Saturday, October 18, 2008

The Latest on Kiddie Bipolar

A recent study in the Archives of General Psychiatry claimed that kiddie bipolar tends to become adult bipolar. I have read the study and have a few comments. First, the authors' main findings:
  • Children diagnosed with bipolar went on to have a manic episode 44% of the time.
Let's look at the study sample. Seven to 16 year olds who were experiencing a manic or mixed episode. At 8-year follow up, 54 kids had reached at least age 18. So we're talking about 24 of 54 kids who went on to experience a manic episode as adults. Not exactly a huge sample. As time moves along, there will likely be more kids from this study who experience manic episodes as adults, so it is very much possible that when all 115 kids originally enrolled in this study hit, say, age 30, more than half of them will have experienced a manic episode as adults.

The argument then goes that we must treat child bipolar early and intensely in order to prevent these kids from going on to develop bipolar disorder as adults. So, were these kids receiving treatment? Definitely. These kids received whatever treatment was offered in the community, which doubtlessly included stimulants, mood stabilizers, antidepressants, and antipsychotics. On many occasions, they were probably undergoing some serious polypharmacy driven out of desperation rather than any sort of reasonable evidence base.

So did the treatments work? 88% of people who had an original manic or mixed episode recovered, but 73% of these kids then had a relapse afterward. And if nearly half went on to experience mania as adults, doesn't that mean that treatment was not exactly working very well? At this point, the authors have not reported what treatments were used, but I am willing to bet that the polypharmacy I mentioned above was often in place and that very few of these kiddos weren't receiving regular psychopharmaceutical treatment.

Bipolar was not the only problem facing these kids. 94% had an ADHD diagnosis at some point during the 8-year followup and a similar number had some sort of disruptive behavior disorder diagnosis. So it's not just bipolar. As I've been saying for a while now, bipolar is just the name du jour for kids whose behavior is really, really bad. We used to call it ADHD or conduct disorder and now it's ADHD, conduct disorder, and bipolar disorder just abbreviated as "bipolar," driven by the market reality that there are quite profitable drugs used to oh-so-successfully treat kiddie bipolar. But it seems they can't be working that well if 73% of these kids who recover from an episode end up relapsing.

I would love to write more about how bipolar was diagnosed in these kids, but I've not been able to land a copy of the measure used to make bipolar diagnoses in the study. The authors state that they only counted episodes that met DSM-IV criteria; if I ever find time, I might look at this more closely.

And note that we don't know what happened to the youngest kids in the study (those who started at ages 7 or 8) because none of them were adults at the end of this study. This study did not include anyone younger than 7, so the rash of 4 year olds being diagnosed as bipolar is left unexamined.

Bottom Line: Assuming that the diagnoses were valid, this study makes me think that:
  • Kids who show really bad behavioral and emotional problems often become adults with major psychological problems. Not exactly earth-shatteringly surprising.
  • Treatments for child/adolescent bipolar are not working very well.

Furious Seasons also has a number of concerns about the study.


Anonymous said...

As far as I'm concerned the fact they left out any mention whatsoever of the treatments the subjects were getting just boggled my mind and made me just want to crumple up the whole study and throw it in the waste basket. I mean seriously -- how can you possibly ignore giving these kids mind altering drugs while you are assessing them for mood disorders and pretend that every symptom that's manifested is part of the underlying bipolar I or ADHD? It's a complete joke -- I'm sorry. Also they kept subjects in the study when they developed SUDs yet apparently didn't weight the symptoms this might lead to any differently as a result. OMG! This is science?

Dreaming again said...

"bipolar is just the name du jour for kids whose behavior is really, really bad"

I have to totally agree with you.

I'm a psychology student ..who's gotten there because of my own experience with my children with OCD/TS (no ADHD/Conduct or Bipolar thank goodness)

However, I've got a friend who's daughter has been dx'd with bipolar.
Frustrated at her being given the standard drugs ..but behavioral therapy? Support therapy? Family therapy?
nope ... med checks every 3 months.

How and why a doctor would give medications to an already tiny, small for her age, and slightly underweight teenage girl rather than try behavioral modifications (for parent and child!) is beyond me!

HCI said...


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soulful sepulcher said...

I'm a broken record here, but my daughter who is now 20 yrs old, was misdiagnosed in 1999 w childhood bp, and I can safely say the drugs did not do anything but damage and destroy our lives.

Her body is damaged, and her childhood and teens can never be given back.

I fear for little kids and these meds, it's very alarming, having witnessed this and lived it for a decade, it's very sad.

Thanks for always keeping up with this topic CP.

Anonymous said...

Great post, keep up the good work ;)

Therapy said...

Some cases have been misdiagnosed and the after effects of treatment are worse than the behavioral disorder

Anonymous said...

Onset between the ages of 15 and 25.....

Bipolar Disorder (manic-depressive illness) has been defined as a major affective mood disorder in which one alternates between the mental states of deep and brutal depression and embellished elation. These mental states can last for months in some bipolar disorder patients. These cyclical episodes are a catalyst for noticeable psychosocial impairment. Also, the episodes of both manic phases as well as depressive ones can last anywhere from weeks to months.
Bipolar Disorder also affect’s one’s cognition, emotions, perceptions, and behavior- along with psychosomatic presentations (such as pain with depressive episodes, for example). It is thought to be due to a physiological dysfunctional brain in one affected with bipolar by many. Yet Bipolar allows for exceptional abilities when a bipolar person is in their manic phase at times (
The etiology for bipolar disorder is unknown. As many as half of those suspected as having a bipolar are thought to have at least one parent with some sort of mood disorder similar to bipolar disorder, which suggests a genetic predisposition may be present. Because of the complexity associated with bipolar disorder, greater than 50 percent of those afflicted are misdiagnosed as major depression, or perhaps schizophrenia.
It is also believed that bipolar presents itself with symptoms associated with the definition of bipolar when one is between the ages of 15 and 25 years old. The disorder was entered in the psychiatrists’ bible, the DSM, in 1980, although bipolar disorder is thought to have existed for quite some time.
Also, those with bipolar are thought to be in possession of heightened creativity during their manic phases, as well as they have accelerated growth of their neurons. This is not necessarily a bad thing, it seems. Conversely, those with bipolar disorder experience up to 3 times the number of depressive episodes as manic ones.
Research has determined that as many as 15 to over 30 percent of bipolar patients commit suicide if they are left untreated, or undertreated. Also, as many as half of those affected with bipolar also have at times severe substance abuse issues along with their bipolar as well. Co-morbid medical conditions should be taken into consideration when evaluating one suspect of, or having bipolar disorder.
Bipolar patients are also often experiencing anxiety issues that vary, and are treated often as a result of these medical issues. The disorder varies as far as severity goes- with some bipolar patients being more severely affected than others. In fact, there are at least 6 classifications of bipolar, according to the DSM.
Bipolar patients are thought to be symptomatic half of their lives. As stated previously, the depressive episodes occur more frequently than manic ones. When symptomatic, bipolar patients are thought to be rather disabled, according to some, when in their depressive state in particular. The diagnosis has become more frequent recently. In one decade, the assigned diagnosis of bipolar rose from being about 25 per 100 thousand people to being 1000 per 100,000 people.
Most diagnosed with bipolar are not diagnosed based on solid, comprehensive, or psychiatric review that is often absent of valid or standard diagnostic methods. Some believe as many as 5 percent of the human population may be affected by bipolar disorder- which may include as many as 12 million people in the United States. This is if the diagnostic criteria developed by others were to be fully utilized. An emphasis should be implemented by the health care provider to utilize available clinical evidence, and review this scientific literature.
A subjective questionnaire called the Mental Status Examination is often utilized when diagnosing one suspected has having bipolar disorder. Many believe the diagnosis has increased recently due to the progressive treatment options now available. It is an argument of increased awareness versus over-diagnosis.
Yet the diagnosis is vague, as children and adolescents are often absent in research with bipolar. Also, there is not any objective diagnostic testing to rely upon for bipolar. There is also a mental diagnosis of what is called mixed depressive disorder, which is one with depression who also has minimal manic episodes.
Many younger than 18 years of age are prescribed atypical anti-psychotics as first line treatment, which is largely not recommended as treatment options. In fact, close to half a million of those younger than 18 years of age are prescribed the atypical anti-psychotic Risperdal alone, it has been determined. The class of medications overall is thought to be prescribed to about 10 percent of those non-adults thought to have bipolar.
While not recommended, about a half of all those assessed as being bipolar are prescribed antidepressants, such as SSRIs, as first line treatment. It has been suggested that this class of drugs has decreased the risk of suicide attempts compared with other classes of antidepressants for close to 20 years.
Yet tricyclic antidepressants have been determined to be efficacious in over half of those diagnosed with bipolar - with a greater amount of research behind this class of drugs. Furthermore, therapy with any antidepressants has been associated with what is known as treatment-emergent mania. This is when a bipolar disorder that is in a depressive state rapidly enters a manic phase. This occurrence can be unmanageable by the bipolar disorder patient.
The most recognized treatments for bipolar long term are lithium (Ekalith or Lamictal- along with an anti-convulsant. Sugar intake is thought to vex the symptoms of one with a bipolar disorder as well.
Atypical anti-psychotics have been prescribed for bipolar, which change some aspects of the brain, physiologically, as does the disease itself. In fact, one may argue the brain becomes more efficient due to both the disorder and the treatment with the atypical anti-psychotics. Yet many recommend the utilization of this class of drugs with bipolar disorder only if psychosis is present as well.
As many as 15 percent of bipolar disorder patients diagnosed as such are prescribed an atypical presently. This class of medications may be particularly beneficial for those women who are diagnosed with bipolar who are pregnant, however.
Lithium, which is essentially a very light metal with low density in which the salts are obtained for medicinal treatment, and an anti-convulsant are believed to be standard bipolar treatment, pharmacologically, studies have shown. This is due to Dr. John Cade and his examination with lithium and its benefits with those who have psychotic excitement close to 60 years ago.
Ekalith is believed to be both neuro-protective as well as having an anti-suicidal affect in those believed to be bipolar- and is viewed as a mainstay as far as treatment for bipolar goes with many who treat the disorder. Lithium is thought to regulate the calcium molecule in the brain, so this and valporate are historically the medicinal treatment options preferred for those with bipolar disorder.
Bipolar is difficult to detect, and is often diagnosed as major depression with many affected by this disorder. There is no objective criteria protocol available to utilize when assessing any patient believed to be suffering from any mental disorder. So such mental disorders that are diagnosed are ambiguous, yet that does not conclude that such disorders do not exist, such as the case with bipolar disorder.
Yet perhaps a health care provider should be very thorough and knowledgeable when assessing a patient believed to have a mental condition such as bipolar. As should the health care provider keep in mind that the ultimate goal with this disorder is to stabilize the mood of the one affected.
Dan Abshear
Author’s note: What has been annotated is based upon information and belief.

Dan said...

Bipolar disorder is diagnosed in this country about three times more than any other.

Bipolar disorder has an onset age range between the mid teens and mid 20s.

Lithium should be a therapeutic agent prescribed in authentic patients. It's not, so standards of care are bypassed, and what is prescribed for such a patient is unreasonable and likely unnecessary.