Thomas Insel, MD, is the Director of the National Institute of Mental Health. In June of last year, he published, on the Director’s Blog, an article titled Are Children Overmedicated? The gist of the article is that children are not being overmedicated, but rather that there is an increase in “severe psychiatric problems” in this population.
Here are some quotes, interspersed with my comments.
“The latest estimate from the National Center for Health Statistics reports that 7.5 percent of U.S. children between ages 6 and 17 were taking medication for ’emotional or behavioral difficulties’ in 2011-2012. The CDC reports a five-fold increase in the number of children under 18 on psychostimulants from 1988-1994 to 2007–2010, with the most recent rate of 4.2 percent. The same report estimates that 1.3 percent of children are on antidepressants. The rate of antipsychotic prescriptions for children has increased six-fold over this same period, according to a study of office visits within the National Ambulatory Medical Care Survey. In children under age 5, psychotropic prescription rates peaked at 1.45 percent in 2002-2005 and declined to 1.00 percent from 2006-2009.”
Dr. Insel points out that psychiatrists, parents, schools, and drug companies are often blamed for these increases. He challenges these perspectives.
“…most of the prescriptions for stimulant drugs and antidepressants are not from psychiatrists.”
This is a frequently-heard psychiatric assertion, but it is beside the point. It is indeed the case that GP’s and various medical specialists prescribe psychiatric drugs for various problems of thinking, feeling, and/or behaving, but they can only do so because psychiatry has developed and promoted the fiction that these problems are illnesses, and the drugs are medications. In fact, it’s even worse than that. Psychiatry’s spurious medicalization of all human problems of thinking, feeling, and/or behaving has been so thoroughly integrated into mainstream medical care, that a physician who doesn’t prescribe psychiatric pills in certain situations could find himself legally liable for malpractice in the event of an adverse outcome.
Dr. Insel provides equally facile reasons why parents, schools, and drug companies are not to blame for the increased drugging of children. And with that whole issue out of the way, he continues:
“If psychiatrists, parents, schools, or drug companies are not the culprit, who is? The answer is potentially more complicated and more worrisome. Is it possible that the increased use of medication is not the problem but a symptom? What if more children were struggling with severe psychiatric problems and actually the problem was not over-treatment but increased need? Surely, if we discovered more children were being treated for diabetes or immune problems, we wouldn’t blame the providers or the parents. We’d be asking what drives the increase in incidence.”
Note how Dr. Insel equates psychiatric problems with real illnesses such as diabetes and immune problems. The big difference, of course, is that real physicians don’t invent the illnesses they treat, as do psychiatrists. Yes, more children today are “struggling with severe psychiatric problems”, but the primary reason for this is that pharma-psychiatry has been so successful in promoting the notion that virtually every problem that a child could display is an illness which needs to be “treated” with psychiatric drugs. Former generations regarded childhood temper tantrums as a problem that needed to be addressed by parents using the normal time-honored ways. Today these temper tantrums are a “symptom” of “disruptive mood dysregulation disorder”, a severe “psychiatric illness” warranting the attention of psychiatrists and the prescription of drugs. There is, in fact, no difference between the temper tantrums of former years and disruptive mood dysregulation disorder of today. All that’s changed is that psychiatry has, once more, expanded its turf through the simple expedient of creating yet another “illness” by voting it into existence. Similar observations apply to childhood inattentiveness, defiance, misconduct, boredom, etc…
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“Skepticism regarding increased rates of emotional and behavioral difficulties as opposed to increases in other medical disorders can be attributed in part to the absence of biomarkers or laboratory tests for psychiatric diagnosis comparable to glucose tolerance tests for diabetes or anaphylactic reactions for allergies. Absent these kinds of consistent, objective measures for mental disorders, we cannot distinguish between a true increase in the number of children affected or simply changing values or trends in diagnosis. Clearly context matters. What one parent might consider hyperactivity, another parent might consider healthy exuberance. What physicians once called attention deficit hyperactivity disorder (ADHD), often now elicits a diagnosis of childhood bipolar disorder, leading to a 40-fold increase in prevalence from 1994-1995 to 2002-2003.”
So, skepticism regarding the increased rates can be attributed partly to the absence of biomarkers. This is true, but it is not the central issue. The central issue is that for at least the last fifty years, organized psychiatry’s primary agenda has been the medicalization of all significant problems of thinking, feeling, and/or behaving. They have asserted, without evidence, that these problems are illnesses and have even concocted baseless neurological pathologies as putative causes of these so-called illnesses. By comparison, the absence of biomarkers or lab tests is a trivial issue.
And note the extraordinary dexterity with which Dr. Insel trivializes the 40-fold increase in the prevalence of “childhood bipolar disorder”. This increase was driven largely by the efforts of Joseph Biederman, MD, and caused such a scandal that the APA created the label “disruptive mood dysregulation disorder” for the express purpose of reducing the use of the bipolar label. This whole business was a very black chapter in a profession not noted for its moral or intellectual integrity, and resulted not only in a 40-fold increase in the “diagnosis of bipolar disorder”, but also an unprecedented increase in the prescription of neuroleptic drugs to children. But Dr. Insel spins Dr. Biederman’s excesses as comparable to two parents holding different views as to the significance of a child’s hyperactivity. Oh my! What a fuss about nothing!
And incidentally, on the subject of biomarkers and lab tests, there are still vast numbers of psychiatric “patients” who have swallowed the psychiatric lie, and who believe that a scan of their brains would reveal the putative pathology. Why is it that the Director of the NIMH will acknowledge on his blog that no biomarkers or lab tests exist to confirm a psychiatric “illness”, but has taken no steps to enlighten the general public on this matter? Why is the NIMH not screaming this message from the rooftops, and calling for the censure of those psychiatrists and drug companies who continue to deceive their clients and the public in this way?
“No question, in a field without biomarkers, there is a risk of over-diagnosis. No question, subjective diagnosis could invite unnecessary treatment and over-medication. But what if the increased use of medication reflected more children with severe developmental problems and more families in crisis? What if the bigger problem is not over-medication but under-treatment? Hearing that 7.5 percent of children are on medication (4.2 percent on psychostimulants) seems stunning, but knowing that 11 percent of children have a diagnosis of ADHD raises a possibility of under-treatment.”
Dr. Insel concedes a “risk of over-diagnosis” and the possibility of “unnecessary treatment and over-medication”. But his terminology is problematic. “Over-diagnosis” or, for that matter “under-diagnosis”, inevitably implies that there is a correct level of diagnosis. To take an analogy from general medicine, there is a rare autoimmune disease called Wegener’s granulomatosis. It is generally acknowledged that this illness is under-diagnosed. In other words, a certain proportion of people who really have this disease are not so diagnosed during medical examinations. But the point is that the terms under-diagnosis and over-diagnosis only have meaning in reference to something that is reliably definable, a condition which does not apply to psychiatric “illness”. Psychiatric “illnesses” are nothing more than loose clusters of vaguely defined problems of thinking feeling, and/or behaving. There is no accurate or real level of diagnosis against which judgments of over-, or under-, diagnosis can be made.
But Dr. Insel makes no attempt to address this question of possible “over-diagnosis” and “over-medication”. Instead, he goes straight to the heart of psychiatry’s ever-expansionist agenda: “What if the bigger problem is not over-medication, but under-treatment?”
This, incidentally, is the same Dr. Insel who in April 2013 wrote:
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.” [Emphasis added]
So, although “symptoms alone rarely indicate the best choice of treatment”, here he comes, a year later, expressing concern that only 4.2% of America’s children are taking stimulant drugs, when 11% have “a diagnosis of ADHD.” The clear implication being, that if a child has this invalid diagnosis, he should be taking the pills.
“What I hear from families in crisis is lack of access, poor quality care, and a desperate need for answers. In the media reports on over-medicating children, this perspective is missing. The possibility that there is a real increase in the number of children suffering with severe emotional problems, just as there is a real increase in the number of children with diabetes and food allergies, is not even considered. Shouldn’t we be asking why so many children, at younger ages, are being seen for emotional and behavioral problems?”
To which I can only reply: “Yes, Dr. Insel, we certainly should!”
And we should also be asking why the Director of the NIMH, the nation’s think-tank on mental health matters, is addressing these profound and controversial issues in such misleadingly simplistic terms.