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Bipolar Disorder in Youths May Be Overdiagnosed    [

    Bipolar Illness Soars as a Diagnosis for the Young
    By Benedict Carey
    The New York Times

    Tuesday 04 September 2007

    The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers report today in the most comprehensive study of the controversial diagnosis.

    Experts say the number has almost certainly risen further since 2003.

    Many experts theorize that the jump reflects that doctors are more aggressively applying the diagnosis to children, and not that the incidence of the disorder has increased.

    But the magnitude of the increase surprises many psychiatrists. They say it is likely to intensify the debate over the validity of the diagnosis, which has shaken child psychiatry.

    Bipolar disorder is characterized by extreme mood swings. Until relatively recently, it was thought to emerge almost exclusively in adulthood. But in the 1990s, psychiatrists began looking more closely for symptoms in younger patients.

    Some experts say greater awareness, reflected in the increasing diagnoses, is letting youngsters with the disorder obtain the treatment they need.

    Other experts say bipolar disorder is overdiagnosed. The term, the critics say, has become a catchall applied to almost any explosive, aggressive child.

    After children are classified, the experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side effects like rapid weight gain.

    In the study, researchers from New York, Maryland and Madrid analyzed a National Center for Health Statistics survey of office visits that focused on doctors in private or group practices. The researchers calculated the number of visits in which doctors recorded diagnoses of bipolar disorder and found that they increased, from 20,000 in 1994 to 800,000 in 2003, about 1 percent of the population under age 20.

    The spread of the diagnosis is a boon to drug makers, some psychiatrists point out, because treatments typically include medications that can be three to five times more expensive than those for other disorders like depression or anxiety.

    "I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder, but the tremendous controversy reflects the fact that we haven't matured enough," said Dr. John March, chief of child and adolescent psychiatry at the Duke University School of Medicine, who was not involved in the research.

    "From a developmental point of view," Dr. March said, "we simply don't know how accurately we can diagnose bipolar disorder or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness. The label may or may not reflect reality."

    Most children who qualify for the diagnosis do not proceed to develop the classic features of adult bipolar disorder like mania, researchers have found. They are far more likely to become depressed.

    Dr. Mani Pavuluri, director of the pediatric mood disorders program at the University of Illinois, Chicago, said the label was often better than any of the other diagnoses often given to difficult children.

    "These are kids that have rage, anger, bubbling emotions that are just intolerable for them," Dr. Pavuluri said, "and it is good that this is finally being recognized as part of a single disorder."

    The senior author of the study, Dr. Mark Olfson of the New York State Psychiatric Institute at the Columbia University Medical Center, said, "I have been studying trends in mental health services for some time, and this finding really stands out as one of the most striking increases in this short a time."

    The increase makes bipolar disorder more common among children than clinical depression, the authors said. Psychiatrists made almost 90 percent of the diagnoses, and two-thirds of the young patients were boys, said the study, published in the September issue of The Archives of General Psychiatry.

    About half the patients were identified as having other mental difficulties, mostly attention deficit disorder.

    The children's treatments almost always included medication. About half received antipsychotic drugs like Risperdal from Janssen or Seroquel from Astrazeneca, both developed to treat schizophrenia.

    A third were prescribed so-called mood stabilizers, most often the epilepsy drug Depakote. Antidepressants and stimulants were also common.

    Most children took a combination of two or more drugs, and 4 in 10 received psychotherapy.

    The regimens were similar to those of a group of adults with bipolar diagnoses, the study found.

    "You get the sense looking at the data that doctors are generalizing from the adult literature and applying the same principles to children," Dr. Olfson said.

    The increased children's diagnoses reflect several factors, experts say. Symptoms appear earlier in life than previously thought, in teenagers and young children who later develop the full-scale disorder, recent studies suggest.

    The label also gives doctors and desperate parents a quick way to try to manage children's rages and outbursts in an era when long-term psychotherapy and hospital care are less accessible, they say.

    In addition, drug makers and company-sponsored psychiatrists have been encouraging doctors to look for the disorder since several drugs were approved to treat it in adults.

    Last month, the Food and Drug Administration approved one of the medications, Risperdal, to treat bipolar in children. Experts say they expect that move will increase the use of Risperdal and similar drugs for young people.

    "We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that, Oh my God, we're missing bipolar," said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at the Stony Brook University School of Medicine on Long Island. "And if you're a parent with a difficult child, you go online, and there's a Web site for bipolar, and you think: 'Thank God, I've found a diagnosis. I've found a home.' "

    Some parents whose children have received the diagnosis say that, with time, the label led to effective treatment.

    "It's been a godsend for us," said Kelly Simons of Montrose, Colo., whose son Brit, 15, was prone to angry outbursts until given a combination of lithium, a mood stabilizer, and Risperdal, which was often given to children "off label," several years ago. He now takes just lithium and is an honor roll student.

    Other parents say their children have suffered side effects of drugs for bipolar disorder.

    Ashley Ocampo, 40, of Tallahassee, Fla., whose 8-year-old son is being treated for bipolar, said that he had tried several antipsychotic drugs and mood stabilizers and that he had improved.

    "He has gained weight," Ms. Ocampo said, "to the point where we were struggling find clothes for him. He's had tremors and still has some fine motor problems that he's getting therapy for. But he's a fabulous kid. And I think, I hope, that we're close to finding the right combination of medications to help him."

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    Bipolar Disorder in Youths May Be Overdiagnosed
    By Denise Gellene
    The Los Angeles Times

    Tuesday 04 September 2007

A new study says a fortyfold increase can be partly attributed to doctors mislabeling children and teens with the illness.

    The diagnosis of bipolar disorder in children and adolescents has risen fortyfold since 1994, according to a study released Monday. But researchers partly attributed the dramatic rise to doctors over-diagnosing the serious psychiatric disorder.

    The report in the journal Archives of General Psychiatry said bipolar disorder was found in 1,003 of every 100,000 office visits from children and adolescents in 2002-03, compared with 25 of 100,000 office visits in 1994-95.

    The diagnosis of bipolar disorder among adults increased twofold during the same period, researchers said.

    The study didn't investigate the reasons for the sudden rise in bipolar cases among children and adolescents. A book published in 2000, "The Bipolar Child," made the controversial assertion that one-third to one-half of children with depression had bipolar disorder.

    Dr. Mark Olfson, a psychiatrist at Columbia University's College of Physicians and Surgeons and senior author of the latest study, said part of the increase was attributable to an under-diagnosis of bipolar disorder in the past.

    But Olfson said another reason was the mislabeling of children and adolescents with aggressive or irritable behaviors as bipolar, an illness that is treated with powerful psychotropic medications, many of which have not been tested in children.

    Dr. Thomas R. Insel, director of the National Institute of Mental Health, which funded the study, called the increase in bipolar diagnoses worrisome.

    "The way the label is being used is probably a little exuberant - not fitting with the strict definition of the illness," Insel said. The disorder "is probably not as common as the very high rates we're seeing."

    Bipolar disorder is marked by severe mood swings between depression and mania, which is characterized by an excess of energy and restlessness. For most patients, depressive episodes are three times more common and longer lasting than those of mania. Symptoms of the disorder can interfere with daily activities, and severe cases carry a risk of suicide.

    Until recently, the illness, which appears to run in families, was seldom diagnosed in children. It was believed to begin in late adolescence or early adulthood. About 2% of American adults are believed to have bipolar disorder, although not all of them have been diagnosed.

    In the latest study, researchers analyzed data from an annual national survey that collected information from doctors about the nature of patient visits.

    Researchers found striking differences between adults and the young. Among children and adolescents, boys were more likely to be diagnosed with bipolar disorder. Among adults, it is more common in women.

    Olfson said the gender difference between the groups suggested that some boys with behavior problems or conduct disorders were being misdiagnosed as bipolar. Irritability is a characteristic of bipolar disorder, he said, but it is also a normal part of adolescence.

    "The definition of bipolar disorder tells us what it looks like in adults but not in children," Olfson said.

    Young people were 10 times more likely to also receive a diagnosis of attention deficit hyperactivity disorder than bipolar adults, the report noted. Olfson said it was likely that some children with ADHD received the additional diagnosis of bipolar disorder because the symptoms of the two illnesses overlapped. For example, he said, some children and adolescents with ADHD have a "volatile, aggressive subtype" that is easily confused with bipolar disorder.

    The report found that children and adolescents diagnosed with bipolar disorder received the same medication as adults with the illness. Sixty percent of children and adolescents received a mood stabilizer, and about 33% of them received an antidepressant or antipsychotic medication, which can cause weight gain.

    Dr. Gabrielle A. Carlson, a psychiatrist at Stony Brook University in New York, said 1 of every 5 children referred to her with a diagnosis of bipolar disorder actually had it. The rest had autism, depression, anxiety or another psychological disorder. All these conditions involve different treatments, with drugs, behavioral therapy or both.

    Carlson, who has studied the increase in bipolar diagnoses, said some parents seemed to prefer a diagnosis of the disorder because the illness, which is thought to be largely genetic, absolves them of blame.

    "They don't have to deal with their chaos, their psychiatric disorder, their marital troubles or abuse," she said.

    She said that in some cases, providers would diagnose psychological problems in children as bipolar disorder to obtain insurance reimbursement for hospitalizations, a practice called upcoding.

    Insel said his institute was conducting research that might lead to more accurate diagnoses of bipolar disorder in young people. The agency said recent imaging studies had detected differences between the brains of normal children and those with bipolar disorder.

    A large study looking for the genes responsible for the disorder is nearing completion and may yield some additional clues, Insel said.

    The agency is also tracking children with bipolar disorder to see how their symptoms change over time. Only a small fraction of children referred for the study actually had bipolar disorder, Insel said, another indication that the label is misused.

    "We urgently need to improve diagnosis and treatment for these kids with severe emotional problems," he said.