A Diagnosis Emerges? Pediatric Bipolar

Does pediatric disorder exist? Who decides what the criteria are?

Furious seasons has a fact-filled post today on exactly this topic. What is most curious about this possibly emerging diagnosis is that it does not yet appear in the DSM. Yet officials at the FDA are claiming it is a diagnosis, by virtue of the fact that medications have been approved for treating it. Pretty circular logic. As problematic as the DSM is, it at least has the supposed backing of research (which actually turns out to be flimsy in many cases…) But this is an unusual case of a diagnosis being created outside the DSM.

Here are several paragraphs from the post:

More pointedly, McClellan told me earlier this year that the kids and teens he was seeing (he sees some very intense kids and teens at two Seattle-area hospitals) who had been diagnosed with bipolar were in fact kids with oppositional defiance disorder and conduct disorder who were largely the product of extreme, and extremely dysfunctional, environments. The leader of the Harvard group, Joe Biederman, has said kids are born this way.

McClellan is far from the only one flying red flags around the bipolar child business. Steven Hyman, a Harvard psychiatrist and former NIMH head, has publicly expressed his concerns about the meds these kids are given: “We don’t know the first thing about safety and efficacy of these drugs even by themselves in these young ages, let alone when they are mixed together.”

In 2006, Thomas Insel, NIMH director, also pointed to the meds being given bipolar kiddos as being a concern, telling the New York Times, “There are not any good scientific data to support the widespread use of these medicines in children, particularly in young children where the scientific data are even more scarce.”

In an op-ed, Larry Diller of UCSF noted: “Biederman shocked the child psychiatric world in 1996 by announcing that nearly a quarter of the children he was treating for attention deficit hyperactivity disorder also met his criteria for bipolar disorder. Up until then bipolar disorder was rarely diagnosed in teenagers and unheard of in prepubertal children. Biederman could justify his findings by simply broadening the semantic definitions of a previously more circumscribed condition contained within American psychiatry’s bible — the ‘Diagnostic and Statistical Manual of Mental Disorders’.”

FDA and Child Bipolar

Philip over at Furious Seasons is on a rant about the FDA legitimizing the childhood bipolar diagnosis, one which does not yet occur in the DSM. Essentially, it sounds like the rationale is that since they’ve approved studies about medicating the disorder and approved dosages of Abilify and Risperdal with children — then the disorder exists. Today Furious Seasons posts all about the adverse effects of those two drugs. The excerpt from yesterday’s post:

Earlier today, I asked the FDA to respond to a statement made by Harvard child psychiatrist Janet Wozniak, wherein the doctor claimed that the FDA accepted the validity of the hotly-debated child bipolar disorder. That was news to me, since the diagnosis does not exist in the DSM and many child psychiatrists such as Jack McClellan and Larry Diller, both affiliated with major medical schools, even claim that the child bipolar diagnosis is not real.

Addendum: Clinical Psychology and Psychiatry also posts on this topic, and points to a John Grohol post at Psych Central, also on child bipolar. Dr. Grohol rightly points out that the FDA logic for sanctioning this diagnosis is circular…

Family Therapy for Bipolar Disorder

Biopsychosocial model. Interesting article in today’s New York Times about incorporating family therapy for bipolar disorder. Family therapy, as the article points out, doesn’t always assume that the “identified patient” is the cause of the problem. Usually there are other dynamics within the family that contribute to the problem, even with a disorder conventionally looked upon as being biological in nature. In family therapy, focus sometimes shifts from the “identified patient” to another member of the family.

The key advantage of family therapy in this setting, is enlisting family members to assist in noticing symptoms, particularly oncoming mania. Here’s a bit about family therapy from the article:

Family-focused therapy, as it is called, breaks the image of the psychiatrist sitting in his chair, alone in a room with the patient, as well as the traditional wisdom that patient confidentiality is sacrosanct. In family therapy, the family might be treated as part of the problem; in contrast, in family-focused therapy the point is not to treat relatives, but to enlist their help in managing the patient’s illness.

And here’s a bit about the effectiveness of this kind of treatment:

“We’ve tested it in a number of different trials against different types of therapy, and consistently find that if you combine medication and family-focused therapy, you get quicker recoveries from episodes and longer intervals of wellness,” said David J. Miklowitz, a professor of psychology and psychiatry at the University of Colorado, whose pioneering research on the topic inspired the Beth Israel clinic. “So the relapses are less common, and their functioning improves, including relationship and family functioning.”

And a bit about the effectiveness of therapy as an adjunctive treatment:

For many years, Dr. Miklowitz said, the extreme mood swings of bipolar disorder had been thought of “as sort of an exclusively genetic, biologically treated illness,” to be managed primarily with medication. But his most recent study, reported a year ago in the Archives of General Psychiatry, showed that long-term therapy of 30 50-minute sessions over nine months, with medication, cut median recovery time to 169 days, compared to 279 days for those receiving short-term therapy of three sessions over six weeks.

One of the reasons enlisting the family is the opportunity they have for spotting early signs of mania:

… [the] founder of Beth Israel’s clinic, Dr. Igor Galynker, said their experiences with patients showed that families are in the best position to catch early warning signs of a manic or depressive episode.

“It can be something as subtle as a change in lipstick shade,” Dr. Galynker said. “Only a person who knows them very, very well would know.”

This is a nice example of where medication, therapy, and family work together in treatment. Hence, bio-psycho-social.

Kalea Chapman, Psy.D.

Bipolar Disorder: Overdiagnosed?

Two indicators: Research and practice. Well a new study seems to indicate that overdiagnosis is the order of the day. Furious Seasons has two stories on this topic, April 6 and 7, both quotes are straight from Furious Seasons.

Clinical Psychology and Psychiatry, advocating a Bipolar Overawareness Week, has an extensive treatment of the topic, with some great quotes from David Healy, an Abilify video, and some wise words about the significance of getting a diagnosis, from The Last Psychiatrist.

To top it off, John Grohol at Word of Psychology covers the study and links to a first-person account of being diagnosed. It’s called To Hell and Back published in the Daily Kansan. Here’s a quote from the initial study’s author, Mark Zimmerman:

Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive.’ He continues, ‘This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder.

Zimmerman concludes, ‘The results of this study suggest that bipolar disorder is being overdiagnosed and we recommend that clinicians use a standardized, validated method in diagnosing bipolar disorder.

Antipsychotics as the New Antidepressants

In case you were skeptical of the April 2 post. Here’s Furious Seasons (April 4 entry) with a quote from the maker of Seroquel describing it as an antidepressant.

A bizarre incident in Mississippi: a middle school student gave the antipsychotic Seroquel to several friends, the friends took the drug, the students began acting oddly, the students were taken to a hospital, and the student who gave them the drug is in big trouble.

Then this from a press account:

“Seroquel is an antidepressant drug used to treat manic depression, schizophrenia and bipolar disorder, according to the Web site http://www.Seroquel.com.”Where the hell does AstraZeneca get off describing the drug, which is not approved for depression, as an anti-depressant? The drug is approved for bipolar depression, but it’s most common use is as an antipsychotic, shut-people-up drug. If it’s an anti-depressant, then I am Zeus.

Kalea Chapman, Psy.D.

2.5 Million American Children on Atypical Antipsychotics?

Those darn kids.

More and more, children that are unmanageable, disagreeable, or just plain moody are getting diagnosed with bipolar disorder or ADHD. What do I hear from more and more clinicians on this issue? Let’s take a look at the parenting. Are the parents willing to take charge of their children? Are they setting limits? A lot of things cause kids to act out, and they might be amenable to something less than antipsychotic medication.

I got wind of this article from Furious Seasons who got it from the Guardian UK. “The chief symptoms are mood swings, which, however are common in children of any age”(!) Here are some quotes from the Guardian:

“Antipsychotic drugs for children have taken off in the US on the back of a willingness to diagnose those with behavioural problems as having manic depression. Even children barely out of babyhood are getting a diagnosis of bipolar disorder, the modern term for the condition.

“The chief symptoms are mood swings, which, however, are common in children of any age.

“David Healy, an expert on bipolar disorder, said there were now 2.5 million American children on antipsychotics. However, the UK guidelines on the disorder, from the National Institute for Health and Clinical Excellence, urge caution.”

Kalea Chapman, Psy.D.

Some Resources for the Depressed

Depressed? You may have come to the right place, at least today. The excellent PsychCentral website has a list of the “top ten best blogs on depression”. One of those blogs, Finding Optimism, has a list of 94 resources for those suffering with depression. You might find it useful.

Kalea Chapman, Psy.D.

The Norming of America

A post from Wired on the over-medication of America. It dovetails nicely with another observation at Furious Seasons. The Furious Seasons post may be a flat-out rant, but it’s rant worth reading. Excerpts from both. First Wired:

Sometime in the 1990s, the concept of better living through chemistry turned a corner, thanks to drug companies’ efforts to synthesize antidotes for every possible mood swing. So writes Yale lecturer Charles Barber in his new book, Comfortably Numb: How Psychiatry Is Medicating a Nation. An OCD sufferer himself, Barber spent a decade working in places like New York City’s Bellevue Hospital. He knew something was wrong when he discovered that his colleagues’ perfectly functional, $300-an-hour Upper West Side clients were taking the same potent pills as his own schizoid, homeless, crackhead patients.

Does Bipolar Disorder Exist?

The popular and worthwhile blog Furious Seasons, written by a guy diagnosed with bipolar disorder, asks the following: Does bipolar disorder exist? Here’s an excerpt, a quote from psychiatrist Paul Minot, from a thought-provoking post well worth reading in its entirety:

Bipolar disorder isn’t actually a disease.

It’s a collection of signs and symptoms lumped together in a diagnostic classification that has no basis or assumption of causation. There is no known neurochemical abnormality associated with “bipolar disorder”, and patients with this diagnosis certainly have a plethora of different problems, all lumped together in one convenient/dumb diagnostic classification.

The expansion of the definition of bipolar disorder over the past two decades is simply a “rebranding” of post-traumatic stress disorder, impulse control disorders, personality disorders, and other problems into a pseudoscientific trashcan diagnosis, to provide an FDA-approved “indication” for the prescription and marketing of anticonvulsants and other medications to treat this “illness”. I know this because I myself am a psychiatrist, actively treating bipolar disorder and prescribing these medications. I think prescribing these medications is reasonably safe and often helpful, but trumping up fictitious diagnoses and deluding people into thinking that they have a lifelong illness without a firm grounding in scientific fact is ridiculous, and unethical. Your own experience isn’t miraculous, it just verifies that much of contemporary psychiatric diagnosis is a bunch of malarkey.

Kalea Chapman, Psy.D.

The Marketing of Bipolar Disorder in Children

Here’s a link to Frontline‘s piece on the medication of what they are calling “pediatric bipolar disorder“. A 2007 article by David Healy and Joanna Le Noury in the International Journal of Risk and Safety in Medicine (citation below) has some sobering and thought-provoking assertions about the marketing and medical treatment of manic depression in general and manic depression in kids specifically. This is an article written by a psychiatrist in a peer reviewed journal. That means a review board of other psychiatrists or researchers reviewed the findings and assertions in the paper and deemed them sound, suitable for publication. Here’s a dirty dozen:

1. manic depression (rechristened bipolar disorder) was not diagnosed in children for over 100 years
2. bipolar disorder in children has markedly different symptoms that in adults
3. we do not know how medications that treat bipolar work
4. children are medicated with the same powerful psychotropics as adults
5. there is “scant research into childhood mental illness and drug treatments to combat them”
6. as recently as 1990 the literature referred to bipolar as manic depression