Psychology Today Blogs - Lawrence Diller, M.D.

Truth, Nihilism and Psychiatry

Lawrence Diller, M.D. — Sat, 27 Sep 2008 15:14:00 -0700

My colleague, Nassir Ghaemi, in response to my challenge of his notion of "truth" in psychiatry, unfortunately, responds with media's "third rail" -- connecting this discussion to the advent of the National Socialist Party or Nazis of Germany. He states that post-modernism was a reaction to the modernist thinking that led to the two world wars of the previous century (yet apparently Nazi theorists were post-modernists). I do not want to pursue this highly emotionally laden and volatile example (my parents were Holocaust survivors incidentally) because I see it as arousing unnecessarily inflammatory feelings.

Also the quick link to a vigorous attack on the critics of conflict of interest in medicine strikes me as an underlying agenda. True most of us cheat on taxes, but there are degrees. A drug company pen or pad is one thing (though in a reaction to the gross abuses of late, they may be a thing of the past). Ten of millions of drug company dollars for the maintainance of psychiatry departments, national conventions, conferences to define diagnoses, drug studies, consulting and speaking fees add up considerably compared to the book sales of a Marcia Angell. Whether Nasser agrees or not, the real or just appearance of conflict of interest, threatens to undermine doctor's professionalism. Major reform is in progress.

So I don't want to talk more of Nazis and drug companies. Rather, I remain concerned about how concentrations of power influence the "truth". Russell Barkley, (the ADHD expert, not the philospher) has stated that "No scientific undertakings or hypotheses are completely divorced from the social values of their time and place." All I am suggesting is that doctors and patients recognize that "science" exists within a context so that when Nassir might cite some study to prove a biochemical point I know a priori that the study's most basic assumptions on diagnosis and treatment are also the most challengeable. That doesn't mean that I can't utilize the information from the study but I remain aware of the possible biases introduced in any science.

Mary Bateson, daughter of Gregory Bateson, and a committed relativist, once said, "If a tree falls in the forest I don't say 'I experienced a tree falling'. I say 'A tree fell in the forest.' I am aware that there may be multiple factors involved in my experience so that you and I could agree or disagree about that tree, but for practical and semantic ease I say 'The tree fell in the forest.'" I have no problem with a lithium level being too high at 4.0 mcg and recognizing that appropriate actions need to be taken clinically at that moment. But I remain semi-aware of an entire ideological structure that has set up my experience of that patient's behavior so that I even bother to prescribe lithium and obtain a blood level to monitor it.

I suspect Nassir and I agree clinically on many things but philosophically I worry that his ideas of "truth" and realism have been the instruments of power and exploitation more than my ideas of relativism and post-modern thinking. The latter philosophies do not preclude a moral and legal system -- yet maintain that the moral system is also based upon relativist and power-based agreements. I do not see this as nihilism. I worry about strict constructionists. I've had the opportunity to try to instruct Antonin Scalia, the Supreme Court justice on the difficulties of drawing a line between extremes of normal and the abnormal (we were on an ethics panel together). He just couldn't get it. "Either it's a disorder or it's normal," he insisted. I'm not sure I'll do any better with Nassir.

Truth and Consequences in Psychiatry

Lawrence Diller, M.D. — Sun, 24 Aug 2008 11:47:41 -0700

No scientific theoretical model is completely divorced from the values of the society and power of its time and place. Nassir Ghaemi and I have been asked by Psychology Today's editors to begin a Cross-Talk blog. I was willing to begin by following up on something Nassir wrote about "truth" in psychiatry (the quote is added by me) in a previous post of his on conflict of interest issues in psychiatry

For the sake of the record, here is what Nassir wrote: "To me, the crux of much of this gets to how we understand science. Science is not about adversarial viewpoints that compete with each other, and in fact glory in such confrontation - as, say, in the law, or in the political theory of democracy (countervailing forces). In science, we actually believe there is a truth, and we need to find and speak the truth. This is not the same, by the way, as being "balanced", a phrase commonly used in our current debates about conflict of interest; one cannot be "balanced" about the truth: the truth is the truth. If I show in my research that lithium level of 5.0 will kill patients, it is not anyone's responsibility, nor at all appropriate, for others to try to do research that shows that a lithium level of 5.0 is safe. Unfortunately, much of our thinking about such matters is suffused with a cultural postmodernsim, with deeply held assumptions about the relativity of truth. "

For the life of me I never understood what post-modernism meant in art and architecture. It wasn't until I read Moving Beyond Prozac by the NYU psychiatrist Bradley Lewis that I finally got it. I hadn't realized all these years in my worry about the power of DSM and biological psychiatry that philosophically I might be a post-modernist. I thought I was being a good behavioral pediatrician to recognize the power of inherent child temperament (the nature factor) and the power of family and educational systems (the nurture factor) in framing behavior as a problem in the most accurate and ethical manner (italics intentional -- check in later).

I was fully committed to George Engel's biopsychosocial model of health and illness. That's why when Nassir started ciriticizing the model in his writings and books I was intrigued enough (because I heard that Nassir was smart and he is) to check him out. I've told him I read his book, Concepts of Psychiatry, and didn't get it. It seemed overall as a defense of the multiple duchies that make up the Psychiatry Department at Harvard. Anyway, what is all this post-modernism about, especially as it relates to psychiatry and mental health and illness?

As far as I understand it "modernism" represented a post-Enlightment, primarily 19th Century ideal, that posits there are specific answers to problems not only in science but in life. All that is required are specific questions and accurate "scientific" models for the answers. Science in this case is represented by a notion of unbiased trial and error experimentation. However, by the early-mid 20th century philosophers and critics began to challenge the universality and rigidity of the modernist viewpoint. They recognized that no standard (scientific or otherwise) operates in a social/power vacuum and that the prevailing theories most often reflect the society and power of its time -- which until recently in Western thought was the province of wealthy, older, white guys (like me).

I would submit to Nassir that the most fundamental aspects of any theoretical system (here DSM III) are also its most challengeable. Hey, DSM III in its early most theoretical form was a big improvement over the previous "truth" of DSM II (which at best in its confusion could be at least ignored). But diagnosis in DSM III was categorical (either you had it or you didn't) and individually based -- a big problem for a guy like me dealing primarily with the problems of children presenting to the adult world. Everyone knows that most problems at least in kids (but in adults too) are dimensional in nature and how can you leave out the effects of family, school and neighborhood on children's behavior. For the moment, I won't go any further in my criticisms of DSM III. I want to move on to working under its dictatorship.

Very quickly (as planned, I believe) DSM III took on a biological and concrete sheen. These disorders, primarily the work of "expert" groups (older, white men with power), were no longer theoretical constructs but "real" biological entities (with barely a modicum of proof). I believe organized psychiatry (power again) was desperately looking for a way to maintain its power within the very powerful medical establishment. It took towards copying the "medical model" ,which had conferred many benefits to society (and doctors) but also has major ethical lapses, rather than leading the rest of medicine to a more complete and ethical biopsychosocial model.

The word ethical comes up again. Let me explain. When a diagnostical model focuses on the individual, socially oppressive factors that compromise health are ignored. When one ignores poverty, violence, prejudice, etc., one is essentially treating the victims of society (and perhaps their genetic vulnerability to stress). Surely in extreme cases, social/environmental factors stll play a role but the patient still has a problem. Thus a developmentally delayed, very hyperactive child with a seizure disorder likely has clear neurological problems and should have access, perhaps immediately to medication.

But the vast majority of patients presenting to doctors under the dimensional bell-shaped curve of illness have less severe problems. I have used this example many times, to explain my hesitance about immediately prescribing Ritalin to children who are only mildly to moderately hyperactive. I liken it to a doctor who chooses to continue to rehydrate, orally or intravenously, children suffering from diarrhea and dehydration while ignoring a factory upstream that may be polluting the river and causing the disease. At the minimum to only treat the dehydration and not speak up and attempt to address the cause (or at least a contributing factor to the illness), the physician becomes complicitous with factors inimical to his/her patients. This individual model of the DSM is most redolent of this complicity, especially when it comes to dealing the problems of children (ADHD, bipolar, whatever).

Furthermore, the "modernism" of DSM III, this "truth" that Nassir refers to, purports to make any challenging or contradictory model "unscientific" and unworthy of real scientists' interests. This is where the model becomes hubristic and totalitarian for a practitioner like me. Though I might add the real practical power of DSM III (IV and beyond) has been its value as a billing system for penurious third party payers.

Yes, a high lithium level is definitely worth paying attention to. Ritalin definitely "works" (at least on the short term). None of this is deniable or unimportant. But the very foundations that make it important are potentially oppressive and limited. Again I speak from the position of thirty years of dealing with children's problems. But when Joe Biederman and company speak (with the power of Fortune 500 drug companies supporting their platform), my concerns fit into a thimble compared to their ocean of power.

I agree with Nassir, that the post-modern solutions for psychiatry are too messy to be practical but I think the powers of organized psychiatry could do more to acknowledge context and the psychosocial aspects of behavior. It was great to read Robert Spitzer's (the father of DSM III) preface to Horowitz and Wakefield's The End of Sadness. Similarly I'm intrigued that Paul McHugh is mentioned as a co-author of the paperback version of Nassir's Concepts of Psychiatry (have there been some changes). I know Paul as one of the most sensible curmudgeon's of the psychiatric establishment.

So there -- a first pass at a public discussion of what may seem like an esoteric topic to many of you but I believe is fundamental to the course of mental health and illness of our country -- at least to the limits that the powers that be allow us professionals to have some influence on that course. I'm very interested hear what Nassir thinks.

The Swimming Cure for ADHD?

Lawrence Diller, M.D. — Sun, 17 Aug 2008 21:12:28 -0700

The Swimming Cure for ADHD?

Michael Phelps’ amazing Olympic triumph belies the notion of a chronic disorder

In the next view days you are certain to read more about Michael Phelp’s childhood including his being diagnosed with ADHD and treated with medication at age nine for two years. A front page New York Times piece on Michael today suggested the diagnosis when his third grade teacher, Mrs. Kines, was quoted in a recent letter to his mother, Debbie, as recalling Michael having “immense difficulties concentrating and sitting still” leading Mrs. Kines to wonder “if he would ever be able to focus on anything.”
A quick Google search revealed a July 22nd local Baltimore TV news piece interviewing Debbie about Michael’s ADHD and a FaceBook essay by Debbie about the same subject. Apparently Michael was a very good athlete, talented in a number of sports growing up (no surprise – most athletic superstars have similar multi-sport histories, e.g. Roger Federer and soccer). But he was also quite hyper and not a particularly good student. So, at age nine he was taken to his doctor, given an ADHD diagnosis and started on medication which Debbie only gave him on school days because his weekends and vacations were filled with sports in which he excelled.
By age eleven he had committed himself only to swimming, which Debbie believes was particularly helpful because it was especially structured and highly regimented given his increasingly intense training. Swimming even for a team is also relatively individualistic. From my years of experience treating children with ADHD, I know that they do better with individual oriented sports like swimming or track (even tennis) compared to team sports like baseball (that’s death for an ADHD with all the waiting around in the outfield) or even soccer. At that point he no longer needed medication for school. My guess is that he had matured significantly or was so excelling at sports so as to feel more comfortable even at school. Debbie feels that Michael as an adult still has some aspects of ADHD. She feels his thoughts at times may still jump around some—apparently though not enough for a national media catering to America’s sound byte short attention span to notice.
Still Michael’s story and success are revealing about the ADHD diagnosis and prognosis in children’s mental disorders these days. I’ve said many times, it doesn’t take much in terms of under performance or misbehavior these days for worried and loving middle/upper middle class parents to take their children to a doctor to at least rule out ADHD. Besides giving parents’ an illusion of security in a name, the diagnosis opens the door for school accommodations and services. Stimulant treatment (Ritalin, Adderall, Concerta, etc.) improves everyone’s performance in boring and repetitive tasks so improvement on medication doesn’t necessarily confirm a diagnosis of ADHD but will definitely increase focus and grades on the short term – especially if there are minor learning difficulties (I strongly suspect Michael’s strengths weren’t in academics in his early years).

Michael’s success cannot be fully explained by his athletic prowess alone. His drive must also be incredible and those qualities of personality – persistence and intensity – can be highly problematic in the childhood years when a child’s interests and strengths are not academic. Things change dramatically once a child finds his/her niche which often doesn’t occur until late high school or beyond.
Michael was lucky in that he was so talented physically that he was already on the path to success at age eleven (which is when he no longer needed the drugs). It is just as well since stimulants are banned on the international competitive level in all sports. Not so surprisingly in America where ADHD is more openly accepted, the NCAA and major league baseball will allow an amphetamine positive athlete to compete if he has a doctor’s note confirming ADHD.
The Phelp’s ADHD story is otherwise important for two reasons. First it calls into question whether we should really be labeling a child with Michael with a mental disorder. One could hardly call him impaired at this time of his life. Yet academics regularly pronounce that ADHD is a life-long disorder. Indeed, perhaps the outcome for the well screened highly impaired university selected children with ADHD is more guarded. But for the garden variety, front-line Tom Sawyers, Pippi Longstockings and now Michael Phelps that make up my and most doctors’ practices, the future is much brighter (once they find their niche).
And that’s leads to the second point – that children with strong persistence and drive who are not academically oriented – who hyperfocus on things they like – but not necessarily what their parents and teachers want – have the potential to do great things. Mrs. Kines in her letter to Michael’s mother continued, on how proud she was of Michael and “it had never been focus he lacked, but, rather a goal worthy of his focus.” So if a diagnosis and medication got Michael and other children like him through a tough time (when their personality and talent peg has to fit into particularly rigid hole, e.g. school) then so be it. But one thing I know for sure -- for the immediate future swimming will be the “treatment of choice” for that hard to fit, slightly hyper, poorly focused kind of kid.

There Are No Heroes

Lawrence Diller, M.D. — Sun, 10 Aug 2008 11:01:00 -0700

Are there no heroes? Can you count on anyone these days without the distinct possibility that they will let you down in the future? The twin revelations this past week of John Edwards' acknoweldgement of his affair and the frontpage New York times story on child sexual abuse charges against America's Preemminent pediatrician, Melvin Levine, devastated me.

First, let's do Edwards. John Edwards along with Elliott Spitzer (what is it with these anti-corporate watchdogs?) were my two heroes when it came to policing the totalitarian power (as in Huxley's Brave New World) of the corporations. In my thirty years of practice as a behavioral pediatrician deciding who gets Ritalin -- for about a dozen years I've come to believe that Fortune 500 drug companies are the single biggest influence in our culture with regards to which child is or isn't mentally ill. The whole field of mental health/illness and treatment gets so tilted when corporate profits are so initimately involved in the process.

Therefore, I was so disappointed that registered Democrats did not more fully respond to Edward's campaign messages which in my mind were the clearest articulations of another way of thinking about America's business "not as usual." I had no problem voting for an ex-trial lawyer as a doctor (remember doctors are supposed to hate trial lawyers because of malpractice suits). I believe, in a society where money speaks the loudest and everybody must make a buck somehow, trial lawyers are the single group able to make money by policing corporations. It's a lousy system because victims must turn over up to half of their compensation to trial lawyers. But on the other hand the cost of doing battle with corporations is enormous because since the late 1880's they have been treated with the same rights as an individual, but one who can live forever and has potentially unlimited resources. I have grown to respect the trial lawyers who mortgaged their own homes to continue a fight against the manufacturers of SSRIs which ultimately led the warranted FDA "black box" warning.

So anyway, I cast an absentee ballot for Edwards in the California primary only to have a worthless vote when he pulled out three weeks before election day. I was bitter. Now I'm relieved and bitter in another way over another guy (this seems very much to be a guy thing, even with women in increasing power) getting narcissistic and hurbristic (his own words) and not being able to keep his penis in his pants. I'm relieved because he is not the Democratic candidate but bitter that another anti-corporate hero of mine has bitten the dust.

Then there is Mel Levine. I know Mel personally (not well) for almost thirty years. There were not many mentors in my field of behavioral-developmental pediatrics when I did my fellowship (there were only three fellowships then, now there are over fifty) in the mid-1970s. I really liked Mel's stuff. He was sensible. His notions that children learned differently and were not necessarily retarded if they couldn't read, seems mainstream now but in the early 1970s it wasn't. He wasn't as family systems oriented as my group at UCSF was, but again there weren't many confreres at the time and compared to the psychoanalysts still dominating my arena Mel was sensible (that word again).

Mel went on to co-edit the definitive textbook of behavioral-developmental pediatrics. He established his own fiefdom at University of North Carolina School of Medicine. He wrote a series of popular books, including the best-selling One Mind at a Time, that became the basis of a popular PBS documentary. He's always been sympathetic to my concerns about over diagnosis and the over and misuse of psychiatric drugs in children but was never willing to publicly support me in print. At times I was disappointed with him, especially over the bipolar issue in children -- not coming more publicly forward about his feelings -- because Mel was so powerful within the field of pediatrics and with the media and public in general. But I still respected him and hoped that he might change his mind in the future.

In the public realm of child sexual abuse claims unfortunately, it's the one arena where you're "guilty, until proven innocent." I don't know what to make of the charges of such a respected individual. I tend not to believe any of it but I am bothered by the one report (if confirmed) that he did physical examinations of prepubescent children without the presence of a parent or another professional. That strikes me as strange and I asked another colleague of mine if my memory was correct that when I was in the fellowship, we used to do physical exams, even on the kids with just major behavioral problems, just for the sense of true completeness (When I began my private practice in 1980 I decided not to do physicals and let the primary care doctor be responsible for that aspect). But even in the 1970s, whether in behavioral or general pediatrics, kids under 13 generally had a parent in the room. My memory is that for boys older than 13, when it came time to examining the genitalia (as part of any general physical exam), the mom (usually the parent present) was briefly sent out of the room (I mean for 30 seconds to a minute). I rarely did full gynecological exams on teenage girls, in which case a female nurse would always be present. So I don't get this private physical examination routine but I still know how troubled children and families can misinterpret even the most benign actions (remember McMaster!).

Since I'm naming names, another doctor, facing trial for child sexual abuse charges in January 2009, is William Ayres, the noted child psychiatrist, ex-president of the American Academy of Childand Adolescent Psychiatry. I do not know Dr. Ayres, personally (his practice was in the Bay Area like mine) but he too is charged with sexual abuse during physical examinations. He settled with one family out of court but then other families came forward (many had exceeded the statute of limitations). The local district attorney feels there is enough evidence to proceed with a trial.

So on it goes. I am not prepared to cast stones because you never know when something horrible like this could happen to you (either as victim or professional). My nineteen year old son says "But what about Barack?" Maybe because he is African-American and Hillary is a woman, the two of them have had to transcend an even higher degree of vetting and purity (Hillary had to deal with the consequences of another philandering powerful man). But I'm too broken by these recent series of allegations and revelations to really trust that this won't happen to anyone I care about in public life.

Say It Ain't So Joe

Lawrence Diller, M.D. — Sat, 14 Jun 2008 12:24:00 -0700

Most parents have never heard of him but Joseph Biederman, head of Harvards Massachusetts General Child Psychopharmacology Clinic, may be the most influential doctor when it comes to determining whether or not children are normal or mentally ill in America. That’s why the New York Times report last Sunday on Senator Charles Grassley’s revelation that Biederman did not declare over $1.5 million in drug company consulting fees is so important, scary and tragic. If true, this scandal is yet one more stake in the heart of American academic medicine’s credibility with front-line doctors like myself and more importantly with the parents of the patients I deal with everyday.

The state of the science of children’s psychiatric medications is so primitive and Dr. Biederman’s influence so great that he may merely mention the name of a drug in passing during a presentation and within a year or two, tens of thousands of children will be taking that drug or combination of drugs – based upon word of mouth between the seven thousand child psychiatrists in America – and even in the absence of a drug trial of any kind.

In 1996 Biederman suggested that drugs like Ritalin might serve ten per cent of American kids for ADHD. By 2004, one in nine eleven year old boys was taking the drug. Also in 1996 Biederman “shocked” the established child psychiatric community by announcing pediatric bipolar disorder criteria that were so broad as to include nearly one quarter of all his ADHD clinic patients. Indeed, by 2008 Biederman and his team at Harvard are more responsible than anyone else for the child bipolar epidemic sweeping America (and no other country) that has two year olds on three or four psychiatric drugs and now, one famous (or infamous) ten year old Newsweek cover boy named Max, who has taken 38 different psychiatric medications in his short unhappy life.

I remember about six years ago my dismay when on the same day I read in the main professional journal of child psychiatry a major article by the Biederman team on the advantages of a non-Ritalin drug pathway for ADHD, I also heard him giving a speech for a Wall Street audience in New York promoting a new drug by Eli Lilly called Strattera. Strattera turned out to be rather a bust both clinically and commercially for ADHD but still I was shaken that so prominent a researcher could be so brazen with his potential conflict of interest appearance.

So what does it mean that Biederman didn’t declare the money? The $1.5 million is only a small fraction of the full amount of research funding Biederman’s clinic receives from at least a half-dozen companies that pay for both the cost of running studies but also the salaries of the doctors involved. Virtually every doctor who receives drug company money says they are not influenced, but nearly every independent study examining the effects of such money says they are. At least Biederman can claim no one company has his ear solely.

The leadership of Harvard’s psychiatry department is strangely silent or even defends Dr. Biederman. These are good men with solid reputations both in drug and non-drug aspects of treatment. Yet they know that their psychiatry department would not exist were it not for drug company money -- what with the withdrawal of federal research dollars over the past twenty five years and the meager reimbursements psychiatrists receive for their services from insurance companies and Medical.
American medicine, with psychiatry the most culpable, has fallen back to a time more than a hundred years ago when doctor credibility was tantamount to the promotion of patent medicine. The Welch and Flexner reforms completely severed ties between medical school doctors and the drug industry – and for decades subsequently there existed a much more ethical balance between the industry and physicians.

This time, I thought reform would only come from outside the medicine – from trial lawyers, government and ultimately big business whose health insurance costs must pay for all of those very expensive me-too trade drugs. However, some small signs within the profession encourage me -- like the growth in the interest for the Carlat Psychiatry Report published by a courageous independent front-line psychiatrist who scrupulously examines paid psychiatric research and refuses all advertisements for his newsletter. More recently, I’m proud of the American Medical Students Association which has put pressure on medical faculty by publicly grading from A to F medical schools throughout the country for their conflict of interest policies.

Now I wait for Dr. Biederman’s explanation and the usual suspects rushing to his defense. But ninety years ago painful news about another “Joe” (Joe Jackson of the 1919 Chicago Black Sox) had the country wishing “Say it ain’t so.” It is with great sadness, I wonder, whether it is not now Dr. Biederman’s turn.

Thoughts About Quitting the Field Again

Lawrence Diller, M.D. — Wed, 28 May 2008 21:21:37 -0700

I only read Newsweek’s cover story from last week (May 26, 2008), “Growing Up Bipolar: Max’s World,” yesterday. The piece by Mary Carmichael relates in great detail the travails of a boy named Max who was diagnosed “bipolar” at age eighteen months by a Tufts University child psychiatrist. He is now ten and a half and by his parents’ reckoning he has been on 28 different psychiatric drugs. The article left me feeling profoundly depressed about my profession and what we are offering as help to children and their families today.

I’ve always been an outsider to child psychiatry. My path towards the mental health professions was through behavioral-developmental pediatrics and family therapy. I’ve never rejected the use of medication in children and have prescribed psychiatric drugs children for thirty years but for about the last decade and a half I’ve been quite disturbed to see how we use these drugs in children often in the absence of other effective non-drug treatments.

So I feel shock and dismay when I read of Max’s course and treatment. I read the article twice hoping to find what I was missing – some remarks on counseling for the parents to help them parent this very, very difficult child. He gets some play therapy which for these kinds of problems is generally useless. I saw somewhere rather late in the game a therapist was coaching them using Robert Greene’s The Explosive Child approach. But that is conceding that more effective discipline of Max was impossible. Not surprisingly Max’s father couldn’t get behind the bargaining/cajoling aspects of the Explosive Child. Indeed very few people outside the immediate family are likely to negotiate with an unruly boy to the extent to which this approach calls.

But Carmichael hardly raises such issues about parenting. She acknowledges the parents have a fundamental disagreement, mom is too soft for dad and dad is too hard for mom – a classic triangle with a difficult kid. The “difficult” part here is Max’s personality which from the time he was a baby was intense, persistent and overly sensitive. Except for autism and mental retardation I believe this temperament triad in combination with inadequate parenting is the basis of nearly all psychiatric diagnoses in children.

But what do we get from Carmichael – she buys into the latest pseudoscientific diagnostic mumbo-jumbo. Bipolar disorder with co-morbidity is invoked to include nearly every diagnostic category for children to describe Max’s recalcitrant behavior. And the saddest part for me is how main stream journalism has bought this message from “the industry” virtually hook, line and sinker.

I felt similar hopeless and depressed after viewing the much anticipated, “Medicated Child,” also about pediatric bipolar disorder, on PBS Frontline in February. I had worked closely with the producer – getting her interested again in children’s psychiatric medication (she had done an excellent balanced documentary on ADHD and Ritalin six years earlier). This time, however, in the name of journalistic neutrality non-drug interventions for this entity, pediatric bipolar disorder, were barely mentioned. The whole absurdity, using DSM – IV criteria for children as young as two, was not addressed. I was on the show for eight seconds (trimmed from an hour’s interview) which I feel accurately represented how far the “center” had moved from my concerns and worries about how we deal with children’s problems today.

So I read the Newsweek piece and felt again, like I did with the Frontline show, about giving up, quitting trying to make any difference in this crazy world of child mental health. I’ve been publicly raising questions about what we are doing with psychiatric drugs for a dozen years and apart from some sensible retreat from the overuse of SSRIs in children for depression, everything else has gotten worse. I had no illusions when I began speaking out that I would make any difference but I was hoping others in my profession or in the mental health world would step up and speak out also. Organizing is not my forte, so I was hoping someone else would try to create a responsible organization (Peter Breggins’s group is totally anti-medication which I feel is too extreme and doesn’t allow for the short term value of some of these medications). But it hasn’t happened. So now I’m writing this blog that probably no one will read. How long can this craziness continue without a loud public professional scream

ECGs, ADHD, Ritalin...Oh My!

Lawrence Diller, M.D. — Sat, 10 May 2008 17:40:08 -0700

On April 21st, the American Heart Association (AHA) shocked families and professionals alike when it recommended that all kids that take or may take Ritalin should have an electrocardiogram (ECG). Stimulant drugs like Ritalin, Concerta and Adderall have been used in children for ADHD for 70 years. Why this recommendation now -- and should you get one for your child if he/she takes one of these drugs?

I read and reread the article in Circulation (the official journal of the AHA) four times trying to make sense of the main points and recommendations. I’ve spoken to two high up academic child psychiatrists. I am awaiting a call back from my contact pediatric cardiologist. We’ve consulted before on a boy with severe ADHD whom I’ve treated with Concerta who also has had surgical repair of his heart that was missing his left ventricle when he was born.

The AHA evaluation and recommendations were prompted by reports two years ago of the sudden deaths of 18 children while taking a prescription stimulant drug over a five year period (1999 to 2004). Only seven of these children were found not to have structural heart problems. Their deaths were felt to be caused by severe irregular heart beats associated with their basic cardiac condition and exacerbated by taking the medication.

For six months the Canadian equivalent of the FDA banned Adderall (felt to be the drug of most concern) for children in Canada. However, after considering all the numbers (how many children take the drug) and the relative risk, the ban was rescinded. Now come the AHA recommendations that include obtaining an ECG for any child (even those without any cardiac symptoms or family history) being considered for a prescription stimulant. The AHA recommends that all children currently on stimulants also get an ECG. Also if the first ECG was obtained before the age of twelve a second ECG should be performed when the child is a teenager.

I commented on this problem of sudden death two years ago. Most of you aware of my writing and stance know that I’ve been prescribing stimulant medication to children for thirty years even as I feel we over prescribe and don’t sufficiently pursue effective non-drug interventions for problems of children’s behavior and performance (at school). I’ve never felt that stimulants were dangerous and I believe they are effective in the short term. My calls for caution were based more for ethical than medical reasons.

Two years ago I tried to figure the risk for a child without heart disease of dying suddenly while taking a stimulant. I used seven as the numerator – the number of kids who died without heart disease present -- and four million as the denominator for my estimate of the number of kids under the age of eighteen taking stimulant drugs in America in 2006. I came up with a number with five zeroes after the decimal point (.00000175) or 0.000175 per cent, approximately two ten thousandths of a per cent chance of dying suddenly if the child is taking a stimulant drug. This represents what I call an “existential” level of risk.

I am not certain of my numbers but suggested the likelihood of getting killed on the local freeway on a Saturday night by a drunk driver was probably higher – and still we take freeways because it gets us from one place to another faster. I’m not sure what the accident rate on surface roads are but it’s all meaningless in terms of real risk – much like debating how many angels dance on the head of a pin.

Even taking eighteen as the numerator and lowering the denominator to 2.5 million (the CDC estimate of the number of children taking stimulants) one gets about four times the risk – now seven ten thousandths per cent – but still infinitesimal. So why did the AHA make their recommendation?

I could answer cynically as say this was a real CYA move so that the AHA and pediatric cardiologists could tell child psychiatrists, pediatricians and family physicians, “See we gave you our warning,” should the public mood ever change over the propriety of the widespread use of stimulant drugs in children. But the AHA recommendation brings up an ethical dilemma for parents (and doctors) who want to feel that they took every possible precaution in the unlikely event (and we’re talking on the level of lightning strikes or lotto winners) of a catastrophe.

The AHA acknowledges that an abnormal ECG alone does not represent a complete contraindication towards using a stimulant drug for a child. Rather AHA experts suggest the family and pediatric cardiologist discuss the relative risks. I suppose in a truly borderline decision it might psychologically (because scientifically, the risk is so so low) have a family lean towards not using the medication for the child. As someone who feels the medication is generally over prescribed, I suppose I should be pleased with this result but I’m not, if the basis is a hysteria over existential risk.

I am planning to let parents decide for themselves. I will give them my opinion that I am willing to assume the theoretical added risk in not knowing whether or not a child has asymptomatic cardiac disease. However, if the family wants to obtain an ECG for their child I will support it. I suspect some of the more anxious parents will opt to get the ECG for their kid. Has anyone in this imbroglio figured in the slightly higher rates of suicidality when one prescribes an SSRI to an anxious child? Confronting hypocrisy and propaganda has routinely been my motive for speaking out and writing. Overreaction and hysteria even in well thought out scenarios require my challenging the “authorities” again.

Mr. Rogers Was Wrong

Lawrence Diller, M.D. — Sun, 20 Apr 2008 10:32:15 -0700

He closes his review with the following quote," It stands to reason, though, that parents must be part of the problem. Some of us have raised dummies and the disengaged not on purpose, surely, but perhaps because we listened to Mr. Rogers and told them (the kids) too often that we liked them just the way they were."

I've watched with concern, helplessness, frustration and bemusement the fruits of our culture's over emphasis on feelings in general and its fixation over children's self-image and self esteem. These are huge cultural trends (read the first essay in my book, The Last Normal Child) that are now playing themselves out, as children raised under these "rules," are now maturing into their mid-twenties.

A rash of books, including my own, is documenting the untended consequences about all this concern and fussing. They include in no particular order Perfect Madness: Motherhood in the Age of Anxiety by Judith Warner, The Price of Privilege by Madeline Levine, One Nation Under Therapy by Sally Satel and most recently, A Nation of Wimps by Psychology Today's Hara Marano. I'm not sure what else is happening out there in media land (TV documentaries pending or websites etc.) but these books could be signalling a tipping point (finally) in our culture's over obsession with feelings and feeling good -- at least on how it can harm our children.

I've been thinking for years that if you want kids to feel good about themselves (and in a moment I'll tell whether that's even all that important) there have to be three ingredients. First and foremost, you've got to get those kids to perform. Here I'm not calling for pre-Harvard/Stanford performance in pre-school. But rather if a kid only listens to his/her parents once out of five times and the parents on the fifth time congratulate the kid for his excellent behavior I can tell you that kid is still going to feel lousy about himself because four of five times, he didn't do what his/her parents said and internally to kids that means "I'm bad." (No matter how much you say "It's not you, Johnny, that's bad -- it's what you did," kids until about age eight cannot intellectually make the distinction -- ask Piaget.) So you've got to get that kid to comply whether through using positives or dare I say discipline (punishment lights up in red on my email screen every time I use the word which I find totally amusing and apropos).

Next, when the kid does perform you've got to acknowledge it otherwise the kid never knows what's good enough. This in general I don't find a problem with the families I work with in that parents are saying "good job" these days for kids' who handle breathing and blinking well enough.

Finally -- and this comes much later for most kids -- is an acknowledgment of difference -- meaning everybody's different and you can't be good at everything. This point hits kids particularly in early adolescence and may not get worked out until one's twenties (that long ain't that bad by the way). However a kid with learning differences may experience this crisis in elementary school so acknowledgment of difference and finding areas of relative competency (everyone has at least one or two) can be helpful.

Still and all the whole self-image/self-esteem concern is blown way out of proportion in terms of long term outcomes. Baumgarten has show quite strongly that self-esteen under the age of thirteen has no predictive value on how kids turn out in their mid-twenties. There are minimal correlations for teen's self-esteem and young adult outcomes. So all this worry about how children feel -- and of course we'd prefer as parents that our kids feel good -- if it leads to weird and untoward outcomes (like wimps or increased diagnoses of ADD/ADHD) should be challenged.

So now we're getting all these books. Ironically, the only thing that hasn't changed is parents' readiness to forego their own common sense and the wisdom of grandparents (yeah, our parents in the 50s and 60s didn't seem to do all that bad after all) and continue to turn to experts who are now reversing 180 degrees their advice from twenty-five years ago.

And you know, it really all doesn't matter in the end. Judith Rich Harris was pilloried ten years ago with her book, The Nurture Assumption, because she was interpreted by critics as saying it's all genetic and parenting doesn't matter. Well, if you look at identical twins reared apart by different families you're impressed with how similar they are by the time they reach thirty. But Harris never said parenting doesn't matter.

If you married your spouse with the idea that you could fundamentally change his/her personality and behavior most of us would consider that naive. However how you act with your spouse on a day to day basis could make a big difference in the quality of that on going relationship. Harris uses that example to try to get parents to chill some in their worry and interventions over their kids. Hey, it'll mostly all work out -- even those kids who've been babied and pampered and worried over by those helicopter parents. It'll all work out. Mr. Rodgers wasn't wrong. He doesn't matter.

MDs Under Pharmarchy: Cooperation or Resistance?

Lawrence Diller, M.D. — Thu, 17 Apr 2008 20:29:19 -0700

On Tuesday in the science section of the New York Times, long time reporter Gina Kolata interviews former chief editor of the New England Journal of Medicine, Jerome Kassirer about his views on doctors facing ethical dilemmas taking drug company money for research or expert speaking. Then she interviews three doctors who have chosen to no longer accept drug money and wonders whether this will be a growing trend in academic medicine.

On Wednesday, in the business section of the Times, Stephanie Saul, reports on an article that appears in this week's Journal of the American Medical Association on scientific journal articles ghostwritten by pharmaceutical industry hired writers then signed by doctor-leaders in the respective field of expertise. The article comes from legal documents obtained during the Vioxx trials and suggests that the practice is quite widespread. The doctors implicated offer weak defenses ("The fact that the draft was written by a Merck employee for later discussion does not in and of itself constitute ghostwriting"). The editor of JAMA that accepted one of the article was not so charitable, "I consider that being scammed."

Danny Carlat, a psychiatrist, who publishes an independent review of psychiatric drugs and therapeutics, The Carlat Newsletter, has been complaining about ghostwritten articles for a couple of years now and it's good that it is getting the attention in mainstream medical journals and newspapers.

What's at stake here apart from good or bad research is the hardwon credibility of doctors as scientists and advocates for their patients. One hundred years ago in this country doctors were considered little more than hucksters for various patent medicines and many neer do well sons of rich scions were sent off to medical school where diplomas could be bought. The professional self-reform efforts led by William Welch of Johns Hopkins and the effects of Flexner Report on medical education created a firewall between the drug companies of old and the medical education of new doctors that was strongly based upon the German/European model of the time. Doctors once again are on the verge of losing their credibility, after nearly 30 years of the Bayh-Dole act passed during the Reagan administration which encouraged financial ties between industry and medical academia.

I have never received money from drug companies but twenty years ago I worked briefly for a start up venture capital firm out to develop educational toys and programs for toddlers to five years old children. I was on the science board and it was my job to vet the product but especially manage the very aggressive marketing set up for these products. I remember saying "You can't say this. You can't say that. Okay you can say this." I often felt that if there was any way I could stretch what I believed to be true to cover what the marketers wanted to say I would try. It was natural. They were paying me. I wanted to help. There were stock options. I wouldn't lie but short of lying if there was some version of the truth that would work I would allow the marketers their version. P.S., the product line failed in part because the marketing never clicked.

I'm neither angel nor devil but I believe that process that worked on me works on all doctors taking money from drug companies today. One doctor in the article said things have changed from 20 years ago. I agree, 20 years ago the doctors had more control (interestingly when the profession separated 100 years ago the drug companies became quite beholden to the doctors). Now we live in a Pharmarchy so any doctor on the Pharma dole faces ethical challenges and scrutiny. The doctors who choose to turn down drug money decided it was no longer worth it to them. Unless, the bulk of my profession makes the same choice, the image and credibility of doctors in our country will inevitably fall.

The Coronation of Pharmarchy

Lawrence Diller, M.D. — Sat, 12 Apr 2008 09:53:33 -0700

The last consensus conference on ADHD in 1998 was meant to trumpet the initial findings of the government's MTA study which at that time was indicating that Ritalin (meaning all the prescription stimulants) worked. This was no great news to most of us in the field but enough controversy remained about Ritalin that the leaders in child psychiatry research (funded primarily by drug companies - though not this particular study) wanted once and for all to end questions about Ritalin.

But in fact the conference was a disappointment to the establishment as the neutral (non experts in the field of chlid psychiatry - doctors, lawyers, parents, etc.) found the evidence that ADHD was simply a brain based disorder not convincing and in not being clear about etiology, did not want to advocate one treatment over another. Nor could the panel recommend preventative strategies. The conference acknowledged the problems of behavior and performance in children and recognized the barriers to getting effective interventions.

Ten years later the triumph of our "pharmacrocy" is nearly complete. The venerable radical avatar of anti-psychiatry, Thomas Szasz, coined this term in a 2001 book. Since he gets credit for that neologism I propose my word "pharmarchy" to mean the absolute power a monarch wields over his/her subjects alluding to the power the drug industry in league with medical researchers now influences our thinking about children and mental health in our country.

If the NIMH bites and convenes another conference I predict the public will be inundated with industry financed experts (each one of them are good men and women who sincerely believe in their research but data and common sense show that they are influenced by their financial sponsors) who will declare the solely biological basis of ADHD trotting out genetic and brain scan data as evidence. The "nature" aspects of this "disorder" in this setting will overwhelm the "nurture" (read family, school, social, economic, and political aspects) with all the usual implications: it's no one's fault (very appealing but then also denies responsibility) and that medication makes the most sense in treating a biological disorder.

I am so tired and weary of this reductionistic, simplistic ultimately unethical view of children's behavior. I've been at this for nearly 15 years (30 years in practice) and recognize society's own responsibility in devouring this propaganda. Anyone who has read my stuff over the years know that I believe there is a biological/genetic/chemical component to all behavior but that's only the beginning of understanding and treating ADHD.

Phenylketonuria deficiency of PKU deficiency is a genetic disorder that all babies are screened for with a heel-stick blood test shortly after birth. Why? Because if you eliminate phenylalanine from a child's diet right at birth, the child grows up to be entirely normal. Untreated, severe mental retardation ensues. Here is a clearly genetic disorder but is "treatable" with a environmental intervention.

I'm not making the case for changing children's diets for ADHD (the evidence for the effectiveness of such interventions is rather weak unfortunately). But I want to nail this reductionistic approach for everyone -- not that it matters. My blog's point will overwhelmed daily by countless drug company ads suggesting to parents "It your child's brain, stupid!"

So we will have this conference if the AACAP has it's way. The government generally caves to industry. I suspect I will even be invited as one of the token heretics. The last time William Carey was the stand-in. He began his presentation with a slide of St. Stephen at the Cross (apparently a saint who after crucifixion also had arrows shot through him). My favorite slide these days is that of Sisyphus. You know that guy in the loin clothe condemned by the gods (by the way what he do wrong to deserve such a fate?) to push the boulder uphill only to have it roll down and start over again. These days I find the slope of that hill becoming steeper and steeper. Oh my.