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Allen Frances

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The False Epidemic of Childhood Bipolar Disorder

Posted: 04/03/2012 7:24 am

In common with all medicine, the history of psychiatry is filled with silly and sometimes dangerous fads in diagnosis and in treatment. Unfortunately, one of the most distressing fads is happening right now. Childhood bipolar disorder used to be vanishingly rare, but has recently become far too common -- in just 15 years, rates have jumped an amazing 40-fold. This has been accompanied by a remarkable increase in the prescription of antipsychotic and mood stabilizing drugs for teenagers, children, and even infants. These medications can cause serious complications -- major weight gain, obesity, diabetes, cardiovascular disease, and possibly shortened life expectancy. Sudden death has occurred in a few cases where excessive doses and/or multiple drugs were given to very young children.

How could childhood bipolar disorder suddenly become so common? Human nature doesn't change fast, but diagnostic labels do -- in this case, the label "bipolar disorder" is being applied loosely and carelessly to describe a wide variety of irritable and difficult-to-manage children. Whenever there is an apparent explosion in the prevalence of any mental disorder, the safe bet is diagnostic fad -- not real change in people. And it is always a good idea to search for the factors that are feeding the diagnostic frenzy.

The causes behind the surge in childhood bipolar disorder are no mystery -- a combustible combination of overly influential thought leaders, aggressive drug company marketing, desperate parents, and gullible doctors.

This false "epidemic" started at Harvard University. Prominent child psychiatrists promoted the seductive idea that developmental differences in children result in their having a different bipolar presentation than what is typical of adults. Rather than clear-cut cycles of mania and depression, bipolar kids were said to have continuous irritability, moodiness, and behavior problems. Supporters of this novel and largely untested developmental approach to diagnosis enthusiastically lobbied us to include a special criteria set for childhood bipolar disorder in DSM-IV, but we found the scientific support unconvincing and refused to do so. This did not inhibit the enthusiasm of the thought leaders in child psychiatry as they spread their new gospel that bipolar disorder is common and is commonly missed in youngsters who were previously considered to have a wide variety of other problems -- including ADD, conduct or oppositional disorder, substance abuse, family or school problems, or moody-but-normal temperaments. Largely by fiat rather than science, childhood bipolar disorder was declared to be a big and open tent. Thus are diagnostic fads started.

The evangelistic message received the enthusiastic support and hefty financial backing of drug companies all too eager to increase market share by promoting unapproved, off-label uses for their products among the young. There was the usual full-court sales push -- conferences and fancy dinners for doctors, beautiful saleswomen and handsome salesmen clogging their offices, and nonstop magazine, TV and internet direct-to-consumer advertising. Bipolar disorder seemed to be ubiquitous and protean in its manifestations. Thus are fads promoted.

This offered an understandably bright ray of hope for families struggling with very difficult to manage kids. Instead of feeling angry and helpless with their out-of-control child, parents could excuse the difficult moodiness and disturbing behaviors -- chalking them up to "chemical imbalance." There was now a simple medical treatment with highly touted drugs for kids previously considered unmanageable and untreatable. The trouble was that the long-term side effects and complications of the medication were often worse the often temporary problems they were meant to treat. But, thus are fads supported.

For reasons to be spelled out in my next piece, children are inherently difficult to diagnose. It takes time-consuming evaluation, longitudinal follow-ups, considerable expertise, and prudent caution to do an accurate assessment. Many doctors, especially in primary care, practice under extremely difficult conditions (with brief patient visits and little continuity of care) that don't really allow for careful evaluation. They may also have little training or interest in the fine points of psychiatric diagnosis and get more of their "continuing medical education" from drug company hype than from a sober and neutral review of the scientific literature. Thus are diagnostic and treatment fads implemented.

There is some upside to the story; no "false epidemic" is ever without beneficiaries. Antipsychotics play a positive role for some kids who are extremely out of control -- even if they don't really have bipolar disorder. Most medicines in psychiatry have non-specific effects that cut across disorders. Antipsychotics can helpfully slow down some kids who need slowing down, whatever the cause of their troubled mood and behavior. But more often than not, the gains do not balance the enormous downside. The problem is not that medications are being used at all (sometimes they have to be), but that they are being used so much, so carelessly, so early in life, and for such inappropriate and sometimes trivial indications.

Those who are working on DSM-5 have been rightly concerned by the over-diagnosis of bipolar disorder and its over-treatment with often harmful medication. Their proposed solution to the dilemma is well intended, but badly misguided. They suggest introducing a newly invented and almost completely untested "diagnosis" that has variously been named "Temper Dysregulation" or "Disruptive Mood Dysregulation." The idea is to provide an alternative diagnostic label that is less likely than childhood bipolar to result in long term antipsychotic misuse. My fear is that this will badly backfire -- that normal kids with temper tantrums who are now undiagnosed will be misdiagnosed and given inappropriate medicine. Hurried clinicians and harried parents may misinterpret the poorly-studied but fancy-sounding 'Disruptive Mood Dysregulation Disorder' as yet another indication for antipsychotics. DSM-5 risks making the already bad situation much worse.

The correct solution to the childhood bipolar fad is obvious -- face it down directly, not try a sidestep that has its own risks. Several things can be done that would cure this "epidemic." DSM-5 should include a prominently displayed warning about the overdiagnosis of childhood bipolar disorder and provide clinical tips on how to prevent it. Drug companies should be prohibited from advertising directly to consumers and should be more closely monitored to ensure they adhere to rules against marketing off label indications. Professional organizations in psychiatry, pediatrics, and primary care should sponsor conferences to re-educate their clinicians on careful diagnosis and cautious prescription.

What should parents do if their kids are now receiving antipsychotics? My advice is to get a second or a third or even a fourth opinion. And be a very informed consumer -- read everything you can find on bipolar disorder and antipsychotics, and don't be shy about opening discussions with the doctor. Antipsychotics are big-time medications -- potentially quite helpful, potentially quite harmful. They should be reserved for big time problems, used only when they are clearly needed and reasonably likely to make a big difference.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

For more on mental health, click here.

 
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