I decided to return from my retirement as an active participant in the psychiatric journals discussions, because I know I will feel guilty if I don’t share what I continue to witness. The crisis that I am alluding to is the same one that I addressed back in 2007. (1)
This is a problem that, even if I wanted to ignore it I can’t, because by doing inpatient work I have the opportunity of observing first-hand the consequences of poor medication management and wrong diagnoses. Both, Orlando and Las Cruces, are college cities, and that circumstance adds young adults to the assortment of patients that require hospitalization. I will discuss them following the presentation of the case that triggered this commentary.
After 2 days of unsuccessfully trying to transfer an elementary school child to a psychiatric hospital, I was asked if I could provide any suggestion. I heard that this child was brought to the ED by a desperate mother due to destructive, aggressive, and defiant behaviors, plus a severe insomnia. My first thought was to suggest a facility in a bordering state with an inpatient Unit, but when I was told that the patient was taking a combination of amphetamine salts for ADHD and sertraline for anxiety, I volunteered to go and speak with the patient and the mother.
After saying ‘Hi’ to an extroverted, friendly, and talkative child, I asked a Resident to stay with the patient while I was interviewing the mother in another room. She told me “my ex is bipolar and we divorced because of his violent temper tantrums…yes, I told Dr. X about him but the answer I got was that it was not relevant because he is not part of the picture and that my child has ADHD and ODD” (Oppositional-Defiant Disorder). (2)
After gathering more information and going back to the child and the resident, I recommended discharging the patient home and stopping the current medications. I also and asked the ED physician to write a prescription for a mood stabilizer. The mother had suspected all along that it was bipolar disorder and not ADHD what her child has, “because it is like watching the father in action”. I should mention that one of the most shocking details of this case was that the patient’s mother said to the ED doctor, “I’d rather call the state to give up custody than taking ‘X’ home”, and how contrasting the sense of relief that lady showed when she heard “yes, your child is bipolar and the current medications are worsening the symptoms”.
As I have said before (3) the quick decision to label any person that complains of feeling “hyper” and “can’t concentrate” as having ADHD can have devastating consequences. As most readers probably know, an individual can feel restless or have problem paying attention, due to multiple reasons such as obsessions, social anxiety, PTSD, auditory hallucinations, racing thoughts and elevated mood, to mention just a few. Furthermore, a defiant child whose elevated mood can become aggressive under the influence of an amphetamine-like medication can end up with the label of Conduct Disorder and behind bars in a Juvenile Detention Center.
This is one of many reasons to obtain a complete family history before making a psychiatric diagnosis. Back in 2004, I wrote a commentary on this subject that included the story of a family with 5 children, all diagnosed with bipolar disorder (4), possibly because both parents have this illness. And this recollection takes me to the debacle that is happening not only with the diagnosis of ADHD in bipolar patients but one most frequent mishap in the treatment of the bipolar spectrum disorders: prescribing antidepressants even when the patient is in a state of mania. (5)
Just in the past 6 months I have treated 154 patients whose symptoms were compounded by using antidepressants. The last one (the day before writing these lines) had a diagnosis of Treatment-Resistant Depression (TRD) and had failed all combinations of mood enhancers drugs. Upon arrival to the ED (referred by a Primary Care Physician) this patient was taking 300 mg of bupropion and 45 mg of mirtazapine and, despite these 2 strong medications, feeling “like I can’t keep going on”.
A very common presentation is that of a patient with an established diagnosis of bipolar disorder or schizoaffective disorder who is taking five or six medications and still feels sad or angry, irritable, can’t sleep because of racing thoughts and is impulsive. Multiple times the person is brought to the ED with a history of overdosing with medications, self-inflicted wounds or attempted hanging. Others come on their own or are referred by their prescribers because they are having thoughts of driving against the incoming traffic, shooting themselves or jumping from a bridge.
A recent case was a good teaching opportunity for the residents because the patient came on a combination of mood stabilizers and 300 mg of venlafaxine, complaining of depression with thoughts of suicide. It was remarkable to see how the affect was becoming brighter and the patient began to report a “better” mood as the antidepressant (ironic?) was tapered off. More irrational yet is the prescription of amphetamines to a person with a mood disorder and anxiety, which present two logical contraindications for the use of a powerful dopaminergic drug. Anyone who understands that caffeine worsens anxiety and the racing thoughts of bipolar disorder would realize that a much more powerful stimulant (amphetamine) would be harmful for those patients. (5) Sadly, this is not the case, and every day thousands of prescriptions are written in the USA for persons that will react adversely to them.
To be fair to prescribers in the “Wild West,” it should be said that I have encountered similar diagnostic and medication management errors in patients coming to Orlando, FL and Phoenix, AZ from prestigious centers in New England, Chicago, NYC and others. I firmly believe that a significant portion of psychiatric patients are not going to get the quality care they deserve until the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry take a strong, rational position against the absurd idea that mental illnesses are not hereditary and several irrational guidelines such as allowing the diagnosis of ADHD in children with Autism Spectrum Disorders. By the same token, the elimination of symptoms labeled as diagnoses (Oppositional-Defiant Disorder and Conduct Disorder) are long due for retirement. This is 2017, and obsolete ideas from the times when the psychoanalytic establishment was in control of psychiatry and determined that children could not have serious mental illness must be discarded. We owe that to our patients.
Mota-Castillo, M.D., The Crisis of Overdiagnosed ADHD, Psychiatric Times, July 2007.
Mota-Castillo, M.D., Is It Really ODD? Psychiatric Times, February 2004.
The Journey Out of Madness, Psychiatric Times, February 2009.
Bipolar Disorder and Genetics: Beyond Question, Psychiatric Times, June 2004.
Scott D Lane, Charles E Green, Joy M Schmitz, Nuvan Rathnayaka, Wendy B Fang, Sergi Ferré, and F Gerard Moeller; Comparison of Caffeine and d-amphetamine in Cocaine-Dependent Subjects: Differential Outcomes on Subjective and Cardiovascular Effects, Reward Learning, and Salivary Paraxanthine, J Addict Res Ther., 2014; 5(2):176.
Ross J. Baldessarini, MD, Gianni L. Faedda, MD, Emanuela Offidani, PhD, Gustavo H. Vázquez, MD, PhD, Ciro Marangoni, MD, Giulia Serra, MD, and Leonardo Tondo, MD, MSc. “Switching” of Mood From Depression to Mania With Antidepressants; Psychiatric Times, Nov. 2013.