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David Baxter

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Another view: Half kids labeled bipolar may be misdiagnosed

Half kids labeled bipolar may be misdiagnosed
September 3, 2007

Study questions the surging number of those doctors say have disorder

CHICAGO - A new analysis suggests there's been a huge increase in the number of U.S. children diagnosed with bipolar disorder, but experts question whether the surge is real and say some kids have been mislabeled.

Researchers looked at the number of times children under 19 went to the doctor and were diagnosed with or treated for bipolar disorder, also known as manic depression. They found a 40-fold increase, from an estimated 20,000 visits in 1994 to 800,000 in 2003. The jump coincided with children's rising use of antipsychotic medicine.

The numbers echo other estimates suggesting as many as 1 million U.S. children are bipolar, but it remains a controversial diagnosis in children. That's partly because their symptoms often differ from adults', and because most powerful antipsychotic drugs used to treat bipolar disorder were approved for adults and have not been well-studied in children.

Some doctors believe bipolar disorder doesn't occur in children, and until last month there was only one drug approved to treat the illness in kids.

The study's lead author, Dr. Mark Olfson of Columbia University and the New York State Psychiatric Institute, said the results likely reflect over-diagnosis now or under-diagnosis in the past, rather than a true increase. Olfson has received speaking fees from Janssen LP, which makes one of the pediatric bipolar drugs, and has consulted for other makers of psychiatric drugs.

'Vast epidemic' in question
Dr. Sharon Hirsch, a University of Chicago psychiatrist, said that while she is treating increasing numbers of bipolar children, she doubts there's a "vast epidemic."

More public awareness about mental illness, spurred partly by heavy marketing of psychiatric drugs, could have contributed to the surge. And early in the study, a leading manual of psychiatric illnesses expanded criteria for diagnosing bipolar disorder, Olfson noted.

Symptoms include extreme mood swings and disruptive behavior. In children, extreme irritability is sometimes the main symptom.

It affects more than 5 million adults. The causes are uncertain but the disorder tends to run in families.

Dr. David Fassler, a University of Vermont psychiatry professor, said research suggests that close to half of children thought to be bipolar may be misdiagnosed. He said parents should get a second opinion if they have concerns about a diagnosis or proposed treatment.

"Bipolar disorder is not always easy to recognize in children and adolescents. There's considerable overlap with other conditions, including ADHD, conduct disorder, anxiety disorders and depression," said Fassler, who was not involved in Olfson's study.

Dr. Thomas Insel, director of the National Institute of Mental Health, which partially funded the research, said the study "waves a flag saying we've got to do much, much better in finding ways to validate psychiatric diagnoses in children. This is an area that really needs hard science."

The study appears in the September issue of Archives of General Psychiatry.

It follows a report showing a big increase in U.S. children hospitalized with bipolar disorder, from 1.3 per 10,000 in 1996 to 7.3 per 10,000 in 2004, published in June in the journal Biological Psychiatry.

Olfson and colleagues analyzed annual surveys of outpatient visits from the National Center for Health Statistics. Adult visits for bipolar disorder also increased during the study but not as markedly.

'They know how I feel'
Charlie Crow, 13, of Verona, N.J., who was diagnosed with bipolar disorder in 2001, said the results don't surprise him because he knows lots of other kids who are bipolar. When he was first diagnosed at age 7, though, he felt alone and isolated.

He said it helps to know there are other kids like him.

"They know how I feel and I know how they feel," he said.

His mother, Susan Montanile, said Charlie was a precocious, disobedient and moody 3-year-old. He later had vivid, violent nightmares and violent outbursts in school.

"He would cycle even within 10 minutes, from hysterical giddiness and laughter watching TV" to screaming when she called him for dinner.

It was "like walking on eggshells," she said. "You never really knew within a given hour what was going to happen."

Psychiatric medicine has helped, but has also caused weight gain, drowsiness and other side effects.

Montanile worries that the new study might embolden skeptics who blame "bad parenting" and think afflicted children are simply misdiagnosed brats.

A generation ago, bipolar kids were likely mislabeled as simply truants or troublemakers, said Christine Walker, of Winnetka, Ill., whose 7-year-old son, Schuyler, was diagnosed a few years ago.

"This has always existed," Walker said. "It just didn't have a name, it didn't have a face."
 

David Baxter

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And from the New York Times

More Children Being Treated for Bipolar Disorder
September 3, 2007
By BENEDICT CAREY, New York Times

The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.

Most experts believe the jump reflects the fact that doctors are more aggressively applying the diagnosis to children, not that the number of new cases has gone up. But the magnitude of the increase is surprising to many experts, who say it is likely to intensify a debate over the validity of the diagnosis that has shaken the field of child psychiatry in recent years.

Bipolar disorder is characterized by extreme mood swings and, until relatively recently, it was thought to emerge only in adulthood. Some psychiatrists say that the disorder is too often missed in children, and that increased awareness ? reflected in the increasing use of the diagnosis ? is now allowing youngsters who suffer from it to get the treatment they need. But others argue that bipolar disorder is overdiagnosed. The term, they say, has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain.

The spread of the diagnosis has been a boon to drug makers, according to these experts, because treatment typically includes medications that can be three to five times more expensive than those prescribed for other disorders, like depression or anxiety.

?I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder, but the tremendous controversy reflects the fact that we haven?t matured enough,? said Dr. John March, chief of child and adolescent psychiatry at Duke University?s school of medicine, who was not involved in the research.

?From a developmental point of view, we simply don?t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness,? he said. ?The label may or may not reflect reality.?

Most children who qualify for the diagnosis do not go on to develop the classic features of adult bipolar disorder, like mania, researchers have found. They are far more likely to become depressed.

But Dr. Mani Pavuluri, director of the pediatric mood disorders program at the University of Illinois, Chicago, said that label is often better than any of the other diagnoses that difficult children often receive. ?These are kids that have rage, anger, bubbling emotions that are just intolerable for them, and it is good that this is finally being recognized as part of a single disorder,? to better tailor treatment, she said.

In the study, researchers from New York, Maryland and Madrid analyzed data from a National Center for Health Statistics survey of office visits, which focused on doctors in private or group practices. The researchers calculated the number of visits in which doctors recorded a diagnosis of bipolar disorder, and found that the numbers went up from roughly 20,000 such diagnoses in 1994 to about 800,000 in 2003

?I have been studying trends in mental health services for some time, and this finding really stands out as one of the most striking increases in this short a time,? said Dr. Mark Olfson of the New York State Psychiatric Institute at Columbia University, the senior author of the study, which appears in the September issue of Archives of General Psychiatry, which is to be published Tuesday.

The increase makes bipolar disorder more common among children than clincial depression, the authors said. The study found that psychiatrists made almost 90 percent of the diagnoses, and that two-thirds of the young patients were boys. About half the patients also had been identified as having other mental difficulties, most often attention-deficit disorder.

The treatment given the children almost always included medication. About half received antipsychotic drugs, like Risperdal from Janssen or Seroquel from Astrazeneca, both developed to treat schizophrenia; a third were prescribed so-called mood stabilizers, most often the epilepsy drug Depakote; and antidepressants and stimulants were also common. Most children were on some combination of two or more drugs, and about four in 10 received some psychotherapy.

Their regimens were very similar to those of a group of adults with bipolar diagnoses, the study found. ?You get the sense looking at the data that doctors are generalizing from the adult literature and applying the same principles to children,? Dr. Olfson said.

The rise in bipolar diagnoses in children reflects several factors, experts say. Bipolar symptoms do appear earlier in life than previously thought, in teenagers and young children who later develop the full-blown disorder, recent studies suggest. The label also gives doctors and desperate parents a quick way to try to manage children?s rages and outbursts, in an era when long-term psychotherapy and hospital care are less accessible, they say.

In addition, in recent years drug makers and company-sponsored psychiatrists have been encouraging doctors look for the disorder, ever since several drugs were approved to treat the disorder in adults. Last month the Food and Drug Administration approved one of these medications, Risperdal, to treat bipolar in children ? which many experts say they expect will escalate the use of Risperdal and similar drugs in young people.

?We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that, ?Omigod, we?re missing bipolar,? ? said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at Stony Brook University School of Medicine on Long Island. ?And if you?re a parent with a difficult child, you go online, and there?s a Web site for bipolar, and you think, ?Thank God I?ve found a diagnosis. I?ve found a home.? ?

Some parents whose children have received the diagnosis say that, with time, the label led to effective treatment. "It?s been a godsend for us," said Kelly Simons, of Montrose, Colo., whose son Brit, 15, was prone to angry outbursts until given a combination of lithium, a mood-stabilizer and Risperdal several years ago. He is now on lithium alone and he is an honor-roll student.

Others say their children have suffered from side effects of drugs given for bipolar disorder, without getting much benefit.

Ashley Ocampo, 40, of Tallahassee, Fla., the mother of an 8-year-old boy, Nicholas Ryan, who is being treated for bipolar disorder, said that he had tried several antipsychotic drugs and mood stabilizers, and that he had been better lately.

But, she said in an interview, ?He has gained weight, to the point where we were struggling find clothes for him; he?s had tremors, and still has some fine motor problems that he?s getting therapy for.?

She added, ?But he?s a fabulous kid, and I think, I hope, that we?re close to finding the right combination of medications to help him.?
 

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