Some of these problems are trivial and tendentious, to be honest, more the effects of pushing our own disciplinary preferences in the way research is presented or semiotic hair-splitting in theoretical terms than substantive concerns. But there are some more profound issues, touched on in recent posts like Daniel’s Neurotosh, Neurodosh and Neurodash and my post, Bench and couch: genetics and psychiatry. Ironically, I was reminded of one of the more serious issues while reading a piece a few weeks ago by psychologist and psychologist-sceptic Bruce Levine on Alternet, The Science of Happiness: Is It All Bullshit?
In a meandering way, this post is a reflection on one of anthropology’s consistent criticisms of psychology; the often unacknowledged role of psychiatry in shaping psyches. That is, the difficulty of studying a phenomenon when one is helping to create it and one’s theories influence your subjects’ accounts. When psychology is successful in breaking through into popular awareness, it becomes entangled with its subject, a kind of folk theory operating in the same space that psychologists seek to study. So this post is a kind of neuroanthropological reflection on clinical psychology as both research enterprise and world-making project, and the way the two come into conflict.
Specifically, Daniel’s post on Neurotosh and Levine’s story of John Stewart confronting Harvard happiness researcher, Prof. Tal Ben-Shahar, reminded me of the recent scandal surrounding psychiatrist Prof. Joseph Biederman. Biederman took large unreported consulting fees from pharmaceutical companies who manufactured anti-psychotic medicines while he was simultaneously encouraging psychiatrists to diagnose children with bipolar disorder, and then to prescribe their young patients anti-psychotic medicines. Senator Charles E. Grassley (R-Iowa) held hearings on the financial conflicts of interest as reported in The New York Times in Researchers Fail to Reveal Full Drug Pay, by Gardiner Harris and Benedict Carey. (For an earlier critical article, see the Boston Globe piece, Backlash on bipolar diagnoses in children.)
Psychopharmaceutical corruption and diagnosis
As the Grassley-led inquiries found, Biederman and two other colleagues at Harvard took $4.2 million from 15 drug companies that they failed to report. (See, also, Levine’s excellent article on Biederman, Exposed: Harvard Shrink Gets Rich Labeling Kids Bipolar.) Grassley’s investigation focused on these serious financial problems, but I find the psycho-cultural consequences of Biederman’s work more interesting from a neuroanthropological perspective. From The New York Times:
Dr. Biederman is one of the most influential researchers in child psychiatry and is widely admired for focusing the field’s attention on its most troubled young patients. Although many of his studies are small and often financed by drug makers, his work helped to fuel a controversial 40-fold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder, which is characterized by severe mood swings, and a rapid rise in the use of antipsychotic medicines in children.
As Levine describes, with Biederman as the flagbearer, the move to diagnose more and more children and adolescents with bipolar disorder not only increased the number of diagnoses ’40-fold,’ it also drove up pharmaceutical companies’ profits: ‘The expanded use of bipolar as a pediatric diagnosis has made children the fastest-growing part of the $11.5 billion U.S. market for anti-psychotic drugs’ (originally from the Bloomberg News, 2007). Biederman still has a number of ongoing clinical trials on a range of psychological drugs (see table here; h/t to Furious Seasons, which has a number of good posts on this scandal)
The childhood diagnosis of bipolar disorder has been controversial; some psychiatrists argue that the condition can’t be diagnosed in children, or even that it simply does not emerge until maturity. Furious Seasons, for example, has covered a number of researchers he vehemently oppose Biederman’s approach to treating children with psychological or behavioural problems (see, for example, Neuroscientist Slams The Bipolar Child Paradigm and Harvard To Teens Who Smoke And Drink: You Are All Bipolar Now, but Phillip’s blog has a wealth of material on this controversy).
Since 1995, when Prof. Biederman started to publish extensively on the subject (he has authored around 300 articles, and proudly has claimed to producing 30 a year as a co-author, a number that seems staggering and improbable to me as a researcher — that’s more than one every fortnight), 800,000 children in the United States, some as young as two, have been treated for bipolar disorder. As The New York Times reported: ‘Some 500,000 children and teenagers were given at least one prescription for an antipsychotic in 2007, including 20,500 under 6 years of age, according to Medco Health Solutions, a pharmacy benefit manager.’ In addition, Biederman has had a direct role in the increasing diagnosis of children with attention deficit hyperactivity disorder (and has received large unreported consulting fees from the pharmaceutical companies that make related drugs, as well).
Although the facts of the case look bad, I don’t really want to get involved in the question of corruption or conflict of interest, nor in the question of whether or not the children being diagnosed have the specific ‘disorders’ with which they’ve been diagnosed. In many cases, the children being diagnosed suffered immensely, and their parents may have been so relieved to have some intervention that helped with their children. For the sake of arguing, let’s just assume, improbably, that there are no serious financial issues nor has any child received an incorrect diagnosis. (Like I said, this is improbable, but indubitably, there were some families who might have been at the end of their rope before getting a diagnosis.)
If everything is above board, then Prof. Biederman has single-handedly helped shift the way in which people view and understand children’s behaviour, and in the process, influenced a shift in the institutional-discursive-knowledge economy among expert psychiatrists so that 800,000 children now receive treatment for disorders that might have gone largely undetected without his influence. The field of psychiatry, even a single psychiatrist with a significant support structure has cast a huge shadow (or a bright light, depending on how you want to see it) over the lives of close to one million children in the United States alone. His position in an institution, the channels of academic publication, the structure of his profession, and the diagnostic framework he invested in meant that his influence could directly affect an enormous number of lives. The reverberations of his ideas were both wide and deep, as even proponents of these drugs acknowledge that they can have profound affects on the lives of the children taking them.
But, in terms of neuroanthropology, we also know that antipsychotics are powerful drugs that can have serious effects on the human brain, nervous system, and body especially when taken for long periods of time. Even on adult patients, these drugs can shape physiological development; the fact that Biederman was calling for earlier diagnosis and treatment, with children under the age of six, for example, going onto intense drug regimens, means that the diagnosis and treatment was directly affecting their development when their brains were still changing quickly. The effects of the drug would be integrated into the children’s neural architecture as they matured with effects we probably can’t entirely anticipate or understand.
Although I frequently become impatient with post-structural theory in anthropology, this is one situation where a robust suspicion of authority and willingness to see how ‘official discourse’ shapes reality seems entirely justified. The only thing that distinguishes the case of Biederman and the proliferation of the ‘bipolar’ diagnosis in children from cases of ‘delinquency’ or ‘madness’ described by Michel Foucault is that Biederman was likely even more cynical than any actor described by Foucault. That is, the money trail, like the case Daniel reports in Neurotosh, Neurodosh and Neurodash, suggests that this isn’t just a case of a person’s worldview shaping what they can and can’t see. Rather, the sums of money involved strongly suggest that people willingly, even intentionally, self-deceive. While that may be fine if you’re a quiet citizen or blogger, when you’re positioned as Biederman was in webs of institutional and discursive authority, you’re self-delusion can become a child’s pharmico-reality. How these people can sleep at night is beyond my imagination…
In a way, Daniel’s post reminded me of how certain ideas from ‘evolutionary psychology’ have provided refuge for very old prejudices; the uptake of these ‘theories’ is much quicker than typical academic theories because they tell people what they believed all along, but the ‘theories’ also short circuit social responsibility or change, becoming formative influences in social-ideological life. I’m not an adherent to a ‘strong form’ social constructionism (where ideas create reality), but I think it’s very hard to discount a weaker form of social constructionism, which might hold that ideological formations, through concrete mechanisms (like a prominent academic appointment, publications, and a professional apparatus), can exercise profound influence on how people are physiologically constituted. The case of Prof. Biederman is even more clearly visible than ‘evolutionary psychology.’
Now these drugs and diagnoses have been integrated into the constellation of forces shaping immature, very plastic brains. Not only will the kids being diagnosed find their brains bathed in powerful psychoactive chemicals, but they will also find that the social and interactional space around them is shaped by other people’s expectations. Parents will be educated in ‘what to expect’ from a bipolar child (and let’s face it, what kid does not demonstrate ‘bipolar’ behavior on occasion?). Who knows how the diagnosis might impact a child who is traumatized or abused, the symptoms attributed to an underlying neurophysiological cause and medicated away. Like the large increase in diagnoses since 1995, the cultural-psychiatric machine will produce greater confirmation for its own theories. Psychiatry as an institution will help to shape the psychological make-up of those who live under it.