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The bipolar epidemic

MagazineDecember 2011 (Vol. 22 Issue 9)The bipolar epidemic

Twenty years ago, bipolar disorder-the mental illness characterized by extreme mood swings-was rare or virtually non-existent in children

Twenty years ago, bipolar disorder-the mental illness characterized by extreme mood swings-was rare or virtually non-existent in children. Today, nearly a third of all children and adolescents discharged from child psychiatric hospitals are diagnosed with the disorder and medicated accordingly.

According to some, this explosion in childhood bipolar diagnoses is not so much an epidemic of mental illness in the paediatric population, but a case of severe medical overreach-with potentially devastating consequences. Children as young as two years of age, they say, are being wrongly diagnosed with the 'trendy' disorder and put on a cocktail of psychotropic drugs that can be harmful or even deadly.

The number of children diagnosed with bipolar disorder has recently skyrocketed. US figures show that outpatients visits for bipolar children and adolescents rose from 20,000 in 1994-95 to 800,000 in 2002-03-a huge 40-fold increase in less than a decade. In contrast, adult visits with a bipolar diagnosis increased about twofold over the same period (Arch Gen Psychiatry, 2007; 64: 1032-9).

Although some psychiatrists argue that this surge in childhood bipolar diagnoses is down to increased understanding of the disorder, others believe it reflects a major problem of misdiagnosis that is putting young lives at risk.

Dr David Fassler, at the University of Vermont, has said that close to half the children thought to be bipolar may be misdiagnosed. "Bipolar disorder is not always easy to recognize in children and adolescents," he said. "There's considerable overlap with other conditions, including ADHD, con-duct disorder, anxiety disorders and depression."
Indeed, in a study of adolescent inpatients in Katonah, NY, nearly half the bipolar disorder diagnoses made by community clinicians were later reclassified as depres-sion or conduct disorder (Psychiatry Res, 2001; 101: 47-54).

Other psychiatrists believe the problem is much bigger. In the view of Dr Stuart Kaplan, a child psychiatrist and clinical professor of psychiatry at Penn State College of Medicine, the majority of childhood bipolar disorder diagnoses are wrong.

"Most of these symptoms can be easily matched to less-trendy conditions like attention-deficit/ hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD)," he argues. "My view is that a diagnosis of bipolar disorder in a child is almost always a case of severe ADHD combined with severe ODD, both fairly common in elementary-school children."

A real diagnosis?
Kaplan goes as far as to say that childhood bipolar disorder (CBD) doesn't even exist. In his recently published book Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis (Santa Barbara, CA: Praeger, 2011), he states that there is no scientific evidence to support the belief that bipolar disorder surfaces in childhood. Rather, he believes the 'epidemic' of CBD is a "diagnostic fad" fuelled by shaky science and clever marketing.

In adults, Kaplan explains, bipolar disorder is characterized by cycles in which a patient rotates between two extremes of feelings-depression and mania-with clear-cut episodes of behaviour that are distinctively abnormal: severe overexcitement lasting for weeks; and crushing periods of deep depression that also last for weeks or months.

But the current description of CBD is radically different. "Where adult bipolar disorder expresses itself in episodic, out-of-character behaviour," Kaplan states, "a child diagnosed with bipolar disorder will have symptoms that characterize the child's typical behaviour." In other words, a child with the disorder may be chronically enraged and have several tantrums per day. Not only is this unlike the accepted definition of bipolar disorder in adults, says Kaplan, but it also means that it's nearly impossible to distinguish between children alleged to have CBD and those with straightforward anger-control issues.

In fact, there are no universally accepted diagnostic criteria for CBD. The diagnosis was proposed in the mid-1990s by two influential research groups-one at Washing-ton University in St Louis, MO, and the other at Harvard University in Cambridge, MA. While the former group claimed that children with CBD display ultra-rapid cycling-they switch between depression to mania much more rapidly than do bipolar adults-the latter team suggested that CBD presents as irritability and explosive emotion-al states in the form of chronic depression, anger, or both (J Psychol Iss Org Cult, 2011; 1: 32-49).

Both schools of thought have been criticized, with psychiatrists and psychologists arguing that bipolar disorder should look the same in adults and in children.

Some have also questioned the science behind the 'proof' for the disorder. Kaplan notes that Dr Joan Luby, a leading researcher in bipolar disorder in small children at Washington University, reported that preschool children who exhibited grandiosity, elation and interest in sexual behaviour were likely to be bipolar. "Most child psychiatrists, including me, would be challenged to weigh the meaning of such behaviours in preschoolers," Kaplan states.

What's more, he points out that several of Luby's studies were based entirely on the reports of parents. "This made her assessment medically incomplete, a failure that counts even more because she was proposing a disorder that hadn't been described previously in the psychiatric literature," says Kaplan.

Money matters
More worrying, researchers from Point Park University in Pittsburgh, PA, have highlighted the heavy pharmaceutical influence in the research and clinical management of CBD. In a report of the conflicts of interest in this area, they described the public exposure of Harvard child psychiatrist Joseph Biederman, a prominent supporter of the CBD diagnosis and a key advocate of powerful antipsychotic drugs as treatment.

In The New York Times on March 19, 2009, Biederman was revealed to have given assurances to Johnson & Johnson that his yet-to-be-conducted research on the atypical antipsychotic risperidone in preschool children "will support the safety and effectiveness of risperidone in this age group", which "strongly suggests that Biederman tailored the Johnson & Johnson study to produce the desired results", the team said.

Moreover, in an inquiry prompted by Senator Chuck Grassley of Iowa, Biederman was found to have earned at least $1.6 million in consultation fees from drug companies, yet disclosed only a small portion of the income to his university. He was also exposed as having promised a variety of outcomes to Johnson & Johnson in his drug trials, thus suggesting that he had manipulated the data to obtain the desired results in exchange for kickbacks from the drug company (J Psychol Iss Org Cult, 2011; 1: 32-49).

Two other Harvard child psychiatrists were also found guilty of failing to report all income earned from drug companies.

In addition, Dr Luby, a keen supporter of using antipsychotics and mood-stabilizing drugs in young children with CBD, has been funded by companies that make the drugs and, in 2009, CBS News online reported that she has not always disclosed these ties in her published research.

With such a big pharmaceutical influence on the study and treatment of CBD, it's hard to believe that what's being recommended is truly in the best interests of the patients.

Dangerous definitions
The consequence of the dramatic rise in CBD diagnoses is that hundreds of thousands of children are being prescribed psychotropic drugs-none of which actually work for the disorder (http://leg2.state.va.us/dls/h&sdocs.nsf/By+Year/HD92010/$file/HD9.pdf) and all of which have nasty side-effects (see Factfile A). US figures show that, from 1993 to 2002, there was a roughly sixfold nationwide increase in the number of office-based visits by youngsters that ended with prescriptions for antipsychotic medications (Arch Gen Psychiatry, 2006; 63: 679-85).

Happily, the people in charge of revising the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)-the reference text for the classification of mental disorders used all over the world-appear to have understood the dangers of a CBD diagnosis, and rejected its inclusion in the new edition due out in 2013.

However, in its place, the DSM-V task force is considering a different diagnosis-'temper dysregulation disorder' (TDD)-for children currently diagnosed as bipolar, but without the symptoms seen in bipolar adults. The main features of TDD are severe, recurrent temper tantrums and persistent irritability.

While this may look like a step in the right direction, this new mental illness will no doubt cause just as many problems as CBD. US psychiatrist Dr Allen Frances, who was chair of the DSM-IV task force, fears that the new TDD diagnosis will only allow the drug industry to expand its market for potentially dangerous psychotropics. Worse, "their use in kids who are having disturbing (but essentially 'normal') developmental or situational storms or are irritable for other reasons (e.g. substance abuse, ADD) would be disastrous", says Frances, "but it will happen."

Literary critic and intellectual historian Christopher Lane points out that the TDD diagnosis "implies . . . that anyone cycling through emotions that are part of normal human development could be susceptible to a psychiatric diagnosis that they're going to be saddled with for the rest of their lives" (J Psychol Iss Org Cult, 2011; 1: 32-49).

Environmental effects
Sadly, given the controversy over CBD and the emphasis on finding the right label for these children, there's a distinct lack of focus on what's really causing these mood and behavioural problems, particu-larly the role of environmental factors.

Nevertheless, some experts have proposed some intriguing theories suggesting that the symptoms might be reversible.

Child/adolescent psychiatrist Dr Victoria Dunckley, for instance, suggests that video games and other forms of electronic stimulation could be contributing to the increasing numbers of CBD diag-noses. "No influence is more underestimated than the hyper-arousal state that goes hand in hand with video games-including non-violent ones-and other interactive screen use, such as texting and Internet surfing," she blogs (www.psychologytoday.com/blog/mental-wealth/201106/misdiagnosed-bipolar-disorder-is-all-the-rage). She claims that video games and other forms of 'screen time' can have negative effects on behaviour and mood that could be wrongly perceived as bipolar disorder.

Indeed, recent studies have found that video-game play is associated with aggression and sleep problems in children-both of which are symptoms of bipolar (Dev Psychol, 2011 Oct 31; Epub ahead of print; Pediatrics, 2007; 120: 978-85).

Others have speculated that ADHD medication could be at the root of the problem. UK researchers at the University of Oxford noted that the symptoms of ADHD overlap with those of CBD, and the treatment of ADHD with stimulants can induce elated states.

In fact, stimulant drugs such as methylphenidate (Ritalin) have recently been reported to cause manic-like symptoms in children, including euphoria, grandiosity, paranoid delusions, confusion, hallucinations and increased aggression (Indian J Pharmacol, 2011; 43: 80-1).

"Is it possible that the wide-spread use of stimulants to treat difficult behaviour in children accounts for the apparent epidem-ic of [CBD] in North America?" ask the Oxford researchers (Adv Psychiatr Treat, 2004; 10: 1-3).

Food factors
Another possible explanation is nutritional imbalance. Mounting evidence suggests that food can have powerful effects on mood and behaviour, so perhaps what looks like bipolar disorder is actually a nutritional deficiency or a problem with metabolizing certain foods.

A lack of omega-3 fats, for example, is associated with both bipolar disorder and ADHD. These fatty acids are important for brain development, and for regulating the behavioural and chemical aspects of mood disorders, such as stress responses, depression and aggression (Expert Rev Neurother, 2011; 11: 1029-47). Trials suggest that omega-3 supplements may help patients with bipolar disorder-with effects on both the manic and depressive symptoms (Eur Neuro-psychopharmacol, 2007; 17: 440-7; Expert Rev Neurother, 2011; 11: 1029-47).

Other nutrients that may be related to bipolar disorder are folic acid and vitamin B12. Food allergies and unstable blood sugar levels could also play a role (see WDDTY vol 14 no 7). Indeed, US child psychiatrist Dr Patric Darby has noted that many children diagnosed with bipolar disorder are well controlled by a sugar-free diet.

These possible causes of mood and behavioural problems in children merit further study, as the result could spare thousands of children from a life sentence of risky medications and stigma.

Joanna Evans

Factfile A: Bipolar drug side-effects

  • LITHIUM (a mood stabilizer): Nausea, vomiting, diarrhoea, muscle weakness, increased frequency of urination, blurred vision, impaired kidney and thyroid functioning
  • ATYPICAL ANTIPSYCHOTICS: Sedation, restless leg syndrome, weight gain, neuromalignant syndrome (a life-threatening neurological disorder), tardive dyskinesia (a disorder of involuntary repetitive movements), diabetes
  • ANTICONVULSANTS: Constipation, mood swings, dizziness, suicidal thoughts and behaviours, increased testosterone levels
  • ANTIDEPRESSANTS: Headache, nausea, sleep problems, agitation, suicidal thoughts and behaviours.

WDDTY ISSUE 22 NO.9, NOV. 2011

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