Can we stem the rising tide of serious psychiatric illness in college?

Last week I "launched" my oldest off to college. As anticipated, it was an intense emotional experience full of joy, sadness, and many things in between. (I have to tip my hat to fellow Globe writer Beverly Beckham for her piece I was the sun, the kids were my planets that was very helpful. However, I might have written that my child was the sun, a burst of light in our household, and the experience of leaving her is like being temporarily knocked out of orbit as our family re-orients to life without her.)

The same week I received in the mail, in exchange for filling out a questionnaire about a study on diversion -use of ADHD medications by individuals for whom it was not prescribed- this pretty laminated poster of all the drugs currently available for treatment of ADHD.

Statistics indicate that serious mental health problems in the college community are growing at rapid rates. Some optimistically speculate that this is because of decreased stigma for getting care. But I wonder at the paradox of the parallel increase in availability of new psychiatric drugs- I counted 22 different formulations for ADHD medications on that poster- and the rise of serious mental health problems. Could it be that the drugs themselves are responsible for this increase? If the drugs were effective in childhood, shouldn't we see a significant decline in serious mental illness in college?

How would this work? Starting at a young age, rather than learning to manage stress in the context of supportive relationships, the symptoms are medicated away. The brain is actually wired in relationships, and in the absence of this kind of co-regulation of emotion, the areas of the brain responsible for emotional regulation do not develop properly. All forms of mental illness, including depression, anxiety and attention problems are essentially problems of emotional regulation. Then as the challenges of life increase in complexity, the medications often increase in strength and complexity. Children learn to be defined by their medication and are further estranged from a core sense of self. Add to that unknown side effects on the developing brain, and it is no wonder that there is a significant increase in serious mental illness by the time a child gets to college.

But what about that issue of decreased stigma? That also is likely true. At a superb talk given by a psychology professor at our child's orientation, we learned about the school's  "invisible safety net." It is made up of an elaborate interconnected system of students, faculty and mental health professionals to monitor the emotional well-being of the students. It is all about relationships and connection.

The very existence of this net reduces the stigma of emotional struggles. The fact that the school goes to the trouble to train such an elaborate system of care (sophomore advisors- or "SA's" the front line of this system, must apply in January of their freshman year, and they get several weeks of training prior to the start of the school year), conveys to both students and parents that it is normal and expected that people will struggle and need help.

I believe there is something to be learned from this "invisible safety net" model. If we as a country were to implement a model of preventive mental health care, we would have in place a net made up of primary care clinicians, early childhood educators, childcare workers, mental health care professionals, as well as others who come in contact with young children and families. There would be open and expected lines of communication. (At this college, if a parent calls with a concern about their child, within the hour there is a person making face-to-face contact with that student, even if it is just inviting them out for a slice of pizza- and that person is trained to recognize when it is necessary to call in a higher level of intervention.)

If such a net were there from infancy-including a system for identification and treatment of perinatal mental health problems- through adolescence, then maybe kids wouldn't need all those pretty little pills to take to college.

Too many psychiatric diagnoses for children: an epidemic of labels

Allen Frances, professor of child psychiatry at Duke University and chair of the DSM IV(Diagnostic and Statistical Manual of Mental Disorders) task force hit the nail on the head in a recent commentary "Why So Many Epidemics of Childhood Mental Disorders?" in the Journal of Developmental and Behavioral Pediatrics. Because he makes his argument so clearly and persuasively (and the full article is only available to those who subscribe to the journal) I will quote it at length.

Since the publication of DSM-IV in 1994, the rates of 3 mental disorders have skyrocketed: attention deficit disorder (ADD) tripled, autism increased by 20-fold, and childhood bipolar disorder by 40-fold. It is no accident that diagnostic inflation has focused on the mental disorders of children and teenagers. These are inherently difficult to diagnose accurately because youngsters have a short track record; are in developmental flux that makes presentations transient and unstable; are sensitive to family, peer, and school stresses; and may be using drugs. If ever diagnosis should be conservative, it should be in kids. Instead, we have experienced an unprecedented diagnostic exuberance encouraged in part by DSM-IV, but mostly stimulated by the powerful external forces of drug company marketing and the close coupling of school services to a diagnosis of mental disorder.

He gives the example of ADHD, describing how the revisions to DSM IV had anticipated a jump in diagnoses in girls with the additon of an "inattentive" subtype. But in fact there was an unexpected tripling of ADHD rates and parallel increase in use of psychiatric medication. He writes:

Three years after DSM-IV was published, drug companies introduced new and expensive on-patent drugs that provided the incentive and resources for an aggressive marketing campaign to psychiatrists, pediatricians, and family doctors. Simultaneously, successful drug company lobbying gave them unrestricted freedom to advertise directly to consumers. Parents and teachers were inundated with the message that ADD was terribly underdiagnosed and easily treated with a pill. Sales of ADD drugs ballooned to an astounding $7 billion.

He then moves on to bipolar disorder:

Childhood bipolar disorder is an even more chilling case. DSM-IV had wisely rejected a proposal that there be a separate and much looser definition of bipolar disorder in children. The argument for inclusion rested on the unreplicated findings of just 1 (albeit very influential) research group suggesting that kids present a developmentally different prodromal form of bipolar disorder characterized by ambient irritability, impulsivity, and temper outbursts, rather than the typical cyclical mood swings of adults. Rejection by DSM-IV did not stop charismatic thought leaders (who were heavily financed by drug companies) from spreading the gospel of childhood bipolar disorder. The 40-fold increase in rates was accompanied by an increase in antipsychotic spending up to $18.2 billion in 2011. These drugs frequently cause massive weight gain in children. The overuse of antipsychotics in kids was not deterred by the fact that childhood obesity is an important risk factor for diabetes and heart disease. Drug companies have received billion dollar fines for off-label marketing to kids, but these pale in comparison to the enormous revenues. Of note, the inappropriate use of antipsychotics is most pronounced among children who are economically disadvantaged.

He then accurately depicts the link between the rise in diagnoses of autism with the fact that a diagnosis is needed for a child to receive appropriate services:

The introduction of Asperger's by DSM-IV was expected to result in a 3- to 4-fold increase rates of autism. Severe classic autism had an unmistakable presentation with rates lower than 1 per 2000. Asperger's blends imperceptibly into normal eccentricity, and the rates of autism are now reported at 1 per 88 in the United States and 1 in 38 in Korea. Theories connecting the increase in prevalence to vaccination have been discredited. Instead, the rates have grown so rapidly because a diagnosis of autism is required to allow a child access to greatly enhanced school services. About half the youngsters who now receive the diagnosis do not really meet the DSM-IV criteria when these are carefully applied. And follow-up studies finding that half the kids no longer meet criteria also confirm that diagnostic inflation is rampant. Eligibility for school services should be decoupled from an unreliable clinical diagnosis and instead be based on educational need. 

The challenge, and Frances does acknowledge this fact, is to avoid over-diagnosis while at the same time not undertreating those who need help. Most of the children who receive these labels, and their families, are struggling in significant ways. They do need help,  and sometimes lots of it. The issue is inextricably linked with the need to "name" the problem, a need comes in part from both clinicians and parents, who may feel more of a sense of control if what they are struggling with has a name, and also insurance companies who require a diagnosis for reimbursement of services.

Psychiatric diagnoses in children, by definition, place the problem squarely in the child, when in fact it is almost always more complex than this. Genetic vulnerability and environment both have an important role to play. A recent article in the Archives of Diseases of Childhood; Poverty, Maltreatment and Attention Deficit Hyperactivity Disorder offers insight in to this complexity:

This paper hypothesises that the population of children receiving a clinical diagnosis of ADHD is aetiologically heterogeneous: that within this population, there is a group for whom the development of ADHD is largely genetically driven, and another who have a 'phenocopy' of ADHD as a result of very adverse early childhood experiences, with the prevalence of this phenocopy being heavily skewed towards populations living with poverty and violence. A third group will have a high genetic risk and have been exposed to violence.

The key phrase here is "aetiologically heterogeneous." Psychiatric labels, be it "ADHD" "bipolar disorder" or "autism," are artificial constructs that provide a false sense of simplicity.  When I see a child and family in consultation, the aim of the work is to take the time to listen to the story and understand where, and it may be in several places, the "problem" actually lies. In order to help these children and families in a meaningful way, we need to be able to, in the words of one of my mentors Ed Tronick, "embrace complexity."

Psychiatric Medication For Children? Important New Book Gives Pause

Two things most stood out for me in Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up. The first is the stories of women struggling to get off of SSRI's (selective serotonin re-uptake inhibitors), started in early adolescence, when they decide to get pregnant. The second is Bell Barnett's review of the literature regarding sexual dysfunction as a side effect of SSRIs in adolescence.

The book as a whole has much to say that is very important. As I write in my blurb for the cover:

Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.

Bell Barnett is a journalist who was herself started on SSRIs as a teenager. Her book intertwines in depth interviews with people who were started on psychiatric medication in childhood and are now young adults, with a journalistic study of the history of psychiatric medication use in children. I could probably write several posts covering all the important issues she addresses, but have chosen to focus on these two.

I first learned of the emerging evidence that SSRIs may cause long term sexual dysfunction last fall when I attended a talk by Robert Whitaker, author of the controversial book about psychiatric illness and medication Anatomy of an Epidemic. I was so alarmed about this data that I wanted to immediately write a blog post about it. But shortly after that talk I received the galleys of Bell Barnett's book. I discovered that she has a through review of the rather scant literature on the subject along with some very poignant stories, so I decided to wait until her book came out. I recommend that anyone who is concerned about this issue (as anyone who takes or prescribes these drugs should be) read her book. The subject is covered in the chapter entitled "Side Effects." Here are a few sample quotes.

A comprehensive review of the literature conducted in 2004 found just one clinical trial that reported erectile dysfunction in a teenager; most clinical guidelines and reviews of SSRIs didn't mention sexual side effects at all.

This is pretty shocking since, as the authors of the study cited above noted, anywhere from 30-40 percent of adults experience some kind of SSRI induced problems with libido, arousal, or orgasm.

And this important point:

Despite the lack of formal studies involving young people, anecdotal evidence suggests that drugs causing decreased libido and sexual dysfunction do sometimes pose a real problem, psychologically and socially, both for teenagers who are in the process of developing a sexual identity and for young adults testing out long-term intimate relationships.

And this from Elizabeth, who started taking SSRIs in 9th grade:

I am not sure I can [over]state the extent to which it impacted things. I didn't grow up with a normal sex drive, and that was obviously due to a combination of factors, but being on and off antidepressants whose impact I really couldn't understand back when I didn't have any real understanding of my sex drive or sex in relationships to begin with means I basically went through adolescence without experiencing anything in that realm in a "normal' way.

There's more, but the bottom line is that this issue is not well studied and yet of major significance in adolescent development.

Bell-Barnett poignantly captures the challenges faced by her interviewees who were started on SSRIs in childhood and now want to have children. Aware of the potential effects on the developing fetus, they try to get off the medication, but rebound with debilitating symptoms of depression. SSRIs are one of the most common medications prescribed in pregnancy. Yet we really do not know what the effects are on the developing fetus. A policy statement put out by the American Academy of Pediatrics earlier this year points to evidence that SSRI use in the third trimester is linked to a constellation of neonatal signs and symptoms. We do know that maternal depression itself can have a negative impact on the developing fetus. So if a woman is already on SSRIs and develops symptoms of depression without them, it may be best to stay on them during pregnancy.

The take home point of Bell Barnett's book, however, is that this issue needs to be considered by parents and clinicians when girls are prescribed these medications in childhood and adolescence well before having children is on their minds. These medications have a great allure as they may very quickly resolve symptoms. But one thing that Bell Barnett makes clear, and that is also supported by the literature, is that getting off these medications is very difficult.

Certainly these children and teenager should get help if they are struggling with depression. But other forms of intervention, including psychodynamic psychotherapy combined with self-regulating activities such as yoga, offer an alternative to medication. There is a severe shortage of quality mental health services due in part to the influence of the health insurance industry. It is a complex issue that must be addressed at the level of health care policy.

Large-scale use of these medications has major life-long impact on identity and sense of self of the current generation, referred to as "Generation Rx." Considering the complex issue of SSRIs in pregnancy, there is also potential for significant impact on the next generation. The time to pay attention to this problem is now. Reading Bell Barnett's book is a good place to start.