The front page of the September 4th issue of The New York Times carried a story by Benedict Carey entitled “Bipolar Illness Soars as a Diagnosis for the Young.” Carey has done a number of important pieces about child mental health over the past few years. The subject of pediatric bipolar disorder stirs strong feelings in child psychiatrists and has become a lightning rod for controversy. The NY Times article describes the findings of a new study that adds important data to the debate. Carey reports that this new study, published in the September issues of The Archives of General Psychiatry, documents a 40-fold increase in the diagnoses of bipolar disorder in children between 1994 and 2003, climbing from 20,000 cases in 1994 to 800,000 cases in 2003.
The article points out that child psychiatrists differ on their opinion about this trend. Many doctors feel that increase in diagnoses indicates an improved awareness of the diagnosis and the ability to treat these children early and with better effect. Others disagree and feel that the diagnosis has been oversold and is used to describe a lot of angry, explosive kids. The NY Times points out that, so far, other data have shown that most kids who fit this broad definition of bipolar do not seem to develop the classic form of the disorder in adulthood. In fact, most of these kids go on to develop depression, rather than manic episodes.
The impact on these kids is enormous when they are given a bipolar diagnosis. They are often prescribed medications such as atypical antipsychotics or mood stabilizers, when the research on these meds in children remains limited. Only four out of ten of the children studied were reported to also be in psychotherapy, according to the NY Times article. The drug companies are pleased with this trend and are looking for pediatric indications for medications already being used to treat bipolar disorder in adults. According to the article, a bipolar diagnosis and the resulting treatment can be good news for some families, helping them deal with very dangerous and difficult situations.
I have strong feelings on this subject and feel that it deserves some serious discussion. In my reading of the literature, we do not have any evidence that a broad definition of bipolar disorder in children is the same illness as classic bipolar disorder in adults. Over the past 15 years or so, I have witnessed this explosion in bipolar diagnoses in kids who are reactive, explosive, impulsive, often hyperactive, oppositional, and usually struggling in every part of their lives. Most of these kids do not have the classic symptoms of BP—periods of major depression interspersed with periods of mania. In fact, the “cycles” are often hours long, rather than days or weeks. They do not typically have the classic sleep changes, grandiose thinking or high levels of productivity, or euphoria that go along with mania. Most, if not all, are chronically irritable with explosive episodes, but do not exhibit sustained periods of higher levels of irritability or energy. Many do have depressive symptoms, such as hopelessness, low productivity and a very negative sense of self, as well as symptoms of ADHD—baseline hyperactivity and impulsivity. These are often more chronic symptoms, rather than episodic as required for a more standard definition of BP.
Some children do have classic manic symptoms that require a bipolar diagnosis, but they are much less common. The more typical picture with full manic or even hypomanic symptoms becomes more prevalent in adolescence and young adulthood, but these are not the kids behind the staggering increase in pediatric bipolar disorder diagnoses over the last 15 years. The kids getting over diagnosed are those who present as explosive, reactive, irritable, impulsive, oppositional, inflexible, and hyperactive. They form the cornerstone of child psychiatry practice and some of the most painful, difficult situations that we work with. Families are overwhelmed and exhausted and everyone is hurting, especially the child. In some cases, it seems that having the bipolar label has been helpful, because it offers hope for treatment and some explanation of these difficult kids. I couldn’t agree more that the benefit of this trend has been to identify that these children are truly struggling with “wiring” issues—neurobiological problems in their emotional and behavioral wiring. It has been a strong place to start the discussion that these are NOT BAD KIDS as they have so long been called and then treated as such.
There are, however, many downsides to this label if it applied haphazardly or prematurely. First and foremost, jumping to the bipolar label (often done in 15 minutes or less) eliminates a more thorough examination of all of the possible causes. Kids with anxiety, language disability, trauma, attachment issues, fetal alcohol and drug exposure, learning and school problems, and certain medical problems can have similar symptoms. ADHD and depression can often be swept into the diagnosis or missed completely. Without a careful history and examination as well as a thorough differential diagnosis, developing a treatment plan becomes shotgun affair.
A similar effect occurs on medication choices if bipolar is thrown into the mix inappropriately. It narrows the medication options dramatically, often to the detriment of the more likely underlying diagnoses. Once a child is labeled bipolar, doctors are extremely hesitant to use antidepressants, because of the risk of “switching” into mania (this is something for another discussion). The problem is, as pointed out in the article, many of these kids actually go on to develop symptoms more in line with depression than bipolar disorder. Depression is a much more common diagnosis in general than bipolar. Not that we should miss bipolar, but we seem to missing a lot of depression now because of the bipolar frenzy. Yes there are risks to using antidepressants in kids—all kids, not just those with bipolar—and if you are going to start these medications you need to work carefully and in close communication with the family. Completely eliminating them from the treatment options, however, is a big problem. Similarly, many of these kids have ADHD and need to be tried on stimulant medication, but again this is shunned when a child is labeled bipolar.
The other dark side of the medication picture with the bipolar label is that the medications that do get used “first line” are “big guns” and create a higher risk. Atypical antipsychotics are very powerful medications with significant risks—weight gain, diabetes, movement disorders—to name a few. “Mood stabilizers” such as Depakote carry their own risks and are really meant to treat a manic episode, which is not classically present in most of these kids anyway. Depakote appears to increase the risk of polycystic ovary disease if given in prepubertal girls, so making sure it is being given for a good reason is important. Lithium is a powerful tool in bipolar disorder, as well treating mania and depression and reducing cycle frequency, but it carries many risks, especially toxicity and kidney and thyroid problems. Interestingly some research shows benefits to the use of Lithium in aggressive and explosive adolescents, even without a bipolar diagnosis, so we may even use these medications in these generally difficult kids, but we don’t have to call them bipolar if they don’t meet the criteria.
Finally, a huge risk of the label bipolar is a tendency to become over focused on medications and to minimize the non-pharmacologic interventions such as cognitive behavioral therapy (CBT), family therapy, and educational planning. These complex kids, whatever they turn out to “be” and their families need enormous amounts of support and coaching to get through every day. Waiting for the “magic pill” combination is frustrating and painful and unrealistic, especially when the diagnosis isn’t really so clear after all. A broader set of interventions is essential with these kids, regardless of their “diagnoses.” In particular, a program called Collaborative Problem Solving, developed by Ross Greene PhD and Stuart Ablon PhD, in Boston, has shown tremendous benefits in working with complex, difficult children with these explosive, reactive, and oppositional types of responses. The focus in this work is on identifying the specific areas of “skills deficits” that these kids have in their emotional and behavioral functions and working with families and educators and the kids to problem solve and build these skills over time. Most importantly in this model, kids are not seen as “bad” or “not trying hard enough,” which in itself creates a new and far more positive and effective platform for working with these children. To find out more about Collaborative Problem Solving, visit www.thinkkids.org.
The bipolar diagnosis craze has had some benefits—most importantly bringing attention to the neurologic nature of the difficulties that these kids have. But the downsides have been and continue to be significant. The field faces a big challenge in trying to help these children and their families. Our research needs to work toward more comprehensive and complex understanding of the underlying neurological issues, the contexts in which these issues occur, the interaction between the brain and its “container,” and the longitudinal picture of how these children evolve over time. We need to continue to develop more effective interventions, medication-based and otherwise. But an overly simplistic label that is not accurate is likely to do more harm than good.