May 17, 2012
In his book Psychiatryland, psychiatrist Phillip Sinaikin recounts reading a scientific article in which it was debated whether a three-year-old girl who ran out into traffic had oppositional-defiant disorder or bipolar disorder, the latter marked by “grandiose delusions” that she was special and cars could not harm her.1
How did the once modest medical specialty of child psychiatry become the aggressive “pediatric psychopharmacology” that finds ADHD, pediatric conduct disorder, depression, bipolar disorder, oppositional defiant disorder, mood disorders, obsessive-compulsive disorders, mixed manias, social phobia, anxiety, sleep disorders, borderline disorders, assorted “spectrum” disorders, irritability, aggression, pervasive development disorders, personality disorders, and even schizophrenia under every rock? And how did this branch of psychiatry come to find the answer to the “psychopathologies” in the name of the discipline itself: pediatric psychopharmacology? Just good marketing. Pharma is wooing the pediatric patient because that’s where the money is. Just like country and western songs about finding love where you can when there is no love to be found at home. Pharma has stopped finding “love” in the form of the new blockbuster drugs that catapulted it through the 1990s and 2000s. According to the Wall Street Journal, new drugs made Pharma only $4.3 billion in 2010 compared with $11.8 billion in 2005—a two-thirds drop.2
Doctors have a “growing fear of prescribing new drugs with unknown side effects,”3explains the Journal, and the government is cracking down on illegal marketing. But also, private and government insurers are less willing to “cough up money for an expensive new drug—particularly when a cheap and reliable generic is available.4
It’s gotten so bad, AstraZeneca, whose controversial Seroquel® still makes $5.3 billion a year though it is no longer new, now conducts “payer excellence academies” to teach sales reps to sell insurers and state healthcare systems on its latest drugs.5No wonder Pharma is finding “love” by prescribing drugs to the nation’s youngest (and oldest) patients, who are often behavior problems to their caregivers, who make few of their own drug decisions, and who are often on government health plans.
“Children are known to be compliant patients and that makes them a highly desirable market for drugs,” says former Pharma rep Gwen Olsen, author of Confessions of an Rx Drug Pusher.6 “Children are forced by school personnel to take their drugs, they are forced by their parents to take their drugs, and they are forced by their doctors to take their drugs. So, children are the ideal patient-type because they represent refilled prescription compliance and ‘longevity.’ In other words, they will be lifelong patients and repeat customers for Pharma.”
Just as it used to be said in obstetric circles, “Once a cesarean, always a cesarean,” it’s also true that “once a pediatric psychiatric patient, always a pediatric psychiatric patient.” Few, indeed, are kids who start out diagnosed and treated for ADHD, bipolar disorder, and other “psychopathologies” who end up on no drugs, psychologically fine, and ready to run for class president. Even if they outgrow their original diagnoses—a big “if” with a mental health history that follows them—the side effects from years of psychoactive drugs and their physical health on mental, social, and emotional development take their toll. Even children on allergy and asthma drugs, which are promoted for kids as young as age one, are now known to develop psychiatric side effects according to emerging research.7
Kids who start out with psychiatric diagnoses are not only lifers—they are expensive lifers usually shuttled into government programs that will pay for psychiatric drug “cocktails” that can approach $2,000 a month. What private insurer would pay $323 for an atypical antipsychotic like Zyprexa®, Geodon®, or Risperdal®, when a “typical” antipsychotic costs only about $40?8
Not all medical professionals agree with the slapdash cocktails. Panelists at the 2010 American Psychiatric Association (APA) meeting assailed Pharma for such “seat of the pants” drug combinations and called the industry nothing but a “marketing organization.”9In a symposium about comparative drug effectiveness, a Canadian doctor castigated the FDA’s Jing Zhang, who had served as a panelist at the symposium, for his agency’s approval of drugs for “competitive reasons” rather than for patient health or effectiveness.10Research presented at the 2010 APA meeting also questioned the psychiatric cocktails. When twenty-four patients on combinations of Seroquel, Zyprexa, and other antipsychotics were reduced to only one drug, there was no worsening of symptoms or increased hospitalizations (except in one case), and patients’ waist circumferences and triglycerides improved (a large waist circumference and high levels of triglycerides [fat] in the blood heighten one’s risk of developing diabetes and cardiovascular diseases).11The drug cocktails were not working and were making patients worse by creating new medical problems.
But pediatric psychopharmacology is a billion-dollar business that sustains Pharma, Pharma investors on Wall Street, doctors, researchers, medical centers, clinical research organizations, medical journals, Pharma’s PR and ghostwriting firms, pharmacy benefits managers, and the FDA itself—which judges its value on how many drugs it approves. The only losers are kids given a probable life sentence of expensive and dangerous drugs, the families of these children, and the taxpayers and insured persons who pay for the drugs.
The father of pediatric psychopharmacology, Harvard child psychiatrist Joseph Biederman, is often called Joseph “Risperdal” Biederman, because he is credited with ballooning the diagnosis of bipolar disorder in children by as much as fortyfold.12In 2008, Biederman, a prolific author who has written five hundred scientific articles and seventy book chapters, was investigated by Congress for allegedly accepting Pharma money he didn’t disclose, and he agreed to suspend his industry-related activities.13After a three-year investigation, Harvard “threw the book” at Biederman and two other professors: they were required to “refrain from all paid industry-sponsored outside activities for one year and comply with a two-year monitoring period afterward, during which they must obtain approval from the Medical School and Massachusetts General Hospital before engaging in any paid activities.” What a deterrent. They also face a “delay of consideration for promotion or advancement.”14