Wednesday, September 28, 2011

Psychiatrists and Ethics: Medicating Children without Symptoms

There is a distinct difference between the practice of psychiatry and the practice of medicine. A medical doctor generally has a definable target involved when a medication is prescribed. There is a tumor, a bacterium, or an inflammation that is being combated. One can assess the effects of the medication. A doctor of psychiatry has the same ability to prescribe any medication he wants, and for any reason, but he gets no such physically measureable feedback.

Psychiatrists must depend on patient feedback to determine whether their prescriptions are having any effect—other than measureable side effects. Clinical tests of psychoactive drugs are notoriously difficult, and notoriously subject to manipulation. Most drugs are tested in double blind procedures against a placebo. Drug companies would not dare test their product against that of another company. The FDA will approve drugs that beat a placebo even if they are no better than existing drugs. Most such drugs have a sizeable placebo effect. If you tell a person who feels ill that you are giving him a pill that might make him feel better, he will tend to feel better. Some have concluded that essentially the entire effect of antidepressants like Prozac can be explained by this placebo effect. On the other hand, psychoactive drugs do modify brain function and can have observable negative effects on mental and physical function. An attempt to commit suicide does not have to be self-reported.

Psychiatrists who prescribe medication also have to face the uncertainty of not knowing whether the drug is actually addressing a medical issue. There is no physical definition for mental illness, so one never knows that the physical changes caused by the drug actually have anything to do with the illness. Psychiatrists tend to define mental illness as a collection of symptoms. They are provided a manual, written by a collection of psychiatrists, listing symptoms associated with a given condition. If some number, say five out of nine, of symptoms are observed in a patient, the psychiatrist can feel that he has made a defendable diagnosis. However, given that psychiatrists now recognize over 300 types of mental illness, it is often the case that several diagnoses are possible. It is somewhat arbitrary what is done in this case, but generally, one presumes, a judgment of the most relevant diagnosis will be made—somehow.

So a psychiatrist deals with symptoms, and chooses a drug that it is believed will alter those symptoms and create a set of other symptoms recognized as being more normal by society. There is no curing that can be assumed here, but most people will believe that this new set of symptoms is an indication that the drug is beneficial. But if there is no cure available, where does one go from here? In an ideal world, patients would use the reprieve provided by medication to find a way to cope with their problems, get off the drugs after a short time, and resume their lives. This is exactly what happens—occasionally. This benign exposure to drugs is not always the case. Other common outcomes include severe side effects that require either multiple drugs in order to counter each other’s side effects, drug dependency and addiction, or a worsening of symptoms after continued use of the drug. Perversely, psychiatrists interpret the inability of a patient to regain functionality after long exposures to drugs as evidence that conditions like depression have somehow switched from episodic to chronic. This of course explains and justifies a lifetime of drug dependence.

The real ethical issue with psychoactive drugs is that of long-term effects. My thoughts on the issue were influenced by two books: Unhinged: The Trouble with Psychiatry—A Doctors Revelations about a Profession in Crisis by Daniel J. Carlat, and Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker.

Whitaker asks the questions: If we are spending so much money on psychoactive drugs why is mental illness increasing rather than decreasing? Could the drugs used be actually worsening the patient outcomes and causing this increase? Whitaker spends his book building a quite convincing case by compiling data and studies that conclude that long-term exposure to these drugs can worsen symptoms, can cause brain damage, and can impair cognitive function.

Carlat is critical of the psychiatric profession for depending too greatly on drugs to the exclusion of other approaches, and he is also highly critical of the unseemly ties between drug manufacturers and their drug vendors (psychiatrists). Carlat believes drugs benefit his patients, but you will struggle to find any mention of long-term side effects. I could only recall one reference, as an aside, about drugs given to children for ADHD causing growth retardation. That may be an off-hand observation to him, but it is a tragedy for the children and parents involved. Especially since he hints that his own former colleagues at Harvard’s Massachusetts General Hospital were responsible for a gross over-diagnosis of ADHD within the profession. For Carlat, there does not seem to be a long term. Patients are looked upon as a problem that must be dealt with immediately, and if some combination of drugs can be found that will allow them to feel in control of their lives, the treatment has been a success. I would love to get Whitaker and Carlat in a room and have them duke it out.

The alliance between drug companies and psychiatrists is probably unique in the healthcare field. The two entities enable each other. There would be no sales without psychiatrists going out and proclaiming that each new generation of drug is the one that is finally the super-drug that will fix all. And psychiatrists could not exist if the drug companies did not keep them supplied with a constant flow of new drugs that can be used to cover up the shortcomings of the previous batches of drugs. This is not a healthy interaction. Carlat goes into great detail in explaining the various ways in which psychiatrists’ integrity can be purchased by drug companies. I was under the impression that the close financial ties between psychiatrists and drug companies provided the worst ethical issues to be dealt with. Unfortunately, I have found something worse.

In reading about these subjects, this collusion between psychiatrists and drug companies aroused the greatest emotion. Then I encountered Kiki Chang and the Stanford Pediatric Bipolar Disorder Program. An article in the San Francisco Chronicle by Julian Guthrie describes Chang and his program. Finding excuses to diagnose young children as suffering from bipolar disorder is no longer new and has gone beyond being controversial (although Whitaker goes to great lengths to demonstrate that bipolar symptoms can be caused by exposing children to antidepressants and the stimulants used for ADHD).

Chang has gone far beyond that stage by attempting to use these psychoactive drugs as a sort of preventive medicine to avoid potential future mental illness.

"’There is a window of time to have a healthy brain,’ said Chang, 43, who runs the Stanford Pediatric Bipolar Disorders Program. ‘Our hope is that if we can get in early, we can prevent it.’ Part of Chang's therapy is to put children at risk for bipolar on medication - something he acknowledges is controversial."

"’We are taking kids who don't yet have bipolar disorder and putting them on medication, something we know is serious,’ he said of the study participants, who range in age from 8 to 18."

"’We hope to find the right medication so the brain develops normally,’ Chang said."

The audacity! The arrogance! He is experimenting with dangerous drugs on children—children who have no signs of illness. Most of these drugs are not approved for use on sick children, let alone healthy ones. I am willing to bet that you could not perform these tests on monkeys without getting formal approval and having peer revues. But doctors can do anything they want to human patients.

To partake in such experimentation consists of (pick one): child endangerment, assault with a deadly weapon, extreme stupidity, mortal sin.... The punishment should be (pick one): lifetime injection with his own drugs, provision of a rope should he become suicidal, eternal damnation....

End of vent....

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