Youth under the influence

Mental health drugs based on biased sources

DRUG BUST by Alan Cassels

• The people’s briefing note on prescription drugs
Portrait of columnist Alan Cassels

A November 2012 press release from the BC Ministry of Health presented us with a bold and hopeful headline: “New program helps BC family doctors treat mental health challenges in children and youth.”

This announcement was readily welcomed in many quarters as it represented an explicit government commitment to help educate BC’s doctors on treating child and youth mental health problems such as anxiety, depression and ADHD. It was pretty encouraging after all the turmoil we’ve seen lately in the province’s health system; from the bizarre firing spree at the Ministry of Health to the continual stream of reports from BC’s Representative for Children and Youth about the horrific treatment of some of BC’s most vulnerable children.

The soothing words about the program having “an emphasis on non-drug treatments” left me quite hopeful, but two years later, there’s little to buoy my hopes. With an obvious pro-pharma bias in its orientation, it seems to me they’ve allowed the moneylenders into the temple once again.

Most of us couldn’t argue against strong public money going towards the education of our doctors – they need to be kept up-to-date and knowledgeable – but we’d also mostly agree that any educational material needs to be absolutely scrupulous and that we need processes in place to prevent the corruption of the program from those with an agenda other than the health of children.

BC’s new program is up and running here in Victoria and it will pay the doctors about $1,400 for attending three half-day group educational sessions. It will also cover attendance for medical office assistants aiming to teach “enhanced identification and diagnosis of common mental disorders in children and youth” and so on. Sounds good, right?

I certainly don’t begrudge physicians getting paid for their time, yet after about 10 minutes of digging into the specifics of the program, my heart sank. Even as the program promises to introduce the docs to “non-drug management tools” (i.e. cognitive behavioural therapy), the key thrust of the program seems to be new ways to begin lifelong drug treatment for youths who happened to get screened and thus labelled with anxiety, depression or ADHD. To me, the suggested screening tools, which go by the names KADS-6, SCARED and SNAP-IV, represent a triumvirate of tools all derived from biased sources tied to the pharmaceutical industry.

You might think I worry too much and there are some treatments that are absolutely needed by very troubled youth. That is true, but what if the screening tools do what other screening tools do: identify people who will never go on to be sick and, in essence, make them worse off?

The KADS screen, named by its creator, psychiatrist Stan Kutcher, employs six questions to screen kids for anxiety. Dr. Kutcher, a bit of a media darling in Canada, is supported by a long list of pharmaceutical companies. He has been a researcher, consultant and advisor to GlaxoSmithKline, Pfizer, Eli Lilly, Lundbeck, Wyeth-Ayerst, Abbott, Bristol-Myers Squibb, Janssen, Novartis, Organon and Boehringer Ingelheim – basically the laundry list of the world’s biggest drug companies.

His KADS-6 questionnaire (Kutcher Adolescent Depression Scale) uses six simple questions to diagnose and assess the severity of adolescent depression by asking kids to self-rate on how frequently they feel low mood, sadness, feelings of worthlessness, tired or feeling life isn’t much fun. The options are “hardly ever,” “much of the time,” “most of the time” or “all of the time.” When you add up the scores, it draws a cutoff between “possible depression” and “probably not depressed.”

While this distinction might not be helpful for your average doctor, it may make it slightly easier to dish out a script for Paxil (paroxetine, a major antidepressant) for kids tumbling into the ‘possible’ range. Speaking of Paxil, if you stick Dr. Kutcher, Paxil and “study 329” into the maw of Google, you’ll marvel at what emerges. Superlatives aside, BBC called study 329, a Glaxo-funded study of using Paxil in kids, “one of the biggest medical scandals of recent times.” Kutcher co-authored the study and he and his colleagues concluded that Paxil is “generally well tolerated and effective for major depression in adolescents.” The reality is that the opposite was likely more true.

Revelations from court proceedings showed the drug was more likely to induce suicides in teens rather than prevent them. Nonetheless, studies like 329 and the researchers who wrote up the results helped Paxil turn into a mind numbingly huge blockbuster drug (sales of more than $11 billion between 1997 and 2005) even as it turned many people around the world into hardened anti-pharma skeptics.

But those facts seem irrelevant when we invite Stan Kutcher and his KAD-6 screening tool to educate BC family doctors and help identify social and emotional problems in children and label them as mentally ill, with the ultimate result of plying them with drugs.

Another 329 study co-author, Dr. Boris Birmaher, is also in the BC tent with his SCARED (Screen for Child Anxiety Related Emotional Disorders) questionnaire, designed to tease out anxiety’s various iterations: General Anxiety Disorder, Separation Anxiety, Social Anxiety Disorder and what’s known as “Significant School Avoidance.” Now that’s a gig: creating a pathology and a mental illness out of kids who don’t want to go to school.

Dr. Birmaher is a widely recognized expert in pharmacological and biological studies of children and adolescents with mood and anxiety disorders and his disclosures indicate he receives or has received research support, acted as a consultant and/or served on a speaker’s bureau for Solvay Pharmaceuticals, Forest Laboratories, Inc. and Schering-Plough. But let’s overlook his pharma connections and ask, “Can we trust that SCARED is a valid way of identifying anxious kids and directing them into programs where they do better?” No, we can’t because no one can say that those kids who have been through the ‘SCARED’ mill will do any better than those who haven’t. We only know one thing: they are more likely to be labelled and given drugs.

The author of the SNAP-IV questionnaire, James Swanson, has acted as a consultant and/or served on a speaker’s bureau for drugmakers McNeil, UCB, Eli Lilly and Company, Cephalon, Janssen, L.P. and Novartis Pharmaceuticals. As far as I can tell, the SNAP-IV (originally created by Swanson, Nolan and Pelham) questionnaire is a fast track to ADHD drugs. We would heartily accept this screening questionnaire if quality research showed kids labelled with ADHD and thus fed stimulants did better than those who aren’t. One three-year study of ADHD drugs found that “medication use was a significant marker not of beneficial outcome, but of deterioration. That is, participants using medication in the 24-to-36 month period actually showed increased symptomatology during that interval relative to those not taking medication.”

For me, all three screening tools strike out. The inning is over. As they say in baseball, “three up, three down.” For the people who organize the ongoing education of BC doctors, I only have one question: “Really?” Do we really have to fund physician training using notoriously unreliable mental health screening tools created by people tied to the pharmaceutical industry? The medical literature is plump-full of research on the pernicious influence of financial conflicts in health decision making and you have invited the creators of SNAP, SCARED and KADS into the temple to besmirch the minds of our doctors?

I still remain hopeful.

My hope is that BC’s doctors are too smart for this and they’ll ask the hard questions about these so-called screening tools. Maybe they can appreciate that broad-based, community oriented, non-medical approaches to mental health are the best guarantee of success. Maybe they’ll realize that, as physicians, they can be very good at writing prescriptions, but we can do better. And maybe they too can be advocates for a program that won’t deliver more of our youth into the waiting arms of the pharmaceutical industry.

Alan Cassels is the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease and admits he has never met a mental illness screening program that delivers on its

Open Pharma is a new campaign to have all drug company payments to physicians made accessible to the public. Open Pharma is calling on the federal government to enact legislation requiring full disclosure of such payments.

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