Healthy Skepticism Library item: 8595

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Publication type: news

Goldberg C.
Bipolar labels for children stir concern
The Boston Globe 2007 Feb 15
http://www.boston.com/news/local/massachusetts/articles/2007/02/15/bipolar_labels_for_children_stir_concern/

Full text:

Hull case highlights debate on diagnosis

The case of Rebecca Riley highlights a hot debate in psychiatric circles over the growing number of children who are diagnosed with bipolar disorder — a battle centered largely in Boston but affecting the treatment of young patients nationwide.

Riley, the Hull 4-year-old who died of an overdose of psychiatric medications, was exceptionally young when she was diagnosed, just 2 1/2. But among somewhat older children, the bipolar label has proliferated to the point that some psychiatrists now suspect the diagnosis may be sometimes misused, placing some children at unnecessary risk from the serious medications that usually follow.

Others argue that many children are given different diagnoses, such as depression, when they should really be considered bipolar, a disorder that involves intense mood swings and hitting, biting, kicking, and screaming rages.

One thing is clear: In the past decade or so, the number of children diagnosed with bipolar disorder has risen dramatically. A study of mentally ill children in community hospitals, published last month in the Archives of General Psychiatry, found the proportion of children diagnosed as bipolar shot up from less than 3 percent in 1990 to 15 percent in 2000. Psychiatrists say the rate has continued to climb.

Why the increase? Psychiatrists at Massachusetts General Hospital were among those who spurred it. In 1995, they published research that contradicted the prevailing notion that bipolar disorder was exceedingly rare in children. Rather, they said, 16 percent of the children referred to their psychopharmacology clinic fit the diagnosis. Overall, that would mean perhaps 1 percent of all children may be affected.

“We support early diagnosis and treatment because the symptoms of this disorder are extremely debilitating and impairing,” said Dr. Janet Wozniak , director of the Pediatric Bipolar Program at Mass. General. They “bring reckless and impulsive behaviors here and now and a long-term risk” for suicide, drug abuse, and crime, she said.

The psychiatric controversy is over diagnosing children before their teen years. There is virtually no scientific research on children younger than 6.

“Diagnosing and treating preschoolers is what I would call uncharted waters,” Wozniak said, but research suggests the disorder often begins that early, and “it’s incumbent on us as a field to understand more which preschoolers need to be identified and treated in an aggressive way.”

Rebecca was prescribed an antipsychotic medication, a drug used to treat bipolar disorder in adults, and a blood pressure medication that is sometimes used to help hyperactive children sleep. She died in December. Her parents are charged with murder, and the Board of Registration in Medicine is investigating the role played by her psychiatrist, Dr. Kayoko Kifuji of Tufts-New England Medical Center.

Recent studies document a steep increase in prescriptions of anti psychotic drugs to children of all ages. That probably stems from the increasing diagnosis of bipolar disorder, said Wozniak, who gets about 90 percent of her research funding from the federal government, 5 percent from philanthropies, and 5 percent from companies that make psychiatric drugs.

“Still,” she said, “the overall number of prescriptions is probably small relative to the number of children who need help.”

The opposing camp, psychiatrists who want to define bipolar disorder more narrowly and sparingly, questions whether the disorder really affects so many children and whether the benefits of the diagnosis outweigh the risks of the drugs in many cases.

“Particularly over the last five to eight years, people like myself have become more alarmed at what we see as the misdiagnosis and the over use of medications,” said Dr. Jennifer Harris , a clinical instructor at Harvard University and supervisor at Cambridge Health Alliance. “I think clinical practice got way ahead of the science. . . . There are so many pressures — some conscious, some unconscious — to medicate these kids that I think clinicians jumped on this diagnosis way ahead of the evidence.”

Harris and others point out that a diagnosis of bipolar disorder is considered more serious than attention deficit hyperactivity disorder or post traumatic stress disorder. A child diagnosed as bipolar thus tends to have much easier access to a range of help, from a spot in a therapeutic school to insurance coverage for hospitalization.

Another factor in the increased use of the diagnosis is the availability of new, potentially effective drugs, particularly anti psychotics and mood stabilizers. As the diagnosis gained popularity in recent years, so did prescriptions for powerful anti psychotic drugs such as Risperdal and Zyprexa — which have been approved for use in adults, but are prescribed for children.

If there’s a chance that a drug may calm down a dangerously out-of-control child and the drug is indicated for bipolar disorder, then it may make sense to diagnose the child with bipolar disorder, said Dr. George Dominiak , medical director of Westwood Lodge, a private psychiatric hospital in Massachusetts.

“It’s a tail-wagging-the-dog kind of thing,” he said. “The treatments affect our observations and our labeling as well. “

Evidence has been mounting, however, that antipsychotic drugs can cause health problems, such as diabetes and significant weight gain.

“These are bad enough in themselves, but the concern is that if you have kids on these medications for extensive periods of time, then they may develop major medical problems as adults,” said Dr. S. Nassir Ghaemi , director of the Bipolar Disorder Research Program at Emory University. (He has consulted for most of the drug companies that make the anti psychotics.)

Another possible factor in the increase of the bipolar diagnosis is the growing awareness among psychiatrists that if they diagnose a bipolar child as being only depressed and prescribe antidepressants, the drugs could make the child dangerously worse, possibly even suicidal and psychotic.

Similarly, if a child has underlying bipolar disorder but is diagnosed as having attention deficit hyperactivity disorder and prescribed a stimulant, the symptoms could worsen, said Cambridge Health Alliance psychiatrist Nancy Rappaport.

Further complicating the diagnosis: Abused or traumatized children can seem to have bipolar disorder when they are actually reacting to horrors in their lives.

Academic researchers have begun to make progress in refining the outlines of what constitutes bipolar disorder in children. But still, Rappaport said, the question of whether to diagnose a child with bipolar disorder can be “an agonizing clinical decision.”

Carey Goldberg can be reached at goldberg@globe.com.