Critical Thinking About Bipolar I Disorder, Kids and Medications

Posted on March 4, 2012 at 12:00 pm

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Younger and younger children are being diagnosed with Bipolar I Disorder (formerly "manic-depressive illness") despite the fact that there are few studies to support this practice.

Once diagnosed, children may be put on so-called “mood stabilizing” medications (e.g. lithium, divalproex, lamotrigine, trileptal) whose efficacy has not been thoroughly studied in pediatric populations. The use of these medications in children has increased almost 300 percent in the last decade as the increase in diagnoses of Bipolar I Disorder in children has increased 40-fold. Clearly something is wrong as this would indicate an “epidemic” of Bipolar I Disorder that we are not seeing in any other age range.

Bipolar I Disorder is typically a chronic, disabling disorder with early-onset considered age 13, but currently children as young as 3 or 4 are receiving the diagnosis. The percentage of the general population thought to suffer from the disorder is between 0.4 percent and 1.6 percent, and those prevalence rates have not increased 40-fold like the diagnosis in children has.

Further, there are different types of Bipolar Disorders. Bipolar I Disorder is characterized by severe mood swings between mania and major depression. In Bipolar II Disorder the mood swings are between major depression and hypomania. In Cyclothymia mood swings are between lower grade depression and hypomania (a period of high energy that is not necessarily dysfunctional). These are not gradations of the same disorder and may in fact represent three different conditions.

We do not know why people get Bipolar I Disorder, but the evidence to date points to genetic vulnerability, which when triggered results in abnormalities in brain structure and function even at the cellular level including neurons and the cells that “insulate” neurons called glial cells. To date there is no physiological marker that can be tested to see if a person has Bipolar I Disorder.

Children who act out impulsively are also sometimes placed on mood stabilizing medication. Some in the psychiatric community working on the forthcoming diagnosis manual (DSM-V) believe that sub-threshold symptoms should be diagnosable and medicated despite a lack of evidence that this is a sound strategy. These “subthreshold symptoms” could very well include “acting out” behaviors which would place a large percentage of children under a “Bipolar Spectrum” diagnosis that leads to unnecessarilly medicating them.

What can parents do? First know, that there are no pediatric criteria for Bipolar I Disorder, and if someone suggests that diagnosis for your child demand evidence of thorough assessment and manic-depressive mood swings.

Second, if your child is prescribed a psychotropic medication ask specifically which “symptoms” or behaviors the medication is supposed to reduce and how long before that reduction is apparent.

Third, if your child is on a medication that is not reducing symptoms, advocate that the child be taken off the medication that is not working before being put on another. If a doctor suggests several medicines ask her what evidence (published studies) she has suggesting multiple medications would be useful.

While children do suffer from mental health disorders, the belief that Bipolar I Disorder has onset in childhood requires far more research support than it currently has. Parents have a right to advocate for their children and understand the evidence the doctor or mental health professional is relying on before allowing a diagnosis of Bipolar I Disorder for a child.

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12:44 pm on Sunday, March 4, 2012

Children were the leading growth demographic for the pharmaceutical industry in 2009, with the increase of prescription drug use among youngsters nearly four times higher than in the overall population, according to a report by Medco Health Solutions Inc.
Among the trends was the rise in children taking antipsychotics -- powerful drugs traditionally used to treat schizophrenia, but increasingly prescribed for other conditions, such as depression and anxiety.

Use of such drugs has doubled since 2001 and more than doubled for girls, according to Medco's nine-year analysis.

Use of some antipsychotics has also been associated with significant weight gain and increased risk of developing type 2 diabetes, potentially compounding health problems.
There was a 23 percent drop since 2004 in use of antidepressants by youngsters. That decline followed U.S. Food and Drug Administration warnings of the increased risk of suicidal thoughts by children using those drugs.
Use of drugs for attention deficit hyperactivity disorder (ADHD), often cited in reports on the over-medication of children, is also on the rise.
Overall ADHD drug use was up 9.1 percent last year, leading to a 23.8 percent rise in spending growth. But the utilization increase was 21.2 percent among those aged 20 to 34.

Wendy

6:09 pm on Sunday, March 4, 2012

Elliot, your psychopharmacology course was one of the top 3 I ever took. I think about the meds my students are on, & could share stories to make your toes curl. It's amazing what parents will ask for & what docs will do. It's also amazing what docs will do, and parents will accept. Is there any good source out there for NNT & NNH data? I've been ISO sporadically for years.

Erin LaBelle

9:16 am on Monday, March 5, 2012

Elliot- I think this might interest you. My friend, Suzy Hoseus, speaks about her journey and book in this short video. She is an amazing woman who is dedicated to helping others
heal. http://www.glutenfreebreakfast.org/rene-oswald-talks-with-suzy-hoseus-about-healing-bipolar-and-depression/.html

Lynda Zielinski

9:13 am on Wednesday, March 7, 2012

Thank you for this, Dr. Elliot. I could not believe the misuse of medications when I worked at the Juvenile Court. Often these kids had been prescribed about every psycho-active drug available. Ironically, the good news ( in my view) was that they often didn't stay on them.

Elliott Ingersoll

11:24 am on Wednesday, March 7, 2012

Thanks for these comments, links and ideas. It does seem that the pharmaceutical industry is one of the driving forces behind some of these trends. In other cases medication seems to be a "default" position for kids who have no "voice" or advocate (like Lynda's example in the court system).

Getting "number needed to treat" and "number needed to harm" data is tricky given the level of prescribing "off-label" but I'll see what I can dig up. Thanks again for sharing your views and information.

Allison M

4:11 pm on Wednesday, March 7, 2012

As a parent of an elementary school student, I have recently experienced even how schools and counselors in the elementary schools are pushing this diagnosis. This is a tough topic for parents, and I am finding out I'm not the only one. It seems as if the schools, counselors, and even doctors find it appropriate to 'diagnose' a child and push the meds, even though there is no direct metric for them to follow. Thanks for taking the time to write this.

linda jenkins

2:51 pm on Thursday, March 8, 2012

Critical thinking as a parent of two adullt children,I've experienced the schools,the counselors and the doctors pushing this diagnosis of bipolar and autism.I agree it is hard to diagnose and to treat.It is critical as a parent to be knowledgeble,and know that your life will face crisis living with the critical episisodes and hardships that sometimes occur from the lack of understanding from society.Our family experienced a crisis lastnight.Thank God for the many support systems we have in place.We need to talk more about this Critical topic.Thank you for writing about bipolar,,really thank you so much.Have a great day!