Anatomy of an Epidemic (36 page)

We now have numbers that tell of an iatrogenic epidemic: 400,000 bipolar children arriving via the ADHD doorway, and at least another half million through the antidepressant doorway. There is also a way that we can double-check that conclusion: When investigators survey juvenile bipolar patients, do they find that most traveled down one of those two iatrogenic paths?

Here are the results. In a 2003 study of seventy-nine juvenile bipolar patients, University of Louisville psychiatrist Rif El-Mallakh determined that forty-nine (62 percent) had been treated with a stimulant or an antidepressant prior to their becoming manic.
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That same year, Papolos reported that 83 percent of the 195 bipolar children he studied had been diagnosed with some other psychiatric illness first, and that two-thirds had been exposed
to an antidepressant.
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Finally, Gianni Faedda found that 84 percent of the children treated for bipolar illness at the Luci Bini Mood Disorders Clinic in New York City between 1998 and 2000 had been previously exposed to psychiatric drugs. “Strikingly,
in fewer than 10%
[of the cases] was diagnosis of bipolar disorder considered initially,” Faedda wrote.
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Not surprisingly, parents bear witness to this iatrogenic course. In May 1999, Martha Hellander, executive director of the Child and Adolescent Bipolar Foundation, and Tomie Burke, founder of Parents of Bipolar Children, jointly wrote this letter to the
Journal of the Academy of Child and Adolescent Psychiatry:

With so many teenagers prescribed SSRIs, an epidemic of mania has erupted on college campuses as well. In a 2002 article titled “Crisis on the Campus,”
Psychology Today
reported that an increasing number of students, having arrived at college with an antidepressant prescription in hand, were crashing badly during the school term. “We are seeing more first episodes of mania every year,” said Morton Silverman, head of counseling services at the University of Chicago. “It’s very disruptive. It generally means hospitalization for the student.” The magazine was even able to identify a precise date when this mania epidemic began to emerge: 1988.
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Readers need only remember when Prozac came to market to connect the dots.

One final bit of evidence comes from the Netherlands. In 2001, Dutch psychiatrists reported only thirty-nine cases of pediatric bipolar illness in their country. Dutch investigator Catrien Reichart then studied the offspring of parents with bipolar disorder in both the United States and the Netherlands, and determined that the Americans were ten times more to likely to exhibit bipolar symptoms before age twenty than the Dutch children. The likely reason for this difference, Reichart concluded, is that “the prescription of antidepressants and stimulants to children in the U.S. is much higher.”
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AN EPIDEMIC UNFOLDS

All of this tells of an epidemic that is mostly iatrogenic in kind. Fifty years ago, physicians virtually never saw manic-depressive illness in preteens, and they rarely diagnosed it in adolescents. Then pediatricians and psychiatrists began prescribing Ritalin to hyperactive children, and suddenly the medical journals began running case reports of manic children. This problem grew as the prescribing of Ritalin increased, and then it exploded with the introduction of the SSRIs. Research then showed that both of these drugs trigger bipolar symptoms in children and adolescents on a regular basis. These are the two “outside agents” fueling the epidemic, and it should be remembered that they do perturb normal brain function. The manic children showing up at hospital emergency rooms have dopaminergic and serotonergic pathways that have been altered by the drugs and are now functioning in an “abnormal” manner. There is a step-by-step logic that explains this epidemic.

In addition, there are at least three more pathways to a diagnosis of juvenile bipolar illness. As El-Mallakh, Papolos, and Faedda all found, there are some children and adolescents so diagnosed who have no prior exposure to antidepressants or stimulants, and it’s fairly easy to see where the majority of those patients are coming from. First, Harvard psychiatrist Joseph Biederman led the way in expanding the diagnostic boundaries in the 1990s, proposing that extreme “irritability” could be seen as evidence of bipolar illness. The child no longer needs to have gone manic to be diagnosed as bipolar. Second, foster children in many states are now regularly given a bipolar diagnosis, their anger apparently not the result of having been born into a dysfunctional family, but rather due to a biological illness. Finally, teenagers who get into trouble with the law are now regularly funneled into psychiatric roles. Many states have set up “mental health courts” that send them off to hospitals and psychiatric shelters rather than to correctional facilities, and these youth are adding to the bipolar numbers as well.

As we saw earlier in this book, outcomes for adult bipolar patients have deteriorated dramatically in the past forty years, and the worst outcomes are seen in those with “mixed state” and “rapid cycling” symptoms. That clinical course in adults was virtually never seen prior to the psychopharmacology era, but rather it was one associated with exposure to antidepressants, and, tragically, those are the very symptoms that afflict the overwhelming majority of juvenile bipolar patients. They exhibit symptoms “similar to the clinical picture reported for severely ill, treatment-resistant adults,” explained Barbara Geller in 1997.
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Thus, this is not just a story of children turned bipolar; it’s a story of children afflicted with a particularly severe form of it. Papolos found that 87 percent of his 195 juvenile bipolar patients suffered from “ultra, ultra rapid cycling,” which meant that they were constantly switching between manic and depressed mood states.
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Similarly, Faedda determined that 66 percent of the juvenile bipolar patients treated at the Luci Bini Mood Disorders Clinic were “ultra, ultra rapid-cyclers,” and another 19 percent suffered from rapid cycling only a little bit less extreme. “In contrast to a biphasic, episodic and relatively slow cycling course in some adults with bipolar disorder, pediatric forms usually involve mixed mood states and a sub-chronic, unstable, and unremitting course,” Faedda wrote.
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Outcome studies have found that the long-term prognosis for these children is grim. The NIMH, as part of its STEP-BD study, charted the outcomes of 542 children and adolescent bipolar patients, and it reported that pre-adult onset “was associated with greater rates of comorbid anxiety disorders and substance abuse, more recurrences, shorter periods of euthymia [normal mood], and greater likelihood of suicide attempts and violence.”
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Boris Birmaher, at the University of Pittsburgh, determined that “early onset” bipolar patients are symptomatic about 60 percent of the time, and that, on average, they shift “polarity”—from depression to mania or vice versa—an astonishing sixteen times a year. The prepubertal patients were “two times less likely than those with
postpubertal onset bipolar to recover,” he said, and it was “expected that children will be poor responders to treatment when they become adults.”
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DelBello followed a group of adolescents hospitalized for a first bipolar episode and concluded that only 41 percent functionally recovered within a year.
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This impairment, Birmaher determined, then worsens after the first year. “Functional impairment in bipolar appears to increase during adolescence regardless of age of onset.”
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Youth diagnosed with bipolar illness are typically put on drug cocktails that include an atypical antipsychotic and a mood stabilizer. This means that they now have multiple neurotransmitter pathways in their brains that are being mucked up, and naturally, this treatment does not lead them back to emotional and physical health. In 2002, DelBello reported that lithium, antidepressants, and mood stabilizers all failed to help bipolar youth fare better at the end of two years. Those who were treated with a neuroleptic, she added, “were significantly less likely to recover than those who did not receive a neuroleptic.”
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Six years later, Hayes, Inc., a Pennsylvania consulting firm that conducts “unbiased” assessments of drugs for health-care providers, concluded that there was no good scientific evidence that the mood stabilizers and atypical antipsychotics prescribed for pediatric bipolar were either safe or effective. “Our findings indicate that at this time, anticonvulsants and atypical antipsychotics cannot be recommended for children diagnosed with bipolar disorders,” said Elisabeth Houtsmuller, senior analyst for Hayes.
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These reports attest to a lack of drug efficacy, but as Houtsmuller noted, the side effects from these “pharmacological treatments” are “alarming.” In particular, atypical antipsychotics may cause metabolic dysfunction, hormonal abnormalities, diabetes, obesity, emotional blunting, and tardive dyskinesia.
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Eventually, the drugs will induce cognitive decline, and the child who stays on the cocktails into adulthood can expect to die early as well.

That is the long-term course of this iatrogenic illness: A child who may be hyperactive or depressed is treated with a drug that triggers a manic episode or some degree of emotional instability, and then the child is put on a drug cocktail that leads to a lifetime of disability.

There are no good studies yet on the percentage of “early onset” bipolar patients who, when they reach adulthood, end up on the SSI and SSDI disability rolls. However, the astonishing jump in the number of “severely mentally ill” children receiving SSI speaks volumes about the havoc that is being wreaked. There were 16,200 psychiatrically disabled youth under eighteen years old on the SSI rolls in 1987, and they comprised less than 6 percent of the total number of disabled children. Twenty years later, there were 561,569 disabled mentally ill children on the SSI rolls, and they comprised 50 percent of the total. This epidemic is even hitting preschool children. The prescribing of psychotropic drugs to two-year-olds and three-year-olds began to become more commonplace about a decade ago, and sure enough, the number of severely mentally ill children under six years of age receiving SSI has
tripled
since then, rising from 22,453 in 2000 to 65,928 in 2007.
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Moreover, the SSI numbers only begin to hint at the scope of the harm being done. Everywhere there is evidence of a worsening of the mental health of children and teenagers. From 1995 to 1999, psychiatric-related emergency room visits by children increased 59 percent.
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The deteriorating mental health of the nation’s children, declared U.S. surgeon general David Satcher in 2001, constituted “a health crisis.”
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Next, colleges were suddenly wondering why so many of their students were suffering manic episodes or behaving in disturbed ways; a 2007 survey discovered that one in six college students had deliberately “cut or burned self” in the prior year.
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All of this led the U.S. Government Accountability Office to investigate what was going on, and it reported in 2008 that one in every fifteen young adults, eighteen to twenty-six years old, is now “seriously mentally ill.” There are 680,000 in that age group with bipolar disorder and another 800,000 ill with major depression, and, the GAO noted, this was in fact an undercount of the problem, as it didn’t include young adults who were homeless, incarcerated, or institutionalized. All of these youth are “functionally impaired” to some degree, the GAO said.
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