Anatomy of an Epidemic (32 page)

When I first met Rachel Klein in the spring of 2008, she hobbled into my office with a cane and a service dog by her side, which flopped by her feet while we spoke. She was not yet forty years old, but very quickly she rewound the clock for me, and soon she was telling of a bright fall day in 1984. Only sixteen years old, she was entering the Massachusetts Institute of Technology, a child prodigy with an IQ of 173 and her ears ringing with predictions that one day she would win a Nobel Prize. “I arrived on campus with a teddy bear sticking out of my backpack,” she says, smiling slightly at the memory. “That’s how ill-equipped emotionally I was.”

Rachel’s emotional crash at MIT got under way at the end of her sophomore year, when she became involved with an older student who was “totally psychotic” and she began using illicit drugs—Ecstasy, acid, mushrooms, and nitrous oxide. Her sense of self began to crumble, and after a summer of talk therapy left her more confused than ever, she was hospitalized for psychotic depression. When she was released, she had prescriptions for an antipsychotic, an antidepressant, and a benzodiazepine (Xanax). “None of those drugs helped me,” she says. “They numbed me out, and trying to get off Xanax was a disaster. That is the evilest drug ever. It is so addictive, and all of the symptoms that caused you to go into the hospital in the first place get one thousand times worse when you try to go off it.”

Although Rachel eventually graduated from MIT and was accepted into an M.D.-Ph.D. program at the University of Colorado, she began cycling in and out of hospitals; her crash at MIT transformed into a case of chronic mental illness. “They told me I was hopeless, and that I would never get better,” she recalls. She enjoyed a period of stability from 1995 to 2001, when she worked as an assistant house manager at a group home in Boston, but then her brother died suddenly and her psychological problems flared up anew. Her psychiatrist took her off Risperdal and switched her to high doses of Geodon and Effexor, and he gave her an injection of another psychiatric medication as well.

“I had a severe serotonergic reaction, a toxic reaction,” Rachel
says, shaking her head at the memory. “It caused vasoconstriction in my brain, and this caused brain damage. I ended up in a wheelchair, and I couldn’t think, speak, or walk. Those centers of the brain need a lot of juice.”

Since then, her life has had its ups and downs. She takes comfort in her volunteer work with M-Power, the Boston peer advocacy group, and in the spring of 2008, she was working sixteen hours a week for Advocates, Inc., which provides services to the deaf. But she also has battled ovarian cancer, and it’s possible that illness was related to the psychiatric medications. She does find such drugs useful today, but when she looks back at her life, she sees a paradigm of care that utterly failed her. “It’s really a travesty,” she says.

In the spring of 2005, Scott Sexton received his MBA from Rice University. A bright future lay ahead at that moment, but then he broke up with the woman he had intended to marry, and he was hospitalized for depression. This was his second bout of major depression (he’d suffered a first episode five years earlier, when his parents divorced), and since Scott’s father had suffered from bipolar illness, he was now diagnosed with that disorder. He was put on a cocktail that included Zyprexa.

That fall, he began working as a consultant for Deloitte, the big accounting firm. Although his first few months on the job went fine, by early 2006 he was sleeping twelve to sixteen hours a day, zonked out by the Zyprexa. He soon needed another pill to get up in the morning, and he began “putting on weight like gangbusters,” his mother, Kaye, recalls. “He was five feet, ten inches tall and he went from 185 pounds to 250 pounds. He had a beer belly, and his cheeks looked like he was a chipmunk. We knew that Zyprexa caused weight gain, and he was alarmed, and so was I.”

By the fall of 2006, Scott was sleeping so much that on weekends he wouldn’t get up until the afternoon. He stopped going into the office and told Deloitte he was working from home. On Thanksgiving, he called his mother to tell her that he was suffering severe stomach pains, and the next day he was admitted to St. Luke’s
Episcopal Hospital in Houston. His mother flew in from Midland. “Scott is beet red, he’s sweating, and his hands are so swollen that they have trouble getting his ring off. He is burning up, and his [laboratory] tests are wacko. They are off the wall. His cholesterol is sky-high. His triglycerides are off the charts.”

Scott’s pancreas was shutting down. Zyprexa was known to cause pancreatitis, but the doctors at St. Luke’s didn’t connect the dots. They kept Scott on that drug until his death on December 7. “I had always told him to take his meds,” his mother says. “I said, ‘Scott, if I ever find out you are off your meds, I will come to Houston and shoot you.’ That’s what I said to him. And here he is doing everything he thinks he needs to do to be functional in our society, to be a productive member of society, and it kills him.”

The prescribing of psychiatric drugs to children and adolescents is a recent phenomenon, as relatively few youth were medicated prior to 1980, and so as we investigate this story, we have an opportunity to put the thesis of this book to a second test. Do we find, in the scientific literature and in societal data, that the medicating of children and teenagers is doing more harm than good? Is it putting many children, who initially may be struggling with a relatively minor problem—a disinterest in school, or a bout of sadness—onto a path that leads to lifelong disability? One of the principles of science is that the results from an experiment should be replicable, and in essence the medicating of children makes for a second experiment. First we medicated adults diagnosed with mental illness, and as we saw in the previous chapters, that did not lead to good long-term outcomes. Next, over the past thirty years, we diagnosed children and adolescents with various disorders and put them on psychiatric drugs, and now we can see if the results this second time around are the same.

I realize that this frames our investigation of the medicating of children in a rather cold, analytical way, given the frightening possibility at stake here. If the outcomes are the same in children and teenagers as in adults, then the prescribing of psychiatric drugs to millions of American youth is causing harm on an almost
unfathomable scale. But that possibility lends itself to an emotional review of the medical literature, which is precisely why we are going to conduct our inquiry in the most dispassionate manner possible. We need the facts to speak for themselves.

The story of progress that psychiatry tells about the medicating of children is slightly different in kind from the one it tells about its advances in care for adults. In 1955, when Thorazine arrived, there were hundreds of thousands of adults in mental hospitals, and they were diagnosed with illnesses that had a recognizable past. But when the psychopharmacology era began, very few children were diagnosed as “mentally ill.” There were bullies and goof-offs in elementary schools, but they were not diagnosed with attention-deficit/hyperactivity disorder (ADHD), as that diagnosis had yet to be born. There were moody and emotionally volatile teenagers, but society’s expectation was that they would grow up into more-or-less normal adults. However, once psychiatry began treating children with psychotropic medications, it rethought that view of childhood. The story that psychiatry now tells is that during the past fifty years it
discovered
that children regularly suffer from mental illnesses, which are said to be biological in kind. First psychiatry fleshed out ADHD as an identifiable disease, and then it determined that major depression and bipolar illness regularly struck children and adolescents. Here’s how Harvard Medical School psychiatrist Ronald Kessler summed up this “history” in 2001:

Illnesses that used to go undetected, it seems, have now been identified. The second part of this story of scientific progress tells of
how psychiatric medications are both helpful and necessary. Millions of children who used to suffer in silence are now getting treatment that helps them thrive. Indeed, the story now emerging in pediatric psychiatry is that psychotropic medications help create healthy brains. In his 2006 book
Child and Adolescent Psychopharmacology Made Simple
, psychiatrist John O’Neal explained to readers why it was so essential that children with mental illness be treated with medication:

If this is true, psychiatry has indeed made a great leap ahead in the past thirty years. The field has learned to diagnose brain illnesses in children that used to go unnoticed, and its “neuroprotective” drugs now turn them into normal adults.

Although attention-deficit disorder did not show up in psychiatry’s
Diagnostic and Statistical Manual
until 1980, the field likes to point out that it didn’t just appear out of thin air. This is a disorder that traces its medical roots back to 1902. That year, Sir George Frederick Still, a British pediatrician, published a series of lectures on twenty children who were of normal intelligence but “exhibited violent outbursts, wanton mischievousness, destructiveness, and a lack of responsiveness to punishment.”
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Moreover, he reasoned that their bad behavior arose from a biological problem (as opposed to
bad parenting). Children with known diseases—epilepsy, brain tumors, or meningitis—were often aggressively defiant, and thus Still figured that these twenty children suffered from “minimal brain dysfunction,” even though there was no obvious illness or trauma that had caused it.

Over the next fifty years, a handful of others advanced the notion that hyperactivity was a marker for brain injury. Children who recovered from encephalitis lethargica, a viral epidemic that swept around the globe from 1917 to 1928, often exhibited antisocial behaviors and severe emotional swings, leading pediatricians to conclude that the illness had caused mild brain damage, even though the nature of that damage couldn’t be identified. In 1947, Alfred Strauss, who was the director of a school for disturbed youth in Racine, Wisconsin, called his extremely hyperactive students “normal brain injured children.”
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Psychiatry’s first
Diagnostic and Statistical Manual
, published in 1952, said such children suffered from an “organic brain syndrome.”

The notion that stimulants might be beneficial for such children arose in 1937, when Charles Bradley gave a newly synthesized amphetamine, Benzedrine, to hyperactive children who complained of headaches. Although the drug didn’t cure their head pain, Bradley reported that it “subdued” the children and helped them concentrate better on their schoolwork. The children dubbed Benzedrine the “arithmetic pill.”
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Although his report was mostly forgotten for the next twenty years, in 1956 Ciba-Geigy brought Ritalin (methylphenidate) to market as a treatment for narcolepsy, touting it as a “safe” alternative to amphetamines, and physicians at Johns Hopkins University School of Medicine, who were aware of Bradley’s findings, soon deemed this new drug useful for quieting “disturbed” children who were thought to be suffering from a “brain damage syndrome.”
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There was no great rush by psychiatrists during the 1960s to prescribe Ritalin to fidgety children who went to regular schools. At that time, there was a sense that psychoactive drugs, because of their many risks, should be administered only to hospitalized children, or children in residential facilities. The population of children so hyperactive that they might be diagnosed with “organic brain
dysfunction” was small. However, psychiatry’s use of Ritalin slowly began to climb during the 1970s, such that by the end of the decade perhaps 150,000 children in the United States were taking the drug. Then, in 1980, the field published a third edition of its
Diagnostic and Statistical Manual
(DSM-III), and it identified “attention-deficit disorder” as a disease for the first time. The cardinal symptoms were “hyperactivity,” “inattention,” and “impulsivity,” and given that many children fidget in their seats and have trouble paying attention in school, the diagnosis of ADD began to take off. In 1987, psychiatry further loosened the diagnostic boundaries, renaming it attention-deficit/hyperactivity disorder in a revised edition of DSM-III. Next, Ciba-Geigy helped fund Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD), a “patient-support group” that immediately began promoting public awareness of this “disease.” Finally, in 1991, CHADD successfully lobbied Congress to include ADHD as a disability that would be covered by the Individuals with Disabilities Education Act. Children diagnosed with ADHD were now eligible for special services, which were to be funded with federal money, and schools regularly began identifying children who seemed to have this condition. As the
Harvard Review of Psychiatry
noted in 2009, even today the diagnosis of ADHD arises primarily from teacher complaints, as “only a minority of children with the disorder exhibit symptoms during a physician’s office visit.”
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