Thursday, March 18, 2010

It Matters What We Call It

The Hastings Center, a bioethics and policy think tank, put out a news release today on a research study conducted by some of its people on bipolar disorder in children:

The study reported the findings of a series of interdisciplinary workshops, and took a dim view of the recent tendency to liberally diagnose chaildren with behavioral problems as having bipolar disorder and treating them with powerful medications frequently used for adults. The report urges use of two newer diagnostic labels, Severe Mood Dysregulation (SMD) or Temper Dysregulation Disorder with Dysphoria (TDD). These, the investigators, say, really amount to "we don't know what causes this" and therefore tend to avoid prompting the use of unproven and potentially dangerous medications and other interventions.

In past posts I've noted the unholy alliance between drug industry marketing and a handful of academic psychiatrists who have been zealots for bipolar disorder in kids--such as:

The present report, however, notes an additional wrinkle that deserves comment: the workshop group universally agreed that “children and families can suffer terribly as a result of serious disturbances in children’s moods and behaviors,” and that these troubled children desperately need help. They also write, “It is a deeply regrettable feature of our current mental health and educational systems that some DSM diagnoses are better than others at getting children and families access to [needed] care and services.”

This, I think, is an excellent and underappreciated point. We often imagine that making a medical diagnosis is an objective, scientific, and completely apolitical exercise. In actuality, saying that somebody has disease X is almost always another way of saying, "I recommend that you treat this person in such-and-such a way." Often that amounts to a highly political statement, and in some environments, a very charged statement. (Witness the long fight over whether a group of sick veterans get to apply the term "Gulf War Syndrome" to whatever they have. We ought all of us to be able to agree, first, that these people have various illnesses; and second, that they deserve help for their illnesses. So just why, one might ask, does it become so very important exactly what this set of illnesses gets called? It is hard to avoid the answer that the issue is more political than scientific.)

If the problem exists for bodily illnesses, it exists in spades for mental illnesses. (And we can easily see why a group of vets would fight tooth and nail to establish the "reality" of Gulf War Syndrome if they thought that the only alternative diagnosis was, "it's all in your head.") Ideally, we should be ready to help people with all different sorts of mental illness at roughly a state of parity with our response to "physical" illness. In reality, we play favorites; those with some mental illnesses are seriously stigmatized and effectively denied good care, while those with some other mental illnesses get a variety of gains from the label they end up with.

So--take an illogical use of mental health diagnoses to create a set of winners and losers among those who end up with various different labels for whatever ails them, and then add the craziness of drug companies that want to market expensive drugs, regardless of what the evidence shows--and you have an especially toxic cauldron for causing harm to kids.

The impressive thing about media coverage of the zealot psychiatrists who drug these kids sometimes to death with multiple antipsychotic medications, is that each has the backing of a dedicated and vocal group of parents of their patients, who think they walk alongside God. Why? Because the psychiatrists agreed with the parents that their kids are indeed deeply disturbed, in ways that the parents did not cause and cannot understand. They then proceeded to try to help the kids, in however wrongheaded a way, with these drug cocktails--but one wonders if what made them heroes was not the "heroic" drug therapy so much as the simple, compassionate act of taking the parents seriously.

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