Treating children as young as 4 for bipolar_WSJ

May 27, 2005

I have spent a lot of time on the boards of CABF (Children and

Adolescent Bipolar Foundation) reading the posts by parents whose

children are diagnosed with early onset bipolar disorder. I know

parents whose children were treated at MGH under the direction of Dr.

Biederman. When he was doing his Seroquel studies, every parent who

posted about her child's being treated at MGH under Biederman

supervision was being pushed to 800 mg of Seroquel per day. The

approved dose for treating adults with schizophrenia was 700 mg/day.

One parent told the PNA who was handling the medication that the child

got worse once they passed 400 mg/day. The response was to raise the

dose from 700 to 800 mg day. Turns out the child has a mild seizure

disorder and the high level of the antipsychotic had lowered the

seizure threshold and the child was having partial seizures.

Eventually the parents lowered the dose to 400 mg on their own. These

were NOT children in clinical studies but in the private practice.

Every child was put on Seroquel before trying lithium or

anticonvulsants approved for the treatment of bipolar. Things he said

convinced many doctors that antipsychotic are mood stabilizers -- which

they are NOT. Tardive dyskinesia which often emerged was treated not

with lower doses but with more drugs to control the symptoms.

Biederman also told the executive director of CABF -- who then posted

it on the board -- that he believed the reason children responded badly

to SSRIs was because they were added too quickly and at too high a

dose. That was a few years ago, I don't know what he would say today.

Biederman is just a drug company whore.

BTW, the antipsychotics are commonly prescribed to treat aggressive

behavior in children. Aggressive behavior as though it is a medical

diagnosis.... And many of those kids are taking SSRIs. And a lot of

them are taking SSRIs after developing depression after taking

stimulants for much of their lives. After years of treatments and tons

of medications, most kids are doing worse than they were when they

first started treatment. Doctors say it is the comorbid disorders.

Many parents are starting to think it's the drugs.

> From: " VERACARE " <veracare@a...>

> " VERACARE " <veracare@a...>

> Subject: Treating children as young as 4 for bipolar_WSJ

> Date: Thu, 26 May 2005 16:39:45 -0400

>

> ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)

> Promoting Openness, Full Disclosure, and Accountability

> www.ahrp.org

>

> FYI

>

> A report in The Wall Street Journal should raise serious concerns about

> the

> legitimacy of psychiatric diagnosing and drug prescribing for children.

>

> The Journal reports that close to 20,000 US children are being

diagnosed

> with bi-polar disorder, a condition that had, until recently been very

> rare

> according to responsible child psychiatrists.

> " The number of children diagnosed as bipolar rose 26% from 2002 to

2004,

> to

> 19,776 cases " according to patient records kept by health-care

> information

> company NDCHealth Corp. " Increased use of antipsychotic medicines, such

> as

> Seroquel and Risperdal, was a big driver of pediatric drug costs last

> year,

> according to pharmacy-benefit manager Medco Health Solutions Inc. "

>

> Yet, the Journal reports that a heated debate is brewing between two

> camps

> of powerful child psychiatrists--all of whom are proponents of

> psychotropic

> drugs. Leading child psychiatrists disagree about whether children

> should

> even have to meet the diagnostic threshold for a diagnosis of bipolar

> before

> being prescribed some of the most powerful mind altering psychotropic

> drugs

> on the planet. Their decisions may irrevocably harm children.

>

> Bipolar disorder is a severe, disabling psychiatric condition broadly

> defined in the diagnostic bible of psychiatry--the DSM IV. To meet the

> diagnostic criteria for bipolar in adults, patients must exhibit:

> Inflated

> self-esteem or grandiosity; Decreased need for sleep; Increased or

> pressured

> speech; Flight of ideas/racing thoughts; Distractibility; Increased

> goal-directed activity; Risk-taking behavior-- " bipolar disorder causes

> people to cycle between manic, euphoric highs and crushing, depressive

> lows

> that last a week or more. " Presumably, a psychiatrist prescribing

> powerful

> mind-altering drugs to a patient meeting those symptoms would be

> justified.

>

> The drugs prescribed for bipolar disorder are the so-called 'atypical

> antipsychotics'--including Risperdal (risperidone), Zyprexa

> (olanzapine),

> Seroquel (quetiapine). These drugs have not been approved for children.

> Neither were they approved initially for bipolar disorder in adults.

> These

> antipsychotics were at first approved only for schizophrenia--the most

> severe, debilitating psychiatric disorder in which psychosis,

> hallucinations, hearing voices, are the core symptoms, affecting 1% of

> the

> population.

> .

> Unfathomably, these powerful--and harmful--psychotropic drugs have

beome

> blockbuster sellers, enriching Eli Lilly, & and Bristol

> Myers Squibb, while producing diabetes in more than 30% of youth.

>

> Since doctors diagnosing children disagree about the basis for

> diagnosing

> and treating children, their practice method may be legitimately

> characterized as child abuse with chemical restraints. Psychiatry's

> rather

> broad diagnostic criteria were established by a group of leading

> psychiatrists. Therefore, current efforts to lower those standards--

both

> in

> terms of prevalence (quantity) and severity (quality) of the symptoms,

> is a

> radical departure from psychiatry's own standards such as they are: " A

> bipolar child can flip between a high and low several times a day.

There

> also is disagreement over what constitutes the highs, with some doctors

> saying the manic phase in children often reveals itself as extreme

> rages,

> violence and emotional outbursts, rather than the traditional euphoria.

"

>

> The push by an influential group of child psychiatrists at Harvard may

> lie

> at the root of what is an epidemiological mystery:

> what disaster can account for the staggering number of children being

> diagnosed with bipolar disorder?

> It appears that the most radical of child psychiatrists who recommend

> prescribing antipsychotics for children are at Harvard. They are

> pressuring

> the profession to prescribe antipsychotics for children --even without

> the

> criteria establshed by their profession, and even in the knowledge that

> the

> risks of harm for children are irrevocable.

>

> Parents need help from Congress to stop the abuse. Parents and

> healthcare

> public policy makers have a right to demand from state licenced medical

> professionals that they adhere to evidence-based medicine:

> what constitutes a legitimate psychiatric diagnosis in children? What

> constitutes a scientifically valid diagnosis of bipolar disorder in

> children?

> Clearly, it is not in a child's best interst to be exposed to powerful

> drugs

> that alter brain function on the basis of " vague " symptoms of attention

> derficit hyperactivity (ADHD).

>

> How can a drug approved for a very small group of very disabled

> patients,

> become Eli Lilly's best selling drug?

>

> How many millions of dollars has Harvard and the members of its

> psyciatry

> department received from the makers of these drugs?

>

> Contact: Vera Hassner Sharav

> 212-595-8974

> veracare@a...

>

> The Wall Street Journal

> Treating Children for Bipolar Disorder; Doctors Try Powerful Drugs On

> Kids

> as Young as Age 4; An Overlap With ADHD

> Leila Abboud.

> May 25, 2005. p. D.1

>

> CHILD PSYCHIATRY, roiled last year by revelations that antidepressants

> could

> increase children's risk of suicidal behavior, now is embroiled in

> another

> controversy: How to treat troubled children who have explosive rages

and

> dramatic mood swings that defy conventional diagnosis.

>

> Doctors increasingly agree that some of these children have bipolar

> disorder. Once thought to be exceedingly rare among children, the

> problem is

> being diagnosed more frequently and at younger ages than ever before. A

> small but growing group of psychiatrists say they are treating children

> as

> young as four for bipolar disorder, prescribing mood-stabilizing drugs

> and

> antipsychotics that have rarely if ever been used on patients so young.

>

> The number of children diagnosed as bipolar rose 26% from 2002 to 2004,

> to

> 19,776 cases in a database of 113 million anonymous patient records

kept

> by

> health-care information company NDCHealth Corp. Increased use of

> antipsychotic medicines, such as Seroquel and Risperdal, was a big

> driver of

> pediatric drug costs last year, according to pharmacy-benefit manager

> Medco

> Health Solutions Inc.

>

> A debate is brewing over how to diagnose and treat these children. In

> its

> classic form, bipolar disorder causes people to cycle between manic,

> euphoric highs and crushing, depressive lows that last a week or more.

> The

> picture in children often is muddier. A bipolar child can flip between

a

> high and low several times a day. There also is disagreement over what

> constitutes the highs, with some doctors saying the manic phase in

> children

> often reveals itself as extreme rages, violence and emotional

outbursts,

> rather than the traditional euphoria.

>

> Making diagnosis even harder is the great overlap between the symptoms

> of

> bipolar and attention deficit hyperactivity disorder. Research has

shown

> that 50% to 80% of children with bipolar also have ADHD.

>

> " We all agree that kids with classic symptoms definitely have bipolar, "

> says

> Boris Birmaher, professor of psychiatry and director of a pediatric

> bipolar

> clinic at the University of Pittsburgh. " The controversy is over the

> kids

> with vaguer symptoms. "

>

> The debate is a key topic at the annual meeting of the American

> Psychiatric

> Association this week in Atlanta, where two camps are airing theories

> about

> which children are actually bipolar and how to treat them. One group,

> led by

> ph Biederman and Janet Wozniak of Massachusetts General Hospital in

> Boston, argues that a child displaying violent outbursts and rages is

> likely

> bipolar even without classic weeklong manic symptoms that help define

> the

> disorder in adults. The opposing group is led by Barbara Geller, at

> Washington University in St. Louis, who believes children should

display

> the

> textbook grandiose feelings or elated moods. In their practices, many

> pediatric doctors who treat bipolar disorder fall somewhere in between

> and

> follow the treatment guidelines for adults.

>

> The difference between the two positions isn't just academic. Children

> incorrectly diagnosed with bipolar would be given powerful

> mood-stabilizing

> medications they may not need, such as lithium or Depakote, or a

> so-called

> atypical antipsychotic such as Zyprexa or Risperdal -- few of which

have

> been tested in children and all of which carry serious side effects.

> Lithium

> can cause thyroid problems and increased thirst, while the atypical

> antipsychotics can cause serious weight gain.

>

> If a bipolar diagnosis is missed, children are likely to be put on

> antidepressants such as Zoloft, or ADHD drugs such as Adderall, both of

> which can actually push bipolar children into a manic mode. Indeed,

some

> psychiatrists believe the whole flap linking antidepressants with a

> heightened risk of suicide in children may be explained by the fact

that

> these children really were bipolar and not depressed.

>

> A number of studies are exploring the diagnosis and treatment of

bipolar

> children. Among the research is a large, six-year study at the

> Washington

> University School of Medicine and five other sites, funded by the

> National

> Institutes of Health, that is trying to determine which medications

work

> best in bipolar patients who are six to 15 years old. The NIH is

> conducting

> another trial that will follow 700 children ages 6 to 17 to try to map

> what

> bipolar looks like in children.

>

> Dr. Biederman's group at Massachusetts General recently presented a

> small

> study of 39 children ages 4 to 6, which showed that those with bipolar

> benefited from treatment with antipsychotic drugs, though with

> significant

> side effects including increased appetite and sedation. The study was

> funded

> by the nonprofit Stanley Medical Research Institute, the NIH and the

> hospital itself. Dr. Biederman's group has received research funds from

> makers of atypical antipsychotics. He and Dr. Wozniak also consult for

> some

> drug makers.

>

> Ann Elliott's daughter, Chloe, was given Prozac for depression when she

> was

> six years old, after a two-year history of rages, giddy spells and

> self-destructive behavior, including bashing her head against a

bathroom

> sink. Within a month of starting on the drug, she became mean and

manic,

> says Ms. Elliott, a computer programmer from Northern California.

Prozac

> was

> stopped. Chloe later was diagnosed as bipolar. Now eight, she is doing

> well

> on Trileptal, a mood stabilizer, and Abilify, an antipsychotic.

>

> Such extreme behavioral problems fall under an umbrella of symptoms

> called

> " irritability " that Dr. Biederman and Dr. Wozniak think is central to

> bipolar in kids. These children can have three-hour rages touched off

by

> something as routine as being told to brush their teeth. The rest of

> their

> families walk on eggshells, never knowing what could set the children

> off.

> Dr. Wozniak says these children are bipolar, even though their symptoms

> differ from those seen in adults.

>

> Dr. Geller and other psychiatrists, however, point out that

> " irritability "

> can be found in many illnesses, like depression, autism and

retardation.

> The

> scientific data aren't yet convincing, she says, to show that children

> who

> have rages, but not the conventional manic symptoms, actually have

> bipolar

> disorder.

>

> In a study funded by the NIH, Dr. Geller for four years followed 86

> children

> whom she identified as bipolar. She identified grandiosity and elated

> mood

> as two key symptoms. Since the two symptoms aren't present in ADHD,

Dr.

> Geller says, grandiosity and elation can distinguish the children with

> bipolar from those with ADHD. She concedes that current science can't

> give

> clear answers. " We need biological tests or markers, " she says.

However,

> genetic tests or brain scans are probably decades away.

>

> Doctors say parents with such troubled children should consult with a

> child

> psychiatrist who specializes in bipolar disorder at a large academic

> medical

> center, where much of the research on bipolar children is done. The

> Child

> and Adolescent Bipolar Foundation Web site at www.bpkids.org also may

be

> a

> helpful source.

>

> Making a diagnosis can take months. It can involve interviews with the

> child, parents, teachers and siblings, and even observation of the

child

> at

> school or at home.

>

> It took more than eight years for doctors to diagnose Sue Cahalan's

> daughter

> with bipolar disorder. The girl had tantrums and violent fits going

back

> to

> age 4. At age 8, she stole from family and neighbors. At 10, she tried

> to

> choke her mother in an argument over the telephone. At 12, Ms. Cahalan

> came

> home to find her daughter holding a butcher knife outside the upstairs

> bathroom in which she had locked her two younger siblings. " The

> psychiatrist

> said he was finally ready to call it bipolar, " says Ms. Cahalan, a

> lawyer

> from the Chicago area.

>

> Her daughter was put on lithium and her condition improved. For the

> years, doctors had to tinker with her medication, but Ms. Cahalan says

> her

> daughter slowly stabilized and was able to attend high school at a

> residential facility and will head to college next year. " I do wonder

> whether things would have been different had she been diagnosed

> earlier, "

> she says.

>

> Medicating Kids

>

> Some drugs being used to treat children for bipolar disorder:

> -- Mood stabilizers

> (Side effects can include thyroid or liver problems and increased

> thirst)

> Lithium (generic)

> Depakote (Abbott Laboratories)

>

> -- Atypical antipsychotics

> (Side effects can include serious weight gain)

> Risperdal ( & )

> Seroquel (AstraZeneca)

> Zyprexa (Eli Lilly)

> ---

>

> Defying Labels

>

> Because many of the symptoms of bipolar disorder and ADHD are similar,

> doctors often have difficulty making a diagnosis. Many children have

> both

> conditions at once.

>

> Bipolar

>

> -- Elation

> -- Grandiosity

> -- Decreased need for sleep

> -- Delusions

> -- Cyclic, symptoms fluctuate a lot

>

> Bipolar/ADHD

>

> -- Hyperactivity

> -- Impulsivity

> -- Short attention span

> -- Irritability/Rages

> -- Daring behaviors

> -- Depression

>

> ADHD

>

> -- Symptoms like those in the intersecting portion but more constant

> -- though severity may fluctuate

>

> Source: " New Hope for Children and Teens with Bipolar Disorder, " by

> Boris Birmaher

>

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May 27, 2005