Questioning Authority: Gail Hornstein on Bipolar Disorder in Children

Questioning Authority asked psychology professor Gail Hornstein to comment on reports in the New York Times and elsewhere of an epidemic of bipolar disorder in children and adolescents. Here are her thoughts on the subject:

QA: Basically, what is bipolar disorder?

GH: You'd think it would be simple to answer this straightforward question, wouldn't you? But debates about definition are a core part of the current controversy about the incidence of bipolar disorder both in children and in adults. How you define the disorder to start with determines how widespread you think it is.

Bipolar disorder used to be called manic depression because it’s characterized by bouts of depression and bouts of mania. Some people have more depressive episodes, others more manic episodes, and still others "cycle" between the two states. In adults, manic periods are marked by euphoria, grandiosity, irritability, racing thoughts, and frenetic activity. In children, irritability and hyperactivity are often the main “manic” symptoms. In both adults and children, bipolar disorder is considered a sign of serious mental illness.

QA: Why has the number of cases jumped so dramatically? Is the medical profession just getting better at diagnosing previously undiagnosed or misdiagnosed bipolar cases, or is something else going on?

GH: Again, it's impossible to answer this question in a straightforward way. Until the 1990s, bipolar disorder was practically never diagnosed in children and adolescents. But of course, once you start looking for something, you're more likely to find it, so we have to assume that some children did in fact manifest this pattern of symptoms but weren't being diagnosed. However, there’s no question that the massive increase in bipolar diagnoses we’re seeing now is due to an aggressive campaign by pharmaceutical companies to expand the market for drugs approved to treat mania in adults to the huge population of children and adolescents.

These trends are part of a much broader medicalization of everyday life, in which the boundaries of "pathology" are constantly being expanded. Marketing consultants now help drug companies to invent names for new problems that their products can solve ("erectile dysfunction," "premenstrual dysphoric disorder," and "restless leg syndrome" are some recent examples). This "corporate sponsored creation of disease," as a recent report for drug company executives called it, is turning more and more of human experience into "conditions" in need of "treatment."

QA: Are there factors in present-day U.S. society that could actually be generating a higher incidence of bipolar disorder in young people?

GH: Again, we have to be careful how we phrase the question we're asking. Since there is no objective metric (for example, a blood test, MRI, or genetic marker) that guides the diagnosis of any mental disorder, the subjective judgments of parents, teachers, and physicians about children's behavior are all that we have to go on. Young people are facing increased pressures of all kinds in contemporary society, and federal regulations about performance on standardized tests are resulting in a narrower and narrower range of behavior being tolerated in schools. We've already seen hundreds of thousands of boys diagnosed with "attention deficit hyperactivity disorder" for what would previously have been considered the normal fidgeting or daydreaming of active children. Today's "epidemic" of bipolar disorder diagnoses may be just another way of labeling children who are rebellious or angry about the ways they're being forced to behave or conform at home and at school.

QA: According to the New York Times, while a great majority of children diagnosed as bipolar are on drug therapy, only four in 10 patients are being treated with psychotherapy. Does that concern you?

GH: I think it's a very frightening trend. Instead of asking about the context or background for children's difficulties (which might include abuse, poverty, racism, etc.), physicians are prescribing very powerful medications that have unknown effects on children’s developing brains. It is often very difficult to get off these drugs once they've been taken for a long time, and withdrawal effects are often mistaken for the symptoms themselves. Today's children and adolescents--some as young as two years old--are essentially guinea pigs for a massive, uncontrolled experiment whose full effects may never be known. And besides the serious side effects and long-term potential damage of the drugs themselves, the stigma of being labeled with a "chronic mental illness" like bipolar disorder can itself be very destructive for a young person.

QA: The Times reported that drug companies make more money on drugs used to treat bipolar patients than other mental disorders such as depression. Does this suggest that the drug companies are responsible to some degree for generating this current "epidemic"?

GH: Yes, without a doubt. The pharmaceutical industry is one of the most profitable on the planet and does everything possible to stay that way. It has the largest lobby in Washington, and spends at least $25 billion each year just in the United States to promote its products. Children and adolescents are one of its biggest growth markets. Diagnosing people early in their lives with conditions said to be "chronic" means being able to sell them more of your product; if they experience side effects, then they can simply be given more drugs. Since data showing the ineffectiveness or dangers of new medications are rarely disclosed by pharmaceutical companies, and the FDA has become less and less vigilant as a watchdog, we simply have no idea how many children and adolescents are being harmed by current prescribing practices. We should all be deeply concerned and deeply skeptical about claims of an "epidemic" of any mental disorder, in children or in adults.

QA: Can you recommend some books for people who want to know more about these issues?

GH: Certainly. I’d suggest starting with these four: Selling Sickness, by Ray Moynihan and Alan Cassels; The Truth About the Drug Companies, by Marcia Angell; Mad in America, by Robert Whitaker; and Making Us Crazy, by Herb Kutchins and Stuart Kirk.

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