Thursday, December 27, 2012

Diagnoses of Bipolar Disorder in Children

Reading a book about behavioral economics, I came across some literature references to the over diagnosis of bipolar disorder in children.  A 2007 study  by Moreno and his colleagues at Columbia University and the NIMH, noted the diagnosis of 800,000 children in 2003 alone compared to an annual diagnosis rate of 20,000 children a decade earlier.  This is a shocking, forty-fold increase in the number of cases diagnosed.

The original classification scheme for mental illness was developed in 1920s Germany by a psychiatrist named Emil Kraepelin.  His classification labels included "manic depressive disorder," which has survived today as "bipolar disorder."  Other of Kraeplin's diagnoses did not stand the test of time, and some of his categories, such as "indviduals with distinctly hysterical traits," including "dreamers, poets, swindlers and Jews" were outside of any science or medicine.

Modern professional associations have taken power unto themselves to affect health care costs by defining and classifying medical and psychiatric conditions.  Mental health disorders are governed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which in turn is governed by the American Psychiatric Association.  Over time and intermediate revisions of the DSM, from III to IV, for example, the definitions of bipolar disorder broadened to include vague descriptors of how the patient felt.  Where formerly a prior hospitalization for a manic episode was a prerequisite for a diagnosis, that prerequisite disappeared.

Bipolar disorder became conflated with depression, and this led to the prescription of selective serotonin reuptake inhibitors like Prozac and Zoloft for children and adolescents. Now the pharmaceutical companies saw a large opportunity to expand the use of SSRIs into younger age groups.  Although the prescribing of these powerful compounds is now mainstream, some meta-analysis studies have shown that SSRIs may have little or no therapeutic effect for severe and moderate depression, respectively.

The diagnoses of bipolar disorders can be given by all manner of health care professionals, including medical doctors, psychiatrists, psychologists, counselors, school nurses, and community health educators. For some parents, it comes as a relief to have a label attached to their child's difficult behavior; it can also be a relief to believe that a pill or psychotherapy can solve their problem.

Dr. Stuart Kaplan M.D., Professor of Psychiatry at the Penn State College of Medicine, writes,
"Despite the dramatic surge in the rates of diagnosis of bipolar disorder in children, the number of children under 12 who actually have the disorder is rare, according to a recent (2010) report of the highly influential American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition (DSM-V)  Child and Adolescent Disorder Work Group.             
The total yearly cost of psychiatric treatment for youth aged one to 24 years was estimated at 18 billion dollars per year in 2007, according to work jointly sponsored by the National Research Council and the Institute of Medicine.  What have we received for the money we have spent studying and treating bipolar disorder in children and adolescents? How much does the misdiagnosis of child bipolar really cost?"
The adoption of Revision V of the DSM will have very significant effects on the growth of health care spending dollars, and yet the seemingly arcane discussions within the APA are barely newsworthy or worthy of critical scrutiny by legislators and disinterested analysts.

Besides the waste of billions of dollars that could be better spent in other ways, children can suffer the effects of being labeled for a condition that may not have; they may also be exposed to powerful drugs that don't benefit them and which could do them harm.

Spending more time on candid, fact-based discussion of issues where billions of dollars are being misdirected  has to be an improvement on the current situation of unfettered, economic self-interest among pharmaceutical companies and mental health practitioners.

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