Bipolar in Kids: Who is the Fearmonger?

Mental health blogger John McManamy has issued a couple of statements regarding people who question the large uptick in child bipolar disorder diagnoses. Here’s one of them…

There is a lot of uninformed discussion out there on early-onset bipolar, but none of it is coming from the Papoloses [the folks behind the book The Bipolar Child]. All their work is concerned with rigorous examination in both the lab and the real world, and on enlightening and educating clinicians, researchers, educators, parents, and the general public. The misguided fear-mongers who criticize them invariably have proved to be too lazy to talk to parents of bipolar kids, much less read their book.

Well, well, well. Allow me to respond. **Grunts, cracks knuckles, stretches all major muscle groups**

I am not sure if he is placing me in the category of “misguided fear-monger,” given my rather skeptical take on the recent “discovery” of bipolar disorder occurring frequently in children, but I’ll assume that I am. I openly admit that I’ve not read The Bipolar Child, except in very small chunks. The only thing I remember thinking was, “Where’s the evidence?” More on that in a minute.

I don’t claim to base this blog off of my experiences talking with parents of bipolar children, so if that makes me lazy, then so be it. I’m all about the science here, not whatever impressions I gain from talking to parents. If someone can address the following points, then I’ll eat a gigantic slice of humble pie and give my blessing (not that it’s worth much) to the bipolar in kids bonanza…

A. Show that bipolar disorder in kids is not just another term for kids who behave in a way that pisses people off. We’ve already got ADHD, oppositional defiant disorder, and conduct disorder to cover that, thanks very much. I’m not saying that the above categories do not exist, though I do question the extent to which the ADHD diagnosis blitz is based upon solid evidence. Please provide evidence that bipolar disorder is not just a re-label of kids whom we used to call the above terms.

B. Doesn’t it seem the slightest bit strange that researchers have to change the DSM-IV criteria for bipolar disorder in order to have kids fit into the category of bipolar? Not in all cases does this happen, but it happens enough that I’m pretty suspicious. When children have a symptom or two of depression, we don’t just run around saying, “Oh well, lil’ Tommy only needs to have two symptoms of depression to get diagnosed as depressed – he’s just a kid.” What’s up with that? Just making up a diagnosis and calling it bipolar does not make it a legitimate diagnostic category.

C. How does labeling youth as bipolar lead to beneficial outcomes? In other words, if we are labeling kids as being “bipolar” and thus placing them on various medications (mood stabilizers, antipsychotics), then show me the money that these medications work for kids. Showing data over the long-term would be nice, by the way.

Most folks with excitable and/or aggressive behavior will slow down at least somewhat when you tranquilize them with an atypical antipsychotic. Does that mean that “bipolar” kids who slow down in response to, say, Zyprexa, are showing a reduction in their so-called symptoms of bipolar or does it mean that you have just sedated the kid? Or are sedation and a decrease in mania one and the same.

Where's the treatment data? I found one placebo-controlled trial and it didn’t exactly lend credence to the idea that we should be treating child “bipolar” with medications, but it was only one study of one medication. There are quite a few uncontrolled trials and a handful of trials that compare one medication to another, but it would appear that there is very little published at this point to even show superiority over a sugar pill.

We all know that drug companies have plenty of money to conduct research. So why such meager and poor quality research on kids labeled as bipolar? Seriously. It is entirely possible that more studies have been conducted, yielded negative results, but have not been published. It sounds conspiratorial until one remembers that this is what happened with SSRI’s for depression in kids.

One More Thing: If this is all so damned scientific, then why is Jean Frazier, proponent of the expanded, um, “awareness” of bipolar in kids, saying things like this…

Dr. Jean Frazier, director of child psychopharmacology at Cambridge Health Alliance and an associate professor at Harvard, said that up to three-quarters of children who exhibit bipolar symptoms become suicidal, and that it is important to treat the problem as early as possible.

"We’re talking about a serious illness with high morbidity, and mortality," Dr. Frazier said, "and for some of these children the medications can be life-giving."

No data, to my knowledge, support the above statements on suicidality, the importance of early treatment, or that medications for these kids “can be life-giving.” Perhaps Dr. Frazier’s statements were from “rigorous examination…in the real world”. Who knows? Seems to me that her statements, though, would fall into what Mr. McManamy might consider “fear-mongering,” and we know that he doesn’t like fearmongers.