Bipolar Disorder Not a 'Quick and Dirty' Diagnosis
A major issue facing the field of psychiatry today may not be that children in the United States are being overdiagnosed with bipolar disorder (BD) but that many clinicians do not truly understand the complexities of this type of diagnosis.
Deborah Brauser / medscape.com
Gabrielle A. Carlson, MD, professor of psychiatry and pediatrics and director of the Child and Adolescent Psychiatry Department at the Stony Brook University School of Medicine in New York, said that no formula currently exists for accurately diagnosing BD in children.
"A certain amount of humility is needed, and it is extremely important to clarify symptoms. Remember: context matters," Dr. Carlson told delegates attending the Ninth International Conference on Bipolar Disorder.
Boris Birmaher, MD, professor of psychiatry and endowed chair in early-onset bipolar disease at the University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic in Pennsylvania, agreed.
During his presentation, he said a diagnosis of BD can be difficult because it is highly comorbid and overlaps with symptoms of other illnesses, including attention-deficit/hyperactivity disorder (ADHD).
"As a field, we're also looking at the issues of periodicity vs chronicity in bipolar disorder (in our practice we require that a child has definite episodes), the definition of rapid cycling, and the differences between narrow vs broad bipolar disorders.
"The big questions today are: What is the prevalence of bipolar in children? Is it more prevalent in the US than in other countries?" said Dr. Birmaher.
United States on Par With Other Countries
He discussed a new analysis published online May 31 in the Journal of Clinical Psychiatry that assessed 12 epidemiologic studies conducted between 1985 and 2007. The investigators evaluated the prevalence of pediatric BD in children from 8 countries between the ages of 7 and 21 years and found diagnosis rates ranged from 0% (in Ireland) to 3%, the same range found in the United States.
"Another study that included a very broad definition of manic symptoms found that that rate could go up to 5%. But still, all of this shows that we are not very different from other countries," said Dr. Birmaher.
However, a previous study (Arch Gen Psychiatry. 2007;64:1032-1039) showed that the number of physician visits ending in a diagnosis of pediatric bipolar in the United States increased significantly during 10 years.
"There was a 40-fold increase in the rate of visits for these children compared to adults, but we need to be careful to look at the absolute numbers. For example, if you go from 1 diagnosis to 2, that's an increase of 100%," Dr. Birmaher explained.
A 2010 national trends study (Bipolar Disorders. 2010;12:155-162) showed rates of BD diagnoses increased from 1.13 to 1.91 per 100,000 inpatients in Germany from 2000 to 2007.
"This was technically an increase of 68%, but really it was only up from 1 to 2 per 100,000 people," said Dr. Birmaher.
"It does not seem that the prevalence of bipolar 1 or 2 is higher in the US, but the diagnosis of subsyndromal forms is higher than in other countries."
Pendulum Can Swing Both Ways
"Pediatric bipolar exists, but we need to be careful because its diagnosis can be difficult," he said. Dr. Birmaher added that it is especially challenging when trying to identify core symptoms, such as grandiosity and elation in young children.
He noted that although some children are being misdiagnosed as having BD, the opposite is also true. There are many children, he said, who have BD but whose conditions are misdiagnosed and treated inappropriately.
"This is something we need to be aware of because bipolar seriously affects the normal development of a child and increases their risk of suicide, substance abuse, and psychosocial problems. Early recognition and appropriate treatment are most important."
Dr. Carlson also discussed the difficulties of diagnosing BD.
"It takes me 3 hours to do an evaluation....This is not something that you just take 30 minutes and get the person in and out. Even when it looks like a kid meets the criteria for [BD], time and effort are necessary before you say, 'I unequivocally know this is bipolar,' "she said.
In a study that has recently been accepted for publication, Dr. Carlson and colleagues assessed the implications of parent and teacher concordance on the Child Mania Rating Scale in 911 children between the ages of 5 and 18 years.
A total of 7.3% of the participating children were found to have a BD. Of these, 20 had BD type 1, 3 had BD type 2, and 43 had BD not otherwise specified.
Although a high parent rating score of manic symptoms (>15) was more associated with a diagnosis of BD than a low score, the child usually ended up having ADHD or oppositional defiant disorder (ODD).
In addition, when the parent rating was high and the teacher rating low, the diagnosis was usually an anxiety disorder, she said.
"The implications are pretty profound. If you think a kid is having a rapidly cycling disorder and in fact they have an anxiety disorder, you're going to use very different treatments."
In a 2010 study (Bipolar Disorders. 2010;12:205-212), Dr. Carlson and colleagues also assessed whether rages are actually manic episodes in 130 children between January 2003 and June 2004. Most were hospitalized for parent-reported rages.
Although the parents often reported manic symptoms, the investigators found that BD usually did not explain the episodes because 84.8% of the children had 1 or fewer rages while in the hospital.
"Not surprisingly, community clinicians were more likely to give a diagnosis of bipolar to these kids. But rages are a fairly nonspecific manifestation of a lot of different conditions, such as ODD, autism, posttraumatic stress disorder, schizophrenia, and more."
She noted that although all of the structured assessments appear useful, "especially in the hands of someone who knows what mania and depression are," the tools are not easily translated "to people who don't understand phenomenology, development, and the breadth of child and adolescent assessment.
"It is not just saying, 'if your parent has bipolar, you must have it too.' It's not a simple, quick, and dirty diagnosis."
9th International Conference on Bipolar Disorder (ICBD): Concurrent Session 3, No. S1. Presented June 11, 2011