Written Testimony on HF 357 – Youth Mental Health Intervention

February 13, 2013

Dear Chairman Mullery and Members of the Early Childhood and Youth Development Committee,

As I am unable to attend this hearing in person, I appreciate your willingness to accept this written testimony on the mental health interventions proposed for funding in HF 357.  I am writing as a mother of three, a pediatrician, and a policy analyst for the International Society for Ethical Psychiatry and Psychology and for Education Liberty Watch

While understanding and sharing the desire to help those who struggle with emotional issues, especially in light of the violent incidents involving those suspected to be mentally ill or under treatment for mental illness, for the sake of those this legislation is supposed to help, their families, and the taxpaying public, please beware of unintended consequences.  Because of the uncertainties of psychiatric diagnosis, especially in youth and because of difficulties with psychiatric medication, things could well become worse if the focus of these efforts is strongly on medication as listed as the first item in the proposed interventions funded in this bill on lines 1.16 and 1.17 dealing with antipsychotic medication management

Let me begin with the diagnostic aspect of mental health in general and psychosis in particular.  Here are two of many examples that I could give you of quotes from leaders in psychiatry:

Dr. Dilip Jeste, president of the American Psychiatric Association, in a December 2012 statement[1] on the completion of the new, about to be published edition of the bible of psychiatric diagnosis, the Diagnostic and Statistical Manual (DSM-5), said, “At present, most psychiatric disorders lack validated diagnostic biomarkers, and although considerable advances are being made in the arena of neurobiology, psychiatric diagnoses are still mostly based on clinician assessment.”

In plain English, that means that psychiatric diagnosis is an educated guess.  Dr. Allen Frances, chief editor of the current edition of the DSM put it much more bluntly in a 2010 interview[2]:“…there is no definition of a mental disorder.  It’s bull****.  I mean, you just can’t define it.”

In fact in a December 2012 op-ed published in the Star Tribune, he said:

There are profound economic consequences to where boundaries are set between what is normal and what is considered a mental disorder. Diagnosis of mental illness brings on a cascade of costs, including doctor visits, tests, medications (and treatment for their complications), forensic and prison costs, disability obligations, the siphoning of educational resources and absenteeism.

We are already experiencing an inflation in psychiatric diagnosis and an explosion in the use of expensive, and often unnecessary and harmful, psychotropic drugs.[3]

In his opinion, the new edition of the DSM will increase these already high costs enormously. In Minnesota, the Department of Human Services spends more on antipsychotic medication than any other pharmaceutical class.

Diagnosis is more complicated in children and adolescents.  The World Health Organization said in the 2001 World Health Report, “Childhood and adolescence being developmental phases, it is difficult to draw clear boundaries between phenomena that are part of normal development and others that are abnormal.”

With regard to psychosis in particular, the problems of accurate diagnosis are even more acute.  Committees of psychiatrists involved in creating the DSM-5 revisions had contemplated an entity called “psychosis risk syndrome” to try to identify adolescents and young adults who were at risk for developing the psychotic symptoms of delusions, hallucinations, and paranoia associated with schizophrenia and bipolar disorder.  Proponents of this approach believe that “clinicians have long noted the existence of early indicators which act as a warning that a first psychotic episode may be imminent” and that, “Since delayed treatment for a first psychotic episode can often worsen the outcome, there is a very real need to act on prodromal symptoms as soon as possible.”[4]

Thankfully, for the health and safety of American adolescents and young adults, the psychosis risk syndrome was abandoned for several very important reasons:

The same psychiatrists and psychologists that though it was important to treat these preliminary symptoms of psychosis as soon as possible acknowledged  literally in the next sentence of the same article, “Unfortunately, given that the presence of prodromal signs do not invariably result in psychosis, acting prematurely can often do more harm than good.”[5]

The DSM-V committee was ultimately never able to satisfactorily answer issues like “the ethics of false positives,” “ how soon biomedical interventions should begin,” and whether if “prodromal patients deoften attached to mental illness in most societies.”

The reputation of the DSM and psychiatry in general has been battered by the disastrous effects of broadening the diagnostic criteria for bipolar disorder to include children.  This decision was the most regretted by Dr. Frances, the lead editor of the current version of the DSM, volume IV.  That decision led to a 40 fold increase in the diagnosis of bipolar disorder in children, most notably  in African American males and in some children as young as 18 months old.  According to an August 2012 study, prescriptions of antipsychotics for children, including for off-label uses, such as for ADHD, increased seven and a half fold.

The other huge issue involved with expanding medication treatment of young people with early psychosis is both the lack of effectiveness and severe dangers of these drugs.  In his book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, award winning journalist Robert Whitaker describes one of many studies cited:

In the 1980s, Martin Harrow, a psychologist at the University of Illinois, began a long-term study of 64 newly diagnosed schizophrenia patients. Every few years, he assessed how they were doing. Were they symptomatic? In recovery? Employed? Were they taking antipsychotic medications? The collective fate of the off-med and medicated patients began to diverge after two years, and by the end of 4.5 years, it was the off-medication group that was doing much better. Nearly 40% of the off-med group were “in recovery” and more than 60% were working, whereas only 6% of the medicated patients were “in recovery” and few were working. This divergence in outcomes remained throughout the next ten years, such that at the 15-year follow-up, 40% of those off drugs were in recovery, versus 5% of the medicated group.  Harrow reported at the 2008 annual meeting of the American Psychiatric Association, “I conclude that patients with schizophrenia not on antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics.” (Emphasis added)[6]

This is not to mention very dangerous effects of these drugs, such as:

DEATH – A 2006 study found 45 deaths in children from 2000 to 2004 associated with these drugs, with that likely only representing one to ten percent of the total.[7]

SHORTENED LIFE SPAN – Researchers believe that those diagnosed with mental illness and treated with medications face a 25 year shorter lifespan[8]

SUICIDE & VIOLENCE – Although not as closely associated with violence as the antidepressants like Prozac, antipsychotics all cause akathisia, a severe inner agitation, “which means that persons who take them can’t sit still and feel like they are jumping out of their skin. They behave in an agitated manner which they cannot control and experience unbearable rage, delusions, and disassociation.”[9]  Below is a table of psychiatric drug associated school shootings that have resulted in many deaths just in the US.[10]

BRAIN SHRINKAGE – “Greater intensity of antipsychotic treatment was associated with indicators of generalized and specific brain tissue reduction after controlling for effects of the other 3 predictors. More antipsychotic treatment was associated with smaller gray matter volumes. Progressive decrement in white matter volume was most evident among patients who received more antipsychotic treatment.”[11]
METABOLIC EFFECTS –  “Children and adolescents seem to have a higher risk than adults for experiencing adverse events such as extrapyramidal symptoms, prolactin elevation, sedation, weight gain, and metabolic effects when taking antipsychotics. “[12]

In addition, sadly, there is an overly large influence of the pharmaceutical industry in the prescription antipsychotic medications to children, especially those children in the juvenile justice and foster care programs:

“Clinicians and patients have a big stake in pushing back, and so do government and industry. The only sector that stands to benefit from the DSM-5 is the pharmaceutical business. The rest of us will pay the price.”[13]

“All DSM[5] task force members on mood and psychotic disorders tied to drug industry”[14]

“From 2000 to 2005, drug maker payments to Minnesota psychiatrists rose more than sixfold, to $1.6 million. During those same years, prescriptions of antipsychotics for children in Minnesota’s Medicaid program rose more than ninefold.”[15]

“In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone.”[16]

“As reported to Senator Grassley, pharmaceutical companies contributed an average of 56% of national NAMI’s budget annually for the period 2005 to 2009”[17]

With all of these problems in diagnosis and medication usage, here are some recommendations that could possibly help the situation:

Require physicians who prescribe psychoactive drugs for children to take and pass the Critical Think Rx curriculum, a curriculum already developed and free to physicians as a result of drug company settlement with the US Justice Department for illegal off label prescribing practices.

Require physicians to provide parents with copy of FDA-approved label + MedGuide.Require signed parental informed consent before any screening and before these drugs are prescribedProhibit use of these drugs in children until:

(i)   evidence-based psychosocial interventions have been exhausted,

(ii)   rationally anticipated benefits of psychotropic drug treatment outweigh the risks,

(iii)   the person or entity authorizing administration of the drug(s) is fully informed,

(iv)   close monitoring of, and appropriate means of responding to, treatment emergent effects are in place.

Thank you for your concern for children, your work on this bill and for your consideration of these recommendations.

Sincerely,

Karen R. Effrem, MD

International Society for Ethical Psychiatry and Psychology

President – Education Liberty Watch

9601 Annapolis Lane North
Maple Grove, MN 55369

952-361-4931