter, why the American Journal of Psychiatry didn’t [and still doesn’t] retract Wagner et al’s ghost written Citalopram [Celexa®] paper [collusion with fiction…]. And I continue to wonder why journals still publish the stream of papers attempting to discredit the Black Box Warning on these drugs about the uncommon but potentially fatal suicidality that the drugs sometimes cause [a betrayal…]. It’s like the ripples from that period when the pharmaceutical industry, complicit psychiatrists, and journals were publishing fiction-as-fact under the cover of darkness won’t die out.
There was one issue from that period that remains very sticky – Pediatric Bipolar Disorder. It’s sticky because the patients in question really exist, and the medications in question really work, and the treatment questions are really tricky for anyone who actually sees these cases. And whether these cases represent a distinct group or not is, itself, an open question in my mind. To use Dr. Joseph Biederman’s term, they are children with super angry, grouchy, cranky, irritability. They drive parents, teachers, siblings, psychiatrists, therapists, and themselves crazy. They usually have the clinical findings of ADHD [with a capital H] but there’s no cure with stimulants, and if you give them antipsychotics, they do become more manageable – but... These are among the kids that get drugged, often in response to pleas by parents, caretakers, psychologists, social workers, teachers, etc. – the exasperated people who deal with them. I’ll skip the many diagnoses invented for this maybe-group, except for one – Pediatric Bipolar Disorder.
When Risperda® was introduced, it came with a study of behavioral treatment for retarded children that was, of course, positive [genuinely positive] [see trial 93: a bad penny…]. Janssen’s application for FDA Approval was turned down. When Dr. Biederman began to say that these kids with super angry, grouchy, cranky, irritability had Pediatric Bipolar Disorder, this study was republished and repurposed under Dr. Biederman’s name [Risperidone for the treatment of affective symptoms in children with disruptive behavior disorder: a post hoc analysis of data from a 6-week, multicenter, randomized, double-blind, parallel-arm study] and the rest is history. Pediatric Bipolar Disorder took off like wildfire and the papers flowed from everywhere [I called it Biedermania].
I’ve reviewed all of this ad nauseum. And I ended up wondering if Pediatric Bipolar Disorder even exists, or if it does, thinking it’s uncommon. In my opinion, the reason Pediatric Bipolar Disorder caught on was that Child Psychiatrists and Pediatricians who were seeing these extremely difficult kids were previously guiltily treating them with antipsychotics for behavior control [unable to place them in the tough love token economy environments of the past], and that the diagnosis of a disease treated with a medicine for that disease took away the guilt. I was volunteering in a child clinic for a time, and I ultimately quit working there because of this very issue. The pressure to medicate with antipsychotics was overwhelming because there were no rational alternatives, and that’s just not my cup of tea. It’s simply a do no harm thing for me. But I felt some empathy for my colleagues who were and are in that double bind, and couldn’t just say, "No thanks."
I wish I knew the contents of numbers 1 and 3, just wondering what they’re saying about Pediatric Bipolar Disorder and the use of the SSRIs in depressed adolescents. But that roster is not intended to be an indictment of the AACAP. Compared to my remembrance of things past, it’s a remarkable improvement. Even the topics are more benign and rational. But they’re all ripples nevertheless. It’s time for the ripples from that time in our history to stop…
the ripple that seems obvious to me from the list of institutes….is an interest in expanding boundaries…”early onset”…”risk”…”early recognition and treatment”..”early age”
i interpret this as interest in psychopharmacological treatment “happening or done before the usual or expected time”.
It’s mission creep. It happens in all institutions that get too big. It’s why the CDC is now involved in playground safety and not doing such a good job with infection control.
Although we would all like to think the era of Paxil Study 329 is in the past, it is still very much with us. Now adults, children prescribed Paxil and other antidepressants in that era are still taking the drugs and having tremendous difficulty going off them if they try. For them, the medical error is enduring even as the studies crumble into dust.
Yes, when will this end? Where’s the new Stephen Stahl who’s going to write over all the errors of psychiatry’s past 30 years?
Stahl’s still at it,
https://www.youtube.com/watch?v=0rm5p3DTyE8&sns=tw
aka white men can’t dance…
Like I said, we need a new one.
At the risk of ruffling a few feathers, allow me to defend Stahl a bit.
1. His pharmacology book is twenty times better than than Schatzberg’s or Maudsley’s, more readable, more straightforward, more everything. And I happen to like the artwork.
2. The Prescriber’s Guide is really useful and I carry it around with me whenever I need to check drug interactions, cytochrome effects, dosing pearls etc. It’s not just limited to on patent medications.
3. He fully acknowledges the problems with diagnostic classification in books and lectures. The DSM5 video is more a manifestation of his hamminess than his complete endorsement of DSM. Besides, some of his videos are pretty funny.
4. Much of his latest book acknowledges the efficacy problems with SSRIs.
5. There is an extensive discussion of MAOIs and mostly not Emsam, and all of these medications except Emsam are off patent. There would be no financial incentive for him to portray these in a positive light as he does. He also criticizes psychiatrists for being afraid to use them, and I agree with that position.