June 7, 2007

Misguided Standards of Care - Boston Globe Op-ed

June 19, 2007

As a doctor, I did the nearly unthinkable at a recent conference on bipoloar disorder in children. I charged another doctor with moral responsibility in the death last December of Rebecca Riley, a 4 -year-old girl from Hull.

Naming names in medicine is just not done very often -- and I knew the personal and professional risks I was taking. Yet I felt compelled to name Joseph Biederman, head of the Massachusetts General Hospital's Pediatric Psychopharmacology clinic, as morally culpable in providing the "science" that allowed Rebecca to die.

Rebecca's parents have been jailed and charged in her death. They are accused of intentionally overdosing her with clonidine, an anti-hypertensive and sedative drug -- one of three psychiatric medications prescribed by a Tufts-New England Medical Center child psychiatrist. Rebecca had been treated with these medications since the age of 2 1/2 for the purported diagnosis of bipolar disorder -- the new name for manic-depression.

While the psychiatrist involved has withheld comment on the case, both her lawyer and the medical center have defended her actions as "within the standards of care." Biederman and his colleagues at Harvard are the professionals most responsible for developing and promoting those standards of care -- which include diagnosing preschool children as young as 2 with bipolar disorder and treating them with multiple medications.

Biederman shocked the child psychiatric world in 1996 by announcing that nearly a quarter of the children he was treating for attention deficit hyperactivity disorder also met his criteria for bipolar disorder. Up until then bipolar disorder was rarely diagnosed in teenagers and unheard of in prepubertal children. Biederman could justify his findings by simply broadening the semantic definitions of a previously more circumscribed condition contained within American psychiatry's bible -- the "Diagnostic and Statistical Manual of Mental Disorders."

Biederman has produced a number of studies and papers purporting to demonstrate the validity of his diagnosis and treatment. His research has always epitomized the best of what the DSM model of psychiatry could expect. But the diagnoses in the manual, in concept, are closely linked to the medical model of biologically based psychiatric disorders and focus exclusively on the individual.

While the manual provides helpful clinical guidance in adults, it begins to unravel with its assumptions about discrete and specific disorders in children and ignores the families and environments in which children live. The ultimate absurdity of this scientific model is diagnosing bipolar disorder in 2 year olds and linking it to the adult disorder with the same name -- in the process saddling young children as chronic mental patients condemned to a lifetime of psychiatric drugs.

Even the American Academy of Child and Adolescent Psychiatry -- in its recent parameters on the diagnosis in children -- eschews the bipolar diagnosis and its consequent medical treatment in children under 6. Still there are thousands of potential Rebecca Rileys being treated with multiple psychiatric drugs because Biederman has said it's OK and necessary. Supported by millions of dollars of drug industry promotional funding, Biederman and his colleagues circle the globe offering professional medical "education" for their singular point of view.

Finally, it's sad but true -- the field of child psychiatry is afraid of Biederman. One can hear the worries and fears whispered in the academic halls and clinics over where Biederman has taken the profession. Yet to politely challenge Biederman in public is to risk public retribution and ridicule from him and his team. Also academic researchers in child psychiatry risk losing their funding if they criticize this darling of the pharmaceutical industry, which provides most of the money these days for psychiatric research.

The silence was deafening -- and Rebecca's death pushed me over the edge -- because for over a decade I've have been uncomfortable about these practices in young children. I am not against psychiatric drugs for children. I've written prescriptions for children for 30 years in a clinical practice not tied to the drug industry.

I risk personal censure and loss of credibility in an advocacy for a broader concept and treatment for children with behavior problems in naming this doctor. But this time, Dr. Biederman, you have gone too far.


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