Monday, September 17, 2007

Labeled and Misunderstood: A Look at the Increase of Bipolar Disorder in Youth

The Children and Adolescent Bipolar Foundation (CABF) is calling it a national wake-up call. But could an issue related to bipolar disorder really demand the attention of the nation? A study that was published at the beginning of the month by the Archives of General Psychiatry stated that there has been a dramatic increase in the number of children and adolescents being diagnosed with bipolar disorder. The disorder, also known as manic-depressive illness, may include symptoms like extreme mood changes, irritability, poor sleep, risky behavior and distractibility. Speculation among various news sources is rampant regarding the cause of the increase. However, in a Columbia University Medical Center press release, Dr. Mark Olfson, one of the doctors involved in the study, stated that “these trends likely reflect a recent tendency to over diagnose bipolar disorder in young people, a correction of historical under recognition, or a combination of both trends.” Undoubtedly, more research needs to be conducted in order to be sure that bipolar disorder is being diagnosed accurately because dismissing this issue of diagnostic uncertainty would only end up negatively affecting the youth of tomorrow.

Susan Resko, M.M., Executive Director of CABF, agrees that more research is imperative. She claims that today “children are being diagnosed and treated when they were previously dismissed as 'bad seeds' or the product of poor parenting." The truth is that over diagnoses leads us to wonder if doctors are misdiagnosing a lot of children and clumping them under labels. Bipolar disorder shares a great deal of resemblance with other illnesses such as schizophrenia and ADHD. During a lecture given by Dr. Terence Ketter, Chief of the Bipolar Disorders Clinic at the Stanford University School of Medicine, the similarities and differences between schizophrenia and bipolar disorder were the focus topic. For example, the two disorders share abnormalities in some of the same neurotransmitter systems. ADHD and bipolar disorder are also said to share many characteristics such as impulsivity, inattention, and hyperactivity. The study itself confirms that “symptomatic overlap between ADHD and pediatric bipolar disorder may be an important source of diagnostic uncertainty.” Considered like a bible to professionals who diagnose psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) works against misdiagnoses. Unfortunately, not everyone will perfectly fit under the categories listed. Dr. Ketter suggests that we now consider a more dimensional approach to diagnosis, one aimed at treating the common symptoms and pathophysiology.

There is, however, light at the end of the tunnel. New research in genetics and brain development provide optimism for more accurately diagnosing bipolar in the future. According to the Lundbeck Institute genetic linkage studies have shown that specific regions on certain chromosomes may be associated with a family history of bipolar disorder. As seen to the image on the right, the orange areas on chromosomes 4, 12, 16, 21, and X are believed to be linked to bipolar disorder. If researchers continue to discover these genetic linkages, doctors in the future will be able to diagnose the disorder more accurately and early. Children and adolescents would benefit greatly from early diagnoses because they would be able to get the treatment they deserve. Scientists studying the brain from the University of California at Los Angeles and The National Institute of Mental Health (NIMH) also have produced groundbreaking research on the brain development of bipolar youth. A recent article published on NIMH’s website shows a time lapse of composite MRA brain scans belonging to youth, ages 7-22, as they develop symptoms of mania and depression. The video shows a complicated pattern of gray matter gain in the left hemisphere and gray matter loss in the right hemisphere and mid-front part of the brain. Scientist Nitin Gogtay, M.D. states that their findings should put an end to speculation that onset schizophrenia and bipolar disorder stem from the same underlying illness. Continued research in both genetics and brain development should help establish a clearer distinction between disorders that resemble bipolar disorder.

Based on the study, we could expect to see the number of youths being diagnosed with bipolar disorder to continue rising; it probably has risen more since 2003. However, the numbers should eventually plateau or increase less over longer periods of time. A continued increase would definitely be a red flag signaling over diagnoses. Thanks to researchers though, who are continuing to seek answers on distinguishing the genetic and mental cause of bipolar disorder, new measures will surely emerge leading to better diagnosis of the disorder in children and adolescents.

7 comments:

ND said...

IC,

I agree that this new research should ultimately improve the accuracy of mental health diagnostics. Dr. Olfson seems concerned that bi-polar disorder is being over diagnosed today, and you indicate that this new research will only result in the discovery more cases each year. Won’t such advances only accelerate the rate with which people are diagnosed with bi-polar disorder? Do you believe that there is a true increase in mental illness in the population, or are we just getting better at diagnosing cases?

Also, mental illness takes a disproportionate toll on the nation’s poor and uninsured. Such patients usually go undiagnosed and untreated for years. While genetic testing and brain imaging promise to improve the accuracy mental health care for some, I worry such tools will remain out of reach to much of the population that would most benefit. Do you have any suggestions that would improve access to these new advances?

IC said...

I do feel that such advances will accelerate the rate with which people are diagnosed with bipolar disorder, but one important thing to note is that it will allow doctors to feel more confident about their diagnosis. In other words, we will know for a fact that children and adolescents are not being misdiagnosed and are receiving the proper treatment. I think that the major problem right now is that there is a chance that many doctors could be misdiagnosing the disorder and this has resulted in the increase.

As for your second concern, yes, many children may go untreated because of limited resources. It is unfortunate that our health care system has not yet been reformed, to provide more health care to our nation’s poor. However, one thing I would suggest would be to establish programs that increase public awareness of the disorder. This in turn would lead adults to notice bipolar symptoms in their children and seek the available help that may be out there. Otherwise children suffering from bipolar disorder could continue being dismissed as hyperactive, disruptive, unstable kids. Thanks ND for your comments.

CL Psych said...

IC,

I like the blog. Nice work.

I think you are being a little optimistic regarding the genetic testing and brain imaging work -- there is a long way to go before these become reasonable methods of diagnosis.

I'm pretty skeptical about this huge increase in child bipolar disorder diagnoses (read here, for example) and I think the CABF and others are overstating their case. If you water down the diagnostic criteria for any disorder enough, you'll find that the disorder is surprisingly common. Badly behaving children are now called bipolar when ADHD, conduct disorder, etc. used to be the more common labels. And perhaps we have more badly behaving kids these days, but that's a topic for another day.

MMR said...

I appreciate your choice of a highly controversial topic to write on. The issues of whether doctors are recognizing a disease more often or if the disease is simply occurring more frequently are highly debatable arguments. I must say I was impressed with your post, as it was engaging and filled with information on this topic. You did a wonderful job not only in explaining what Bipolar Disorder is but you also went beyond just a list of symptoms or quick facts, to quote experts in this field as well as predict what the future may hold if rates plateau, decrease, or increase. I was also very taken with your choice in photos that accompany your post as they seemed to illustrate the points in your post beautifully. Perhaps I would only add a portion of opinion that lends to the more financially motivated potential forces that may be driving this surge in diagnoses. I feel that the financial motivations, often portrayed as a more sinister element, of the medical community should be mentioned. Money is a crucial component in the medical community because more diagnoses mean more money going into the field as well as more money being made by medical groups and pharmaceutical companies. We live in a world in which many doctors are quick to diagnose so as to prescribe medicines that people will pay monthly to take. Please do not misunderstand, I am not at all against taking medicines, however I feel it is incumbent upon society to make sure these prescriptions and diagnoses are fueled by science and medicine, and not the almighty dollar.

IC said...

Thank you all for commenting on my post; I highly appreciate it your opinions.

I would first like to address cl psych, and say that I may be a little optimistic regarding genetic testing and brain imaging; however, what I wanted to point out was that there are researchers out there trying to differentiate this disorder from others. They’re not simply stating an obvious observation and leaving it at that. I believe that examining the underlying factors is much more important.


As for your comment, MMR, I totally agree with what you have to say on the medical community being influenced by pharmaceutical companies. I read in the LA Times that even health care providers are sometimes compelled to diagnose psychological problems in children as bipolar disorder in order to obtain insurance reimbursement for hospitalizations, a practice called upcoding. I do not agree with this and I too feel it is necessary to make sure prescriptions and diagnoses are fueled by science and not money.

Irene said...

In continuing the discussion on Bipolar Disorder in youth, I would like to draw attention to the new diagnosis that might come out in the DSM-V called temper dysregulation disorder. According to the NPR story, Children Labeled 'Bipolar' May Get a New Diagnosis, the new diagnosis will be seen as a biological dysfunction and not a life long condition like bipolar disorder.

Irene said...
This comment has been removed by the author.
 
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