Monday, September 15, 2008

Bipolar Overawareness Week: New York Times Magazine Edition

Jennifer Egan has a roughly 29,000 word piece in the New York Times magazine regarding child bipolar disorder. OK, maybe it just seemed that long. As is apparently required for such articles, there is a very lengthy story about an allegedly bipolar child that constitutes much of the article. I'll not be focusing on that. Instead, I'll be looking at how the article discusses the controversy surrounding the diagnosis. Quotes from the article followed by my comments follow:
The Diagnostic and Statistical Manual of Mental Disorders (the current edition is referred to as D.S.M.-IV) describes bipolar disorder as a condition whose average age of onset is 20, but virtually all the leaders in the field now say they believe it exists in children too.
Well, then. I found two psychiatrists whose opinion appears to differ. Jon McClellan seems to disagree that bipolar exists in young children, as does David Healy. I could probably find others without much difficulty. Maybe they are not "leaders in the field?" But ok, let's say that it does exist in young kids. I'll grant Jennifer Egan that most agree that bipolar exists in adolescents (but toddlers???), though at what rate is a matter of debate. And more importantly, who gives a rat's behind what people think? Um, maybe we should be more concerned about what the actual science has to say about it. And in that regard, there are some serious unanswered questions, as I've described before.

1. Does child bipolar really exist in substantial quantity?
2. Does treatment help kids with this "disorder"?

But to be fair to Egan, maybe I took the last quote out of context, because she adds a somewhat more balanced view by stating that:
Many clinicians say the illness looks significantly different in children than in adults, but the question of how it differs, or what diagnostic terms like “grandiosity,” “elevated mood” or “flight of ideas” (all potential symptoms of adult bipolar disorder) even mean when you’re talking about kids, leaves room for interpretation. For example, it’s normal for children to pretend that they are superheroes, or believe that they can run faster than cars, whereas in an adult, these convictions would be signs of grandiosity. Equally unclear is whether a child who is identified as having a bipolar disorder will grow up to be a bipolar adult. Work on the D.S.M.-V is under way, and discussions have begun on how to address the issue of bipolar children.

As Ellen Leibenluft, who runs the pediatric bipolar-research program at the National Institute of Mental Health, told me, “There definitely will be — and needs to be — more description of what bipolar disorder looks like in children, how one diagnoses it and some of the challenges.”
OK, that's better. But in general, the article focuses on the proponents of the child bipolar paradigm rather than those who raise concerns. And Egan discounts a big study in a pretty odd way...
A study last fall measured a fortyfold increase in the number of doctor visits between 1994 and 2003 by children and adolescents said to have bipolar disorder, and the number has likely risen further. Most doctors I spoke with found the “fortyfold increase” misleading, since the number of bipolar kids at the beginning of the study was virtually zero and by the end of the study amounted to fewer than 7 percent of all mental-health disorders identified in children.
Huh? So it's misleading to say that for every one treatment visit for bipolar in 1994, there were 40 in 2003? No, that's exactly what the study found. Let's try an analogy. The rate of suicide among kids and teens, on an absolute scale, is very low. Very few children and adolescents actually commit suicide. So if the suicide rate went up by a factor of 40 in the next 10 years, would we then say, "Well, that's misleading because suicide was very rare in 2008, when the study began?" That makes no sense whatsoever. And to say, hey bipolar is now only 7% of kids diagnosed with mental disorders, so it's no big deal -- ??? What treatments do you think these kids get? Play therapy and lollipops? Uh, try antipsychotics, often in combination with anticonvulsants, antidepressants, and who knows what else? If you think this is all based on science, go take a spin over to Pubmed and see what you can find. What, there's no evidence that carpet bombing developing brains with a wide variety of psych drugs is effective for "bipolar"? Count me as shocked, shocked, that medications would be prescribed so widely in the absence of supporting evidence. Sure, maybe if you provide highly tranquilizing medications, they mellow out bad behavior a bit in the short-term. Is that an effective long-term solution? And at what cost?
In Leibenluft’s studies at the National Institute of Mental Health, only 20 percent of children identified with bipolar disorder are found to meet the strict criteria for the disease. Breck Borcherding, a pediatric psychiatrist in private practice in the Washington area, said: “Every time one of my kids goes into the hospital, they come out with a bipolar diagnosis. It’s very frustrating.”
OK, so a study that finds that bipolar diagnoses have shot through the roof is "misleading," but at the same time, other Egan then discusses research suggests that bipolar is being misdiagnosed at a high clip. Am I the only one who is confused?

Then there is “The Bipolar Child,” a successful book published by the psychiatrist Demitri Papolos and his wife, Janice, in 1999, and referred to by more than one parent I spoke to as a “bible.” The Papoloses’ description of pediatric bipolar disorder was amassed partly by using responses to an online questionnaire filled out by hundreds of parents on an electronic mailing list, who said they believed their children were bipolar (and who often had strong family histories of the disease). The Papoloses’ diagnostic criteria include some idiosyncratic items — a severe craving for carbohydrates, for example — that are found nowhere in D.S.M.-IV. Nevertheless, many parents walk into doctors’ offices having already read “The Bipolar Child” and concluded that their children are bipolar. Because doctors rely heavily on parental reports when diagnosing disorders in children, these “prediagnoses” may have an impact on the outcome.

Well, if that isn't the most airtight method for a study that I've ever heard. Put up an online questionnaire, have people who insist that their kids are bipolar fill it out, then use whatever these parents say as criteria for the disorder. And... severe craving for carbs? Nope, I've never ever seen a kid who really, really wants candy before. But if I do see such behavior, I'll turn on my bipolar radar; I'll be keeping my eyes peeled at the candy store.

And of course, there are pressures and blandishments from the pharmaceutical industry, which stands to profit mightily from the expensive drugs — often used in combination — that are prescribed for bipolar illness, despite the fact that very few of these drugs have been approved for use in children.

You mean like the part where key opinion leaders sign on for Big Bucks to give talks for psych drugs in treating kiddie bipolar? No, you won't find discussion of that anywhere in the article. Because we are making progress in understanding the biological disease of bipolar disorder and how to treat it. Progress is slow but everything is headed in the right direction -- the time-honored narrative of the academic-pharmaceutical complex always making progress in mental health. There is a sentence dedicated to discussing the influence of Big Pharma. One. Off-label marketing of antipsychotics for kids is never mentioned, despite Otsuka/Bristol Myers Squibb settling a federal lawsuit for pimping Abilify for kids. I suppose mentioning such shenanigans might poke a bit of a hole in the idea that we are making perpetual progress.

And here comes the hammer. Sure, bipolar might be overdiagnosed, but of course the biggest problem is the undertreatment of bipolar kids:

For all the possible overdiagnosing of pediatric bipolar disorder, however, many in the field also say that a lot of truly bipolar children who could benefit from therapy are falling through the cracks. This is a critical issue; studies clearly show that the longer bipolar disorder goes untreated, the worse a person’s long-term prognosis.

If you are so into "studies clearly showing" things, then maybe you could point to studies that clearly show benefits of treating bipolar disorder in children. I'm waiting. In fact, I've been waiting for years. As the rate of drugging kids for bipolar has increased drastically, the research showing treatment benefits is... where? And if you're telling me that kids behaving very badly, which seems to be fit roughly 100% of kids who wind up diagnosed with bipolar disorder, are not getting treatment, I think you aren't paying attention. Desperate parents want a solution, and whether the diagnosis is opposition defiant disorder, conduct disorder, ADHD, autism, pervasive developmental disorder, WTF NOS, or bipolar, I'm pretty sure that these kids are getting treated in droves. But maybe I'm wrong.

Gabrielle Carlson, the director of child and adolescent psychiatry at the Stony Brook University School of Medicine, has studied childhood mania for many years and says bipolar disorder is uncommon in children under 10, revealing itself in the same discrete episodes of mania and depression that we see in bipolar adults — not in chronic irritability. According to Carlson, a large group of aggressive and explosive children, who in fact are “diagnostically homeless,” are being relabeled as bipolar, which is a development she says is unhelpful both to the children and the field. “Diagnostically it ends up being a very important consideration of what the kid really has,” she told me. “If he really has A.D.H.D. and it’s not mania, then you give him medication for his A.D.H.D. You also give him behavior modification.” One patient she saw that day, who was thought to have bipolar disorder, actually had autism, she said. “If you say, ‘Hey, his problem is bipolar disorder,’ then you’re not going to treat his language disorder, you’re not going to give the social-skills treatment he needs,” she said. Problematic conditions in a child’s home life are also less likely to be addressed if the child’s behavioral issues are attributed to bipolar disorder, Carlson said. “Many people, when they hear bipolar disorder, their brain slams shut.”
After including quotes from Janet Wozniak of the ever-present Harvard bipolar child team, it was nice to see comments from someone who has a bit more skepticism. A harsher critic could have been included in the story, but was not. No, I'm not going to quote Wozniak because you already know what she said, which is that we discovered that bipolar disorder in kids is way, way, way, way, more common than previously thought.
The most basic question about bipolar kids remains a mystery: Will they grow up to be bipolar adults?
No, four of the most basic questions are, in no particular order:
  1. How many of these kids labeled as bipolar have been misdiagnosed?
  2. What are the benefits and risks of treatment, in the short-term and in the long-term?
  3. What happens if we try nonmedical interventions aimed at changing discipline strategies, proving more structure at home, etc.
  4. Is child bipolar at least partially a medical term for bad behavior? And where does the bad behavior stem from? Could social problems have anything to do with it? Think of things like poverty, absent parenting, violent TV programming and video games, vastly unequal income distribution, gangs, unemployment/underemployment, and the list goes on... In other words, our society ain't exactly ideal and some of these problems will impact mental health. Isn't throwing pills (or even therapy) at these problems a little shortsighted? This ain't the place to discuss how to improve society; I'm just saying that many of these problems discussed on the site probably arise from more than just intrapsychic issues or troubles with an alleged (not proven) "chemical imbalance." Do you think there is a reason, for example, that foster kids are so frequently on antipsychotics? As written by The Last Psychiatrist: "A 20% increase in therapy visits will be interpreted by psychiatry as a 20% increase in depression and anxiety. It will say depression has a prevalence of X, it will say it is underdiagnosed and undertreated, etc. And it will creep into the social consciousness that these are pre-existing diseases with triggers, not the consequences of external events. Society needs that illusion, it needs that lie, because it has created unrealistic expectations in people and no way of fulfilling them."

Think my question 4 is a little weird, that it's wild speculation? Well, if you want some wild speculation that exceeds mine, try a few slices from the NYT mag piece:
Some studies suggest that bipolar disorder may actually be on the rise among young people. One intriguing hypothesis involves a genetic phenomenon known as “anticipation,” in which genes become more concentrated over generations, bringing a stronger form and earlier onset of an illness with each successive generation. Another theory is “assortative mating,” in which a more mobile and fluid society, like ours, enables the coupling of people whose mutual attraction might be partly due to a shared genetic disposition to something like bipolar disorder, thus concentrating the genetic load in their offspring.
Yeah. That's the ticket. We've had how many thousands of generations of human existence and now, suddenly, bipolar is becoming more concentrated in kids. Intriguing hypothesis? Wouldn't such a trend be gradual, not sudden? Same story with "assortative mating" -- is it just now that bipolar folks would choose to mate with each other? Presumably, this would have happened throughout human existence, so pulling this kind of thing out of a hat now makes absolutely no sense. But there's an answer to that -- we're living in a "more mobile and fluid society." So now that we're "mobile," bipolar folks breed with bipolar folks, but before cars and planes, they couldn't breed with each other. Huh?
Kiki Chang, director of the pediatric bipolar-disorders program at Stanford, has embraced the kindling theory. “We are interested in looking at medication not just to treat and prevent future episodes, but also to get in early and — this is the controversial part — to prevent the manic episode,” he told me. “Once you’ve had a manic episode, you’ve already crossed the threshold, you’ve jumped off the bridge: it’s done. The chances that you’re going to have another episode are extremely high.”
Oh boy. Preventive psychopharmacology. If you are a hyper kid, we'll give you antipsychotics because they might keep you from becoming bipolar later. Trust us, your son is fine in our hands, ma'am.

Also see Furious Seasons' take on the matter. And give him some $$$ to help with his fundraiser. If you ever wanted to give me money, don't. Pass it his way.


Anonymous said...

Absolutely fabulous shredding of a flawed article. Congratulations! And you had me laughing besides. I like your graphics too -- and the plug for Furious Seasons.

Donna B. said...


I love that, finally a diagnosis that FITS me and my entire family!

CL Psych said...

Thanks for the comments. I am glad that you found some amusement value in the post. I think that WTF NOS will be making an encore appearance in future writing.

Anonymous said...

We had our oldest daughter evaluated for ADHD in high school, because she complained that she couldn't think or maintain concentration in class. Surprise! The doctor (a psychologist) administered a battery of tests and declared she was bipolar!

This despite the fact that she has never been depressed or manic, and is not moody, but does have occasional, brief outbursts of irritability. This has been a life-long pattern, not a recent symptom.

We left the psychologist's office unconvinced and disgusted.

Now she's a sophomore in college, carrying a 3.9 GPA, and no longer complains of concentration problems. In retrospect, I think what we mistook for ADHD was simply a bi-product of attending a high school where the students are disruptive and the classes chaotic.

As a side note, my psychiatrist knows the psychologist who offered the bipolar dx and said, "He diagnoses everyone bipolar."

Anonymous said...

I, too, loved your dx - WTF NOS. Another great post.

Anonymous said...

This may be relevant:

Publication Bias and the Pharmaceutical Industry: The Case of Lamotrigine in Bipolar Disorder Posted 09/10/2008

S. Nassir Ghaemi, MD, MPH; Arisha A. Shirzadi, DO; Megan Filkowski, BA

Medscape J Med. 2008;10(9):211.

Publication bias, especially the lack of publication of negative treatment studies, is known to be a major problem in the medical literature. In particular, it appears that the pharmaceutical industry is not routinely making data from negative studies available through the published scientific literature. In this paper, we review the case of studies with lamotrigine in bipolar disorder, describing evidence of lack of efficacy in multiple mood states outside of the primary area of efficacy (prophylaxis of mood episodes). In particular, the drug has very limited, if any, efficacy in acute bipolar depression and rapid-cycling bipolar disorder, areas in which practicing clinicians, as well as some academic leaders, have supported its use. The negative unpublished data now made available on lamotrigine provide an important context for clinical practice and research, and also raise important scientific and public policy concerns about having access to studies showing inefficacy with psychotropic medications.

Donna W., RN said...

The problem with overdiagnosis of bipolar disorder stems from the lack of qualifications of the diagnosing psychiatrist. There is a shortage of Child and Adolescent psychiatrists throughout the country. Instead of seeking care from these physicians, parents seek treatment from psychiatrists who are given two weeks of child and adolescent training in medical school. These are the physicians who are overdiagnosing these kids. If we want to fix this problem, then we need to train the physicians who treat the children.

Anonymous said...

Am tellin' ya. It's a cabal of them bipolars mating with each other and concentrating their genes using their Bene Gesserit powers. Waaait, I gotta finish writing this, can't take my Zyprexa right now!

GK said...

This type of highly pointed, critical feedback (in this post) is extremely valuable. An important challenge to the various dogmas and biases which influence medical practice.

Yet, consider the experience of most of us who have worked in the area of child & adolescent psychiatry:
1) there are many children whose behaviour is very abnormal (violent, aggressive, extremely inhibited, extremely disinhibited, either episodically, continuously, or progressively).
2) Many of these children come from unstable homes, many are not well cared-for. Arguably this is to a large degree a social, public health problem, rather than a "neuropsychiatric" problem. Yet, of course, social and neuropsychiatric problems are causative of each other.
3) Many others of these children come from stable homes, and are well cared-for, by exhausted, demoralized, and frustrated parents
4) Many of these children do not have good social, community, and medical support.
5) Many others of these children do have good social, community, and medical support.

--I recognize that there can be strong biases in clinical practice caused by industry influence & advertising--
But, in the immediate medical situation, of trying to care for a profoundly disturbed child -- it is important to have a range of options.
Yes -- diagnosis may not be certain. Certainly many diagnostic categories in children do not fit with adult DSM categories. Often times--just as in adults--"diagnosis" if it becomes crucially important at all, only becomes clear over the passage of time. We can overuse, and over-rely upon diagnostic labels. We shouldn't be dogmatic about this, though we also shouldn't ignore the issue altogether.
--It becomes a judgment call in many cases about whether to offer a biological treatment to a child.
--While I affirm the need for cynical feedback such as this entry -- let us not become so cynical that we deny a suffering individual something that may legitimately help!
--Many of the options for treating violent children have included hospital stays and other programs; foster care; and a variety of older sedating drugs such as chlorpromazine.
--The option of not using any of these drugs carries serious ethical problems! To NOT treat with something effective is arguably a MORE serious problem in a child with a "developing brain" than in an adult! (mind you, I would suggest to you that even adults have "developing brains"!)
--Many of the newer drugs -- despite my wariness over the marketing hype -- are actually safer, more effective, better tolerated, with less risk of particularly noxious, permanent side effects, in my opinion!
--In any case, you have no argument from me that more unbiased research is required to study psychopharmacological treatments in children -- in the meantime, though, we shouldn't become so "anti-pharmaceutical" that we deny suffering children potential treatments that could help them.