Healthy Skepticism Library item: 12210

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Publication type: Journal Article

Healy D, Le Noury J.
Pediatric bipolar disorder: An object of study in the creation of an illness
International Journal of Risk & Safety in Medicine 2007; 19:(4):209-221
http://iospress.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,5,9;journal,1,27;linkingpublicationresults,1:103162,1

Abstract:

In the past decade bipolar disorder in children has been diagnosed with rapidly increasing frequency in North America, despite a century of psychiatric consensus that manic-depressive illness rarely had its onset before adolescence. This emergence has happened against a background of vigorous pharmaceutical company marketing of bipolar disorder in adults. In the absence of a license demonstrating efficacy for their compound for bipolar disorder in children, however, companies cannot actively market pediatric bipolar disorder. This paper explores some mechanisms that play a part in spreading the recognition of a disorder in populations for which pharmaceutical companies do not have a license. These include the role of academic experts, parent pressure groups, measurement technologies and the availability of possible remedies even if not licensed.

Full text:

First, each company has produced patient literature and website material aimed at telling people more about bipolar disorder, often without mentioning medication; this is a feature of what has been termed disease mongering [32]. In the case of Zyprexa, patient leaflets and booklets – routed in Britain through a patient group, the Manic-Depressive Fellowship – aim at telling patients what they need to do to stay well. Among the claims are “that bipolar disorder is a life long illness needing life long treatment; that symptoms come and go but the illness stays; that people feel better because the medication is working; that almost everyone who stops taking the medication will get ill again and that the more episodes you have the more difficult they are to treat”.4

A similar message is found in a self-help guide for people with bipolar disorder sponsored by Janssen Pharmaceuticals which under a heading ‘the right medicine at the right time’ states: “Medicines are crucially important in the treatment of bipolar disorders. Studies over the past 20 years have shown without a shadow of doubt that people who have received the appropriate drugs are better off in the long term than those who receive no medicine” [8].

If studies had shown this, there would be a number of drugs licensed for the prophylaxis of bipolar disorder when in fact until recently lithium was the only drug that had demonstrable evidence for prophylactic efficacy but even this had not received a license from the FDA. More to the point all studies of life expectancy on antipsychotics show a doubling of mortality rates on treatment compared to the non-treated state and this doubling increases again for every extra antipsychotic drug that the patient takes [25].
Patients taking these drugs show a reduction of life expectancy of up to 20 years compared to population norms [6].

Furthermore, to date when all placebo-controlled studies of Depakote, Zyprexa and Risperdal in the prophylaxis of bipolar disorder are combined they show a doubling of the risk of suicidal acts on active treatment compared to placebo [21,38]. In addition, valproate and other anticonvulsants are among the most teratogenic in medicine [10]. These claims about the benefits of treatment therefore appear misleading. No company could make such public statements without the regulators intervening. But by using patient groups or academics, companies can palm off the legal liability for such claims [20]. xxxxxxx

The sixth strategy involves the co-option of academia and is of particular relevance to the pediatric bipolar domain. The American Psychiatric Association meeting in San Francisco in 2003 offers a good symbol of what happened. Satellite symposia linked to the main APA meeting, as of 2000, could cost a company up to $250,000. The price of entry is too high for treatment modalities like psychotherapy.

There can be up to 40 such satellites per meeting. Companies usually bring hundreds of delegates to their satellite. The satellites are ordinarily distributed across topics like depression, schizophrenia, OCD, social phobia, anxiety, dementia and ADHD. At the 2003 meeting, an unprecedented
35% of the satellites were for just one disorder – bipolar disorder.8 These symposia have to have lecturers and a Chair, 9 and 57 senior figures in American psychiatry were involved in presenting material on bipolar disorder at these satellites, not counting other speakers on the main meeting
program. One of these satellite symposia, a first ever at a major meeting, was on juvenile bipolar disorder.

The upshot of this marketing has been to alter dramatically the landscape of mental disorders. Until recently manic depressive illness was a rare disorder in the United States and Canada involving 10 per million new cases per year or 3300 new cases per year. This was a disorder that was 8 times less common than schizophrenia. In contrast bipolar disorder is now marketed as affecting 5% of the United States and Canada – that is 16.5 million North Americans, which would make it is as common as depression and 10 times more common than schizophrenia. Clinicians are being encouraged to detect and treat it. They are educated to suspect that many cases of depression,
anxiety or schizophrenia may be bipolar disorder and that treatment should be adjusted accordingly [23]. And, where recently no clinicians would have accepted this disorder began before adolescence, many it seems are now prepared to accept that it can be detected in preschoolers.

3. Bipolar disorder in children
The emergence of bipolar disorder in children needs to be reviewed against the background outlined
above. Until very recently manic-depressive illness was not thought to start before the teenage years and even an adolescent onset was atypically early. The clearest indicator of change came with the publication of The Bipolar Child by Papolos and Papolos [35]. This sold 70,000 hardback copies in half a year.
Published in January 2000, by May it was in a 10th printing. Other books followed, claiming that we
were facing an epidemic of bipolar disorders in children [24] and that children needed to be treated
aggressively with drugs from a young age if they were to have any hope of a normal life [12]. Newspapers throughout the United States reported increasingly on cases of bipolar children, as outlined below.
A series of books aimed at children with pastel colored scenes in fairy tale style also appeared. In My Bipolar Roller Coaster Feelings Book [23], a young boy called Robert tells us he has bipolar disorder. As Robert defines it doctors say you are bipolar if your feelings go to the top and bottom of the world, in roller coaster fashion. When Robert is happy he apparently hugs everybody,
he starts giggling and feels like doing backflips. His parents call it bouncing off the walls. His
doctor, Doctor Janet, calls it silly, giddy and goofy.

Aside from giddiness, Robert has three other features that seem to make the diagnosis of pediatric
bipolar disorder. One is temper tantrums. He is shown going into the grocery store with his Mum and
asking for candy. When she refuses, he gets mad and throws the bag of candy at her. His mum calls this rage and he is described as feeling bad afterwards.

Second, when he goes to bed at night Robert has nightmares. His brain goes like a movie in fast
forward and he seemingly can’t stop it. And third, he can be cranky. Everything irritates him – from the seams in his socks, to his sister’s voice, and the smell of food cooking. This can go on to depression when he is sad and lonely, and he just wants to curl up in his bed and pull the blanket over his head. He feels as though it’s the end of the world and no one cares about him. His
doctor has told him that at times like this he needs to tell his parents or his doctor and he needs to get help.

Dr. Janet gives Robert medication. His view on this is that while he doesn’t like having bipolar disorder, he can’t change that. He also doesn’t like having to take all those pills but, the bad nightmares have gone away and they help him have more good days. His father says a lot of kids have something wrong with their bodies, like asthma and diabetes and they have to take medicine and be careful, and so from this point of view he’s just like many other children.

His parents have told him that his bipolar disorder is just a part of who he is, not all of who he is. That they love him and always will. Finally his doctor indicates that it’s only been a little while since doctors knew that children could have bipolar disorder, and that they are working
hard to help these children feel better.

In another book, Brandon and the Bipolar Bear, we are introduced to Brandon, who has features in
common with Robert that the unwary might fail to realize indicate bipolar disorder [1]. When we are
introduced to Brandon, he has just woken up from a nightmare. Second, when requested to do things
that he doesn’t want to do he flies into a rage. And third, he can be silly and giddy.
His mother takes both Brandon and his bear to Dr. Samuel for help, where Brandon is told that he has
bipolar disorder. Dr. Samuel explains that the way we feel is controlled by chemicals in our brain. In people with bipolar disorder these chemicals can’t do their job right so their feelings get jumbled inside. You might feel wonderfully happy, horribly angry, very excited, terribly sad
or extremely irritated, all in the same day. This can be scary and confusing – so confusing that it can make living seem too hard.
D. Healy and J. Le Noury / Pediatric bipolar disorder.

When Brandon responds that he thinks he got bipolar disorder because he is bad, Dr. Samuel responds
that many children have bipolar disorder, and they come to the doctor for help. Neither they nor Brandon are bad – it’s a case of having an illness that makes you feel bad. Brandon moves on to asking how he got bipolar disorder if he didn’t get it from being bad, to which Dr. Samuel
responds by asking him how he got his green eyes and brown hair. Brandon and his mother respond that these came from his parents.
And Dr. Samuel tells them it’s the same with bipolar disorder. That it can be inherited. That someone else in the family may have it also. The final exchange involves Brandon asking
whether he will ever feel better.
Dr. Samuel response is upbeat – there are now good medicines to help people with bipolar disorder,
and that Brandon can start by taking one right away. Brandon is asked to promise that he will take his medicine when told by his mother. Brandon and the Bipolar Bear comes with an associated coloring book, in which Brandon’s Dad makes it clear that a lot of kids have things wrong
with their bodies, like asthma and diabetes, and they have to take medicine and be careful too.

Janice Papolos, co-author of The Bipolar Child, in a review on the back cover of Brandon and the
Bipolar Bear says: ‘children will follow (and relate to) Brandon’s experience with rapid mood swings, irritability, his sense of always being uncomfortable and his sadness that he can’t control himself and noone can fix him. The comforting explanation that Dr. Samuel gives him makes
Brandon feel not alone, not bad, but hopeful that the medicine will make him feel better. We were so
moved by the power of this little book and we feel better that we can now highly recommend a book for children aged 4 through 11’.
The book The Bipolar Child arrived at Sheri Lee Norris’ home in Hurst, Texas, in February 2000.
When it did Karen Brooks, a reporter in the Dallas Star-Telegram describes Norris as tearing open the package with a familiar mix of emotions. Hope, skepticism, fear, guilt, shame, love. But as she reads in the book about violent rages, animal abuse, inability to feel pain, self-abuse and erratic sleeping patterns, Norris is reported as feeling relief for the first time in over a year. Now
she finally knew what was wrong with her daughter. . . Within days, Heather Norris, then 2, became the youngest child in Tarrant County with a diagnosis of bipolar disorder [5].

Brooks goes on to note that families with mentally ill children are plagued with insurance woes, a
lack of treatment options and weak support systems but that parents of the very young face additional challenges. It is particularly hard to get the proper diagnosis and treatment because there has been scant research into childhood mental illness and drug treatments to combat them.
Routine childcare is difficult to find, because day-care centers, worried about the effect on other
children, won’t accept mentally ill children or will remove them when they are aggressive. Few baby sitters have the expertise or the desire to handle difficult children, leaving parents with little choice but to quit work or work from home.
Having outlined these difficulties, Brooks also notes that the lack of public awareness of childhood
mental illness means that parents are judged when their children behave badly. They are accused of
being poor parents, of failing to discipline their children properly, or even of sexual or physical abuse or neglect. The sense of hopelessness is aggravated when they hear about mentally ill adults; this leaves them wondering whether the battles they and their children are fighting will go on forever.

In a few short paragraphs here Brooks outlines the once and future dynamics of disease from ancient
to modern times – the reflection on parents or family, the concerns for the future, the hope for an intervention.
But she also covers a set of modern and specifically American dynamics.
Heather Norris’s problems began with temper tantrums at 18 months old. Sheri-Lee Norris had a visit from the Child Protective Services. Someone had turned her in because Heather behaved abnormally. Sheri-Lee was furious and felt betrayed. She brought Heather to pediatricians, play therapists and psychiatrists, where Heather was diagnosed with ADHD and given Ritalin. This made everything
worse. Faced with all this, a psychiatrist did not make the diagnosis of bipolar disorder because the family had no history of it. But Sheri-Lee began asking relatives and discovered that mental illness was, indeed, in her family’s history.
She presented that information along with a copy of The Bipolar Child to her psychiatrist, and Heather got a diagnosis of bipolar disorder immediately.

Heather Norris’ story is not unusual. The mania for diagnosing bipolar disorders in children hit the
front cover of Time in August 2002, which featured 9-year-old Ian Palmer and a cover title Young and
Bipolar [26], with a strapline, why are so many kids being diagnosed with the disorder, once known
as manic-depression? The Time article and other articles report surveys that show 20% of adolescents
nationwide have some form of diagnosable mental disorder. Ian Palmer, we are told, just like Heather
Norris, had begun treatment early – at the age of 3 – but failed to respond to either Prozac or stimulants, and was now on anticonvulsants.

While Heather Norris was in 2000 the youngest child in Tarrant County to be diagnosed as bipolar,
Papolos and Papolos in The Bipolar Child indicate that many of the mothers they interviewed for their book remembered their baby’s excessive activity in utero, and the authors seem happy to draw continuities between this and later bipolar disorder. The excessive activity amounts to hard kicking, rolling and tumbling and then later keeping the ward awake with screaming when born.
Or in some instances being told by the sonographer and obstetrician that it was difficult to get
a picture of the baby’s face or to sample the amniotic fluid because of constant, unpredictable activity [35]. It is not unusual to meet clinicians who take such reports seriously.

Anyone searching the Internet for information on bipolar disorder in children are now likely to land
at BPChildren.com, run by Tracy Anglada and other co-authors of the books mentioned above. Or at
the Juvenile Bipolar Research Foundation (JBRF), linked to the Papoloses and The Bipolar Child. Or
at a third site, bpkids.org, linked to a Child and Adolescent Bipolar Foundation, which is supported by unrestricted educational grants from major pharmaceutical companies.

In common with the mood-watching questionnaires in the adult field, all three sites offer moodwatching questionnaires for children. The Juvenile Bipolar Research Foundation has a
65-item Child Bipolar Questionnaire, which also featured in the Time magazine piece above;
on this scale most normal children would score at least modestly.10

The growing newsworthiness of childhood bipolar disorder also hit the editorial columns of the American Journal of Psychiatry in 2002 [40]. But where one might have expected academia to act as a brake on this new enthusiasm, its role has been in fact quite the opposite…..

• copy of complete article upon request.

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