Bipolar Soars As Diagnosis For the Young - 40 fold increase

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Mama Suntwinkle <mamasuntwinkle@ >WhiteRose4r <mamasuntwinkle@ >Wed, 5 Sep 2007 08:31:05 -0700 (PDT)[Avian2005] Bipolar Soars As Diagnosis For the Young - 40 fold increase

 

 

 

An analysis of national outpatient medical records documents an exponential 40-fold increase in the "diagnosis" of bipolar disorder in youth (0 to 19 years old) within a 10-year period (1994-2003). The increase in adults diagnosed with bipolar during that period is twofold. Furthermore, among children and adolescents, boys were more likely to be diagnosed with bipolar disorder, whereas among adults, it is more common in women.Dr. Mark Olfson, the lead author of the study published in the Archives of General Psychiatry, told The New York Times: "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."The astounding 'bipolar' epidemic among America's children has no scientific-epidemio logical explanation. It is generated by child psychiatrists who misdiagnose normal, but irritable children who may be disruptive, as having a severe, chronic, disabling condition. The diagnosis of bipolar condemns a child to be "treated" with the most toxic drugs (antipsychotics and anticonvulsants) whose documented severe adverse effects pose life-threatening risks for children and adults. Dr. Olfson acknowledged the potential harm for children in the Los Angeles Times:

"the mislabeling of children and adolescents with aggressive or irritable behaviors as bipolar, an illness that is treated with powerful psychotropic medications, many of which have not been tested in children." He also acknowledged that the gender difference between the groups suggested that some boys with behavior problems or conduct disorders were being misdiagnosed as bipolar. He noted that "irritability is a characteristic of bipolar disorder, but it is also a normal part of adolescence. " Dr. Thomas R. Insel, director of the National Institute of Mental Health, which funded the study, called the increase in bipolar diagnoses worrisome."The way the label is being used is probably a little exuberant -- not fitting with the strict definition of the illness," Insel said. The disorder "is probably not as common as the very high rates we're seeing." "We urgently need to improve diagnosis and treatment for these kids with severe emotional problems," he said.Current diagnostic practice has been largely shaped by the drug industry and its most influential leaders in US child psychiatry who promoted the loosening of criteria. Before the introduction of the new 'atypical' antipsychotics children were not diagnosed with bipolar. This raises the specter of children being exposed to drugs that undermine their health--drugs that induce insulin resistant diabetes--to increase drug sales.

Manufacturers are not the only beneficiaries of the expanded antipsychotic drug market. Prominent child psychiatrists, such as Dr. Joseph Biederman and his disciples at Harvard and elsewhere, have extensive financial ties to drug manufacturers. Harvard's child psychiatrists have been among the most ardent promoters of aggressive psychopharmacologic al intervention for children as young as two.Already in 1998 the misdiagnosing of children as manic was a concern within psychiatry leading to a debate between Dr. Biederman and Columbia University psychiatrists, Drs. Don Klein, his wife, Dr. Rachel Klein, and Dr. Daniel Pine in the Journal of the American Academy of Child & Adolescent Psychiatry. http://www.bpso. org/debate. htm

 

Dr. Biederman argued that children are misdiagnosed as ADHD when they should be diagnosed as bipolar. When it was pointed out that children whom he "diagnosed" as bipolar did not meet the DSM criteria, his solution was to argue that child psychiatrists should not be bound by DSM-IV diagnostic criteria for adult bipolar disorder.

Drs. Klein and Pine argued against:"Clinical descriptions of mania have been remarkably consistent over the years, if not centuries, consisting of a distinct episode of elevated mood or irritability, with well-established associated features (briefly: grandiosity, flight of ideas, pressure of speech, distractibility, increased motor activity, decreased sleep, unrestrained pleasure-seeking activities), usually interspersed with episodes of major depression. No diagnostic criteria have ever been proposed for stable, continuous mania. Yet it is repeatedly stated that children labeled with BPD, unlike adults, display chronic mania. On what basis can this assertion be accepted? If DSM-IV criteria are applied, as we feel they must, this clinical feature alone precludes the diagnosis. Moreover, unlike manic adults, in whom expansive mood is usual, even if often coupled with irritability, elevated mood is rare in children labeled with BPD. Consequently, we are not dealing with identical phenomenology. It appears that the question debated should be reformulated to address whether children who lack the "distinct period" requirement, and elevated mood, are misdiagnosed as having ADHD, when in fact they have BPD."Furthermore, they argued, "If there is frequent misattribution of manic symptoms to ADHD diagnoses in young children, childhood mania must be common, in contradiction to the general consensus that it is very rare. The most recent epidemiological study found not a single child with mania, and only about 1 per 1,000 children with hypomania among a screened sample of nearly 4,000 children."The astounding 40-fold increase in bipolar diagnosis demonstrates that Dr. Biederman's view prevailed among US child psychiatrists. Some clinicians have laid moral responsibility for the psychiatry's loose diagnostic standards and irresponsible prescribing practices--such as prescribing lethal drug cocktails to two year olds-as was reported to have been the case of Rebecca Riley who died of a toxic reaction at age four--on the shouldersof Dr. Biederman.

http://ahrp. blogspot. com/2007/ 06/boston- globe-portrait- of-one-of. html

Dr. Gabrielle A. Carlson, a psychiatrist at Stony Brook University in New York, who has studied the increase in bipolar diagnoses, said 1 of every 5 children referred to her with a diagnosis of bipolar disorder actually had it. The rest had autism, depression, anxiety or another psychological disorder. All these conditions involve different treatments, with drugs, behavioral therapy or both.Dr. Carlson said some parents seemed to prefer a diagnosis of the disorder because the illness, which is thought to be largely genetic, absolves them of blame. But she also acknowledged that "in some cases, providers would diagnose psychological problems in children as bipolar disorder to obtain insurance reimbursement for hospitalizations, a practice called upcoding."Of note: Even the director of the bipolar and mood disorders program at Harvard's Massachusetts General Hospital, acknowledges: ``There's no question that there is misdiagnosis going on.' ``You can dispute whether it's under- or overdiagnosis. ''To gain insight into what propels this preventable potentially catastrophic phenomenon, one must examine the financial stakes and who the stakeholders are. Bloomberg News reports, "The expanded use of bipolar as a pediatric diagnosis has made children the fastest-growing part of the $11.5 billion U.S. market for antipsychotic drugs." And documents obtained from the Minnesota Attorney General reveal that psychiatrists have been greatly enriched by aggressive prescribing.http://ahrp. blogspot. com/2007/ 03/minnesota- is-first- of-handful- of-states. html

Finally, a full investigation is needed to lay bare the contribution of FDA officials who have recently bestowed the government seal of approval to the misprescribing of Risperdal and Zyprexa for pediatric use. FDA's sealprovides an appearance of legitimacy to massive misprescribing of antipsychotics for children.

ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)Promoting Openness, Full Disclosure, and Accountabilitywww.ahrp.org and http://ahrp. blogspot. comContact: Vera Hassner Sharav 212-595-8974 veracare (AT) ahrp (DOT) org

 

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Bipolar Soars As Diagnosis For the YoungBy BENEDICT CAREY, THE NEW YORK TIMEShttp://www.nytimes. com/2007/ 09/04/health/ 04psych.html Pub: September 3, 2007The 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 manyexperts, 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 otherdisorders, 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 arekids 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 PsychiatricInstitute 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 sameprinciples 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 andpediatrics 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'vefound 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 isbeing 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 afabulous kid, and I think, I hope, that we're close to finding the right combination of medications to help him."

 

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Bipolar Disorder In Youths May Be Over-Diagnosed - A New Study Says A Fortyfold Increase Can Be Partly Attributed To Doctors Mislabeling Children And Teens With The Illness

By Denise Gellene Los Angeles Times September 4, 2007

http://www.latimes. com/news/ nationworld/ nation/la- sci-bipolar4sep0 4,1,145237.story?coll= la-headlines- nation

 

 

 

The diagnosis of bipolar disorder in children and adolescents has risen fortyfold since 1994, according to a study released Monday. But researchers partly attributed the dramatic rise to doctors over-diagnosing the serious psychiatric disorder.

The report in the journal Archives of General Psychiatry said bipolar disorder was found in 1,003 of every 100,000 office visits from children and adolescents in 2002-03, compared with 25 of 100,000 office visits in1994-95. The diagnosis of bipolar disorder among adults increased twofold during the same period, researchers said.

The study didn't investigate the reasons for the sudden rise in bipolar cases among children and adolescents. A book published in 2000, "The Bipolar Child," made the controversial assertion that one-third to one-half of children with depression had bipolar disorder.

Dr. Mark Olfson, a psychiatrist at Columbia University's College of Physicians and Surgeons and senior author of the latest study, said part of the increase was attributable to an under-diagnosis of bipolar disorder in the past. But Olfson said another reason was the mislabeling of children and adolescents with aggressive or irritable behaviors as bipolar, an illness that is treated with powerful psychotropic medications, many of which have not been tested in children.

Dr. Thomas R. Insel, director of the National Institute of Mental Health, which funded the study, called the increase in bipolar diagnoses worrisome. "The way the label is being used is probably a little exuberant -- not fitting with the strict definition of the illness," Insel said. The disorder "is probably not as common as the very high rates we're seeing."

Bipolar disorder is marked by severe mood swings between depression and mania, which is characterized by an excess of energy and restlessness. For most patients, depressive episodes are three times more common and longer lasting than those of mania. Symptoms of the disorder can interfere with daily activities, and severe cases carry a risk of suicide.

Until recently, the illness, which appears to run in families, was seldom diagnosed in children. It was believed to begin in late adolescence or early adulthood. About 2% of American adults are believed to have bipolardisorder, although not all of them have been diagnosed.

In the latest study, researchers analyzed data from an annual national survey that collected information from doctors about the nature of patient visits. Researchers found striking differences between adults and the young. Among children and adolescents, boys were more likely to be diagnosed with bipolar disorder. Among adults, it is more common in women.

Olfson said the gender difference between the groups suggested that some boys with behavior problems or conduct disorders were being misdiagnosed as bipolar. Irritability is a characteristic of bipolar disorder, he said, but it is also a normal part of adolescence. "The definition of bipolar disorder tells us what it looks like in adults but not in children," Olfson said.

Young people were 10 times more likely to also receive a diagnosis of attention deficit hyperactivity disorder than bipolar adults, the report noted. Olfson said it was likely that some children with ADHD received the additional diagnosis of bipolar disorder because the symptoms of the two illnesses overlapped. For example, he said, some children and adolescents with ADHD have a "volatile, aggressive subtype" that is easily confused with bipolar disorder.

The report found that children and adolescents diagnosed with bipolar disorder received the same medication as adults with the illness. Sixty percent of children and adolescents received a mood stabilizer, and about 33% of them received an antidepressant or antipsychotic medication, which can cause weight gain.

Dr. Gabrielle A. Carlson, a psychiatrist at Stony Brook University in New York, said 1 of every 5 children referred to her with a diagnosis of bipolar disorder actually had it. The rest had autism, depression, anxiety or another psychological disorder. All these conditions involve different treatments, with drugs, behavioral therapy or both.

Carlson, who has studied the increase in bipolar diagnoses, said some parents seemed to prefer a diagnosis of the disorder because the illness, which is thought to be largely genetic, absolves them of blame. "They don't have to deal with their chaos, their psychiatric disorder, their marital troubles or abuse," she said. She said that in some cases, providers would diagnose psychological problems in children as bipolar disorder to obtaininsurance reimbursement for hospitalizations, a practice called upcoding.

Insel said his institute was conducting research that might lead to more accurate diagnoses of bipolar disorder in young people. The agency said recent imaging studies had detected differences between the brains of normal children and those with bipolar disorder. A large study looking for the genes responsible for the disorder is nearing completion and may yield some additional clues, Insel said.

The agency is also tracking children with bipolar disorder to see how their symptoms change over time. Only a small fraction of children referred for the study actually had bipolar disorder, Insel said, another indication thatthe label is misused. "We urgently need to improve diagnosis and treatment for these kids with severe emotional problems," he said.

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Bipolar Diagnosis in Kids Jumps 40-Fold in 10 Years (Update3)

By Rob Waters, BLOOMBERG NEWSSept. 3 (Bloomberg) -- The number of children in the U.S. diagnosed with bipolar disorder, a mental illness once seen mostly in adults, jumped 40-fold between 1994 and 2003, according to a study in the Archives ofGeneral Psychiatry.By 2003, about 1 percent of children were diagnosed, or 1,003 for every 100,000 people age 19 and younger. The adult rate almost doubled to 1,069. Nine in 10 kids diagnosed with the disorder were on at least one drug, and two-thirds took two or more, said researchers led by Mark Olfson, a psychiatrist at Columbia University in New York.Doctors said they don't know if the rise was caused by too little diagnosis in the past, or too much now as a one-size- fits-all response to aggressive behavior. The question is sparking debate as companies such asIndianapolis- based Eli Lilly & Co. and New York-based Bristol-Myers Squibb Co. seek to market drugs for children linked to weight gain and diabetes.``There's no question that there is misdiagnosis going on,'' said Gary Sachs, director of the bipolar and mood disorders program at Massachusetts General Hospital in Boston, who was not involved with the study. ``You candispute whether it's under-or overdiagnosis. '' The absolute number of children treated jumped to 800,000 from 20,000 during the 10-year study, according to data gathered from the National Center for Health Statistics survey of office visits by the researchers. The ratejumped from 25 for every 100,000 people age 19 and younger.Manic DepressionBipolar disorder was once known as manic depression. In classic, adult versions of the disease, people stay lodged for weeks or months in states of deep depression, then shift to a manic phase in which they sleep little,have intense energy, talk rapidly, and may engage in risky behavior.Starting in the mid-1990s, some psychiatrists began to argue that the disorder looks different in children, who may alternate more rapidly between depression and mania. In their view, the key sign of a bipolar child is ahigh level of irritability and rage. The disorder has been linked to poor school performance and substance abuse.Sachs said that one-third to one-half of patients who have been referred to his clinic with a diagnosis of bipolar turn out not to have a confirmable case. Patients treated for a diagnosis they don't have won't respond to thetreatment and end up getting a lot of different medications, he said. ``They're likely to get more side effects than benefit,'' he said.`True Rates Higher'Sachs says his ``personal belief is that the true rates of bipolar disorder'' in children may be as much as twice the number estimated by the paper. Despite the side effects, the medications can be effective intreating patients who truly have bipolar disorder, Sachs says. Treating kids is ``the compassionate thing to do when you see a child suffering, or out of control,'' he said.When children are misdiagnosed, the result can be dangerous, said Olfson, a psychiatrist at Columbia University. He said there are several factors that make him question the reliability of many bipolar diagnoses.The disorder in adults is seen mostly in women, yet about two-thirds of diagnosed children are boys. Also, many children said to have bipolar were also diagnosed with attention deficit disorder, a condition that can looksimilar, Olfson said. ``If we're getting this wrong, if substantial numbers of kids are being misdiagnosed with bipolar disorder, it can have serious consequences, '' Olfson said in an Aug. 31 telephone interview.Medication TypesTwo groups of medications are widely used in children.Anticonvulsants, developed to treat epileptic seizures, were taken by about half of the children. Drugs in this group include Depakote made by Abbott Laboratories; Johnson & Johnson's Topomax; GlaxoSmithKline Plc's Lamictal; Novartis AG's Tegretol and Pfizer Inc.'s Lyrica and Neurontin. None are approved by U.S. regulators for treating children with bipolar disorder. Side effects include sedation, weight gain, tremor, and, more rarely, liver and blood problems.The expanded use of bipolar as a pediatric diagnosis has made children the fastest-growing part of the $11.5 billion U.S. market for antipsychotic drugs.Nearly half the children took atypical antipsychotics, such as Lilly's Zyprexa, J & J's Risperdal, AstraZeneca Plc's Seroquel, Bristol-Myers' Abilify and Pfizer's Geodon. Side effects caused by this group of medicationsinclude weight gain, diabetes and hormonal irregularities.Lilly is developing an experimental antipsychotic drug that didn't show the same side effects in the second stage of testing regularly required for regulatory clearance, the company said yesterday. That drug targets a different brain chemical than drugs now on the market.Risperdal in ChildrenRisperdal was cleared for use in children ages 10 and older on Aug. 22, beating Lilly and Bristol-Myers in a push to expand use of such medicines by younger patients. Risperdal, J & J's top- seller, generated $4.2 billion last year while Lilly's Zyprexa had $4.4 billion in sales. The FDA is reviewing Zyprexa and Bristol's Abilify for teens.Vivek Kusumakar, global head of Risperdal development for J & J, said when it was approved that the side effects must be weighed against the potentially fatal conditions it treats.David Healy, a professor of psychological medicine at Cardiff University in Wales, said the rise in the diagnosis was unprecedented. Healy, who has served as an expert witness for lawyers suing drug companies, said he was particularly concerned that so many children were prescribed more than one drug.``The mismatch between possible benefits and likely harms is great,'' he said.To contact the reporter on this story: Rob Waters in San Francisco at rwaters5 (AT) bloomberg (DOT) net

 

 

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