Robert Whitaker’s Hypotheses About Childhood Bipolar Disorder

I read Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America as a counterpoint assignment in one of the diagnosis classes in my Couples & Family Therapy program. It is an excellent book about the history and science of several psychological problems, both as phenomena and diagnoses, including depression, depression, bipolar disorder, ADHD, and schizophrenia. As a university student, I had the opportunity to check out, for free, any of the many academic citations in the book that piqued my interest; each one that I looked at seemed indeed to provide the evidence he claimed. I haven’t read anything like all of them (there are nearly 700 citations), but enough to satisfy myself that Whitaker has done some good journalism here, and that his hypotheses are credible.

Two of these hypotheses is about childhood bipolar disorder, the first of which he calls the “ADHD to bipolar pathway.” The side effects of stimulants such as those used to treat ADHD are substantially similar to bipolar symptoms, as shown in the table below, from p. 238. (The formatting here is slightly different than Whitaker’s, thanks to an Open Office/Wordpress interaction.) Multiplying the estimated rate of stimulant-induced bipolar-like symptoms by the 3,500,000 children and teens taking those medications, Whitaker estimates we should see approximately 400,000 “bipolar youth” as a result.

The ADHD to Bipolar Pathway

Stimulant-Induced Symptoms Bipolar Symptoms
Arousal Dysphoric Arousal Dysphoric
Increased lethargyIntensified focusHyperalertnessEuphoriaAgitation, anxietyInsomniaIrritability

Hostility

Hypomania

Mania

Psychosis

SomnolenceFatigue, lethargySocial withdrawal, isolationDecreased spontaneityReduced curiosityConstriction of affectDepression

Emotional lability

Increased energyIntensified goal-directed activityDecreased need for sleepSevere mood changeIrritabilityAgitationDestructive outbursts

Increased talking

Hypomania

Mania

Sad moodLoss of energyLoss of interest in activitiesSocial isolationPoor communicationFeelings of worthlessnessUnexplained crying

The second part of Whitaker’s thinking on childhood bipolar disorder is an SSRI to bipolar pathway. Estimates of the rate of the well-know SSRI side effect of mania, multiplied by 2,000,000 children and adolescents on the medications, give us the possibility of producing at least 500,000 SSRI-induced bipolar disorders in young people.

If true, these hypotheses could go a long way to explain the skyrocketing rates of childhood bipolar disorder diagnoses, as most diagnoses of childhood bipolar disorder are made on children who are already taking stimulants and/or SSRIs. The primary alternative, and more mainstream, hypothesis is not that stimulants and SSRIs are iatrogenic, but that since those medications solve the problems of ADHD and depression, the symptoms of bipolar disorder that emerge show that the diagnostician had initially guessed wrong, and that bipolar disorder was the previously-existing and underlying cause of the ADHD and/or depression. This, of course, may be true, but it seems very important to discover for certain whether it is!

(Originally published here on Nathen’s Miraculous Escape.)

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Fake Drugs

These fake drug commercials are hilarious. Maybe it’s just that I have psych-meds “on the brain” because I’ve just finished a child-diagnosis class and reading Robert Whitaker’s Anatomy of an Epidemic.

Despondex

Havidol

Nexoriatin

[First published on Nathen’s Miraculous Escape, March 13, 2011.]

Headlines From Psychology, Part 4

Psychology hit the actual headlines last week, with Sharon Begley’s “The Depressing News About Antidepressants” in Newsweek. The story is that, if you look at all the evidence, not just the “successful” trials, SSRIs like Prozac and Paxil do not work better than a placebo for mild and moderate depression. Begley also tells the story as if she’s sorry to break the news and spoil the placebo effect. Here’s my version of the headlines from this story:

Pharmaceutical Companies Have Known For At Least Ten Years That SSRIs Work No Better Than Placebos: At least, anyone there who understood statistics and paid any attention to their research.

The Idea That SSRIs Are Better Than Placebos Was Propagated By Publishing Only the “Successful” Trials: This, obviously, was quite unethical.

The FDA Almost Certainly Knew That SSRIs Were No Better Than Placebos, Too: They had all of the research. Perhaps they did not read it.

People Who Read Psych Journals Knew SSRIs Were No Better Than Placebos Two Years Ago: The news caused a stir in my undergrad psych lab in 2008.

We Do Not Know What Causes Depression: The idea that depression has to do with the neurotransmitter serotonin was based largely on the (incomplete) evidence that SSRIs (selective serotonin re-uptake inhibitors) cured depression. In fact, we have pretty limited knowledge of what goes on inside a living brain. In fact, we have no ethical way to measure how much serotonin or any other neurotransmitter is where inside anyone’s living brain, so when a doctor tells you something like, “You are depressed because you have overactive serotonin re-uptake mechanisms,” they are passing on speculation, not science.

If You Recovered From Mild to Moderate Depression While On An SSRI, It Was Probably Your Own Hope That Lifted You Out: The thing about placebos is that they work pretty well. If you benefited from the placebo effect, it was your own strength, your own hope, that made the difference. You overcame that challenge. I think that’s pretty cool.

While SSRIs Do Not Treat Depression Better Than Placebos, They Do Have Side Effects: Here’s a list from wikipedia: Decreased or absent libido, Impotence or reduced vaginal lubrication, Difficulty initiating or maintaining an erection or becoming aroused, Persistent genital arousal disorder despite absence of desire, Muted, delayed or absent orgasm(anorgasmia), Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia),Premature ejaculation, Weakened penilevaginal or clitoral sensitivity, Genital anesthesia, Loss or decreased response to sexual stimuli, Reduced semen volume, Priapism (persistent erectile state of the penis or clitoris)anhedonia, apathy, nausea/vomiting, drowsiness or somnolence, headache, bruxism (involuntarily clenching or grinding the teeth), extremely vivid and strangedreams, dizziness, fatigue, mydriasis (pupil dilation), urinary retention, changes in appetite, changes in sleep, weight loss/gain (measured by a change in bodyweight of 7 pounds), may result in a double risk of bone fractures and injuries, changes in sexual behaviour,increased feelings of depression and anxiety (which may sometimes provoke panic attacks), tremors (and other symptoms of Parkinsonism in vulnerable elderly patients), autonomic dysfunction including orthostatic hypotension, increased or reduced sweating, akathisia, liver or renal impairment, suicidal ideation (thoughts of suicide), photosensitivity (increased risk of sunburn), Paresthesia, Maniahypomania, sexual dysfunction such as anorgasmiaerectile dysfunction, and diminished libido, a severe and even debilitating withdrawal syndrome, a slight increase in the risk of self-harm, suicidal ideation, and suicidality in children, neonatal complications such as neonatal abstinence syndrome (NAS) and persistent pulmonary hypertension, and platelet dysfunction.

Until Your Medicated Kids Are Old, We Will Not Know What All of the Side Effects of Treatment by SSRIs Are: This is true for any new drug, and it’s worth considering. If your child is on Prozac or other new drug, they are essentially part of a massive experimental trial.

Pharmaceutical Companies Pay for Psychiatric Educations: Why would it surprise anyone that treatment equals drugs in this case?

Most Antidepressant Prescriptions Written by Health Care Providers With No Significant Psychiatric Training: GPs, OBGYNs, pediatricians, etc account for 80% of SSRI prescriptions.

[First published on Nathen’s Miraculous Escape, February 19, 2010.]

Headlines From Psychology, Part 3

This is part 3 of a series of things I learned during my Bachelor’s degree in psychology that I thought should have been headlines in the mainstream news. If you missed them, here’s part 1and part 2. Again, if you’re interested or skeptical, leave me a comment with a specific question and I’ll give you my references.

Egaz Moniz Was Given the Nobel Prize for Medicine in 1949 for Developing the Prefrontal Lobotomy: This “psychosurgery” involved slicing or scrambling the front part of the brain, and tended to produce more manageable behavior in “patients.”

40,000 Human Beings Were Lobotomized in the United States Between 1936 and 1977: These were men, women, and children with “illnesses” like schizophrenia, PTSD, depression, anxiety, homosexuality, criminal behavior, and being hard to manage.

Antipsychotic Thorazine Hailed as “Chemical Lobotomy”: Yes, this was meant as a compliment.

200,000,000 Prescriptions for Antidepressants in the US in 2007: That’s quite a few prescriptions.

80% of Antidepressant Prescriptions in the US Not Written by Psychiatrists:Consider that it may be a good idea to at least see a specialist in mental illness before taking psychotropic drugs or giving them to your kids.

Some Psychopharmaceuticals as Effective as Exercise in Treating Depression: But who wants to exercise when you’re depressed?

Sleep Deprivation the Most Effective Treatment For Depression, By Far: Never heard of this one? Maybe it’ll hit the news when someone figures out how to make money from sleep deprivation.

The World Health Organization Found That Schizophrenics Recover, But Only in Countries Without Easy Access to Psychopharmaceuticals: Schizophrenics can recover? Well, yes, it looks like they can. And yes, the WHO data shows a correlation, not necessarily causation, but an interesting correlation!

[First published on Nathen’s Miraculous Escape, January 30, 2010.]