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Bipolar Disorder in Children and Adolescents: a Caution
(Added 6/2005; updated 9/2007)

Dr. Simon Sobo has written many cautions about the "group think" which is common in psychiatry. One current trend in psychiatry is to look closely for bipolar-like conditions in children. He is very concerned about that trend. At my encouragement, he has prepared the following comments to keep everyone thinking critically about diagnosis and treatment in children.


I have great difficulty with your connecting people to that "wonderful" site www.bpkids.org .

The 2005 APA [American Psychiatric Association -- the big annual psychiatry convention] meetings' hottest controversy was about bipolar disorder in children.  As you know I am not a great fan of spectrum disorders.  They make sense in the abstract but when put into practice they can lead to extremely loose criteria for making an unwarranted diagnosis.  I would prefer that people who do not meet criteria for the illness be labeled as atypical (for now).  If later solid evidence is found to support the inclusion of patients not meeting the criteria, or if solid reasons are found for redefining the criteria so be it. But for now I think the group pushing for very loose criteria are out of control.

Jim, let me remind you of the sequence that has led to their descriptions of bipolar children.  There were a number of huge leaps of faith not justified by any new findings

1. Kramlinger and Post (1996) described clear-cut bipolar (bipolar I) patients who were followed on a ward and rated for mood every two hours during the course of a day. They found a group of five patients(I believe out of 13 patients) who went up and down throughout the day and wondered whether these represented "ultra-ultra rapid cycles" or as they called it "ultradian cycling". Their observation was not all that startling.  Such patients have long been know to exist and were categorized as having the mixed form of bipolar disorder.  Speculating that their mood lability was ultrarapid cycling was interesting and cannot be dismissed out of hand.  But that was not what happened.  The concept was embraced by many psychiatrists with very little discussion as if it were an established fact.  This totally changed what is meant by “mood swings”.  Previously rapid cycling in bipolar disorder meant 4 changes in a year!  Suddenly we were talking about cycling going on many times in a day. And people were being diagnosed as bipolar on the basis of this kind of mood lability.  How we went from the observation that some bipolar I patients are labile and are having extremely rapid cycling (controversial to begin with)  to using these “mood swings” as the basis for  making the diagnosis is completely beyond me.  It is possible but the burden of proof is on those making such claims.

Note added 9/11/07: Consistent with the above observations, a 40 fold ! increase has been found nationally by Dr. Moreno from Columbia University (National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth).  The article is in the Sept 07 issue of Archives of General Psychiatry, page 1032.

2.  The criteria for bipolar was loosened with bipolar II.  Mania was no longer needed.   In my article on bipolar disorder  “Mood Stabilizers and Mood Swings: In Search of a Definition” I agree that there are undoubtedly some patients with a gene for bipolar disorder who have a milder form of the disease.  However, the looser definition of what constitutes the illness has led to many patients being told they have bipolar II when I believe they don’t, particularly when the basis of that diagnosis is “mood swings” as outlined above.

3.Put the two together, add moody kids and now you have a new definition of the disorder and it isn't even being presented as a spectrum disorder.

4.  Add to that  “experts” (for a very critical  discussion of “experts” see my “Can Prozac Make You Into a Murderer?”) from some of  our best universities signing off on the new concept for kids, then send out pamphlets to doctors, stating that patients are going undiagnosed for an unacceptably long period of time.  Warn of malpractice if these kids aren't treated with meds and we have the current situation. That plus spread the word through well meaning sites like the "wonderful" site you alluded to who still have faith in the experts.

There you have it.  A new disease born with speculations built upon speculations upon speculations

 

Mind you. I am not saying that they must be absolutely wrong. Or that I am against progress or "new thinking.”  Who knows at this point what percentage of children diagnosed by their very loose criteria will actually have adult bipolar when they grow up, thereby confirming they do indeed have a disease that will be with them for a lifetime.  They do not have to be wrong.

However, the fact that there are no decent longitudinal studies about whether chronic good treatment affects the long term course of the disease in known bipolar I disorder patients; and all the questions I raised above about the basis of their diagnosis should make the burden of proof fall on those insisting they can identify childhood bipolar disorder and the children must be treated NOW.

In others words supporters of the wildly expanded new definitions of bipolar in children should do some research before they make proclamations for others.  It is astonishing that this minimum requirement of scientific inquiry is not only being ignored but allowed even a hint of respectability.  Before they try to intimidate everyone else they should be held to the hot fires of scientific scrutiny.  If they want to do research in these area (over the several years it will take to establish their position) that is wonderful, but until then their proclamations should be modest ones, that of inquiring minds with several hypotheses to clarify, not experts ridiculing everyone else for "missing" the diagnosis.


Dr. Sobo concluded his note about this as follows:

Thankfully, they were challenged at the APA convention  so that the issue is not yet completely out of control, but I don't think the site you are describing as "excellent" sufficiently addresses the controversy. We are talking about young children with problems which may not be bipolar disorder.  And drugs with plenty of known side effects.  While I appreciate that a well meaning educational site should not burden patients with uncertainties and controversies, especially since the idea of the illness is frightening enough, I am quite concerned that bipolar disorder in children  will turn into the next ADHD, a run-away freight train if ever there was one.  Once again for those interested in a skeptical view of current thinking about ADHD here is another article "ADHD and Other Sins of our Children" : long version, short version and book chapter in  Rethinking ADHD.