Child Psychiatry issue - Pediatric Bipolar Disorder

[eaglepsych]

I'm an early career child psychiatrist and just wanted to start a convo re: use of SGAs (atypical antipsychotics) and the prevalence of the diagnosis of "bipolar disorder" in kids and adolescents.

I, like i have seen others post on similar threads, tend to undiagnose bipolar disorder in kids/adolescents more than i make this diagnosis. also, typically when i am weighing the risks vs benefits of such a dx (which is almost universally linked to consequent tx with mood stabilizers/SGA's); i first tend to do what i can with stimulants and ssri's when meds are indeed indicated (unless obviously there is hx of "manic switching," other side effect hx, etc).

obviously i also see a number of kids that, unfortunately for them, truly are suffering from a cyclical mood disorder that warrants the use of sga's / mood stabilizers. But, in my clinical experience, it seems i see many patients who in the past were dx'd with bipolar d/o and placed on antipsychotics, who then respond either better, or the same, for years once switched from said SGA to a stimulant, ssri, or sometimes both.

Thoughts? i've been reading this forum for years and have gained a lot via this forum as a trainee and an attending.

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[Suedehead]

I'm an early career child psychiatrist and just wanted to start a convo re: use of SGAs (atypical antipsychotics) and the prevalence of the diagnosis of "bipolar disorder" in kids and adolescents.

I, like i have seen others post on similar threads, tend to undiagnose bipolar disorder in kids/adolescents more than i make this diagnosis. also, typically when i am weighing the risks vs benefits of such a dx (which is almost universally linked to consequent tx with mood stabilizers/SGA's); i first tend to do what i can with stimulants and ssri's when meds are indeed indicated (unless obviously there is hx of "manic switching," other side effect hx, etc).

obviously i also see a number of kids that, unfortunately for them, truly are suffering from a cyclical mood disorder that warrants the use of sga's / mood stabilizers. But, in my clinical experience, it seems i see many patients who in the past were dx'd with bipolar d/o and placed on antipsychotics, who then respond either better, or the same, for years once switched from said SGA to a stimulant, ssri, or sometimes both.

Thoughts? i've been reading this forum for years and have gained a lot via this forum as a trainee and an attending.

love this blog post by Allen Frances. He was head of the DSM IV task force. here are his thoughts on childhood bipolar disorder.... to focus on the issue of diagnosis. cause until the diagnostic mess is cleaned up, it's really hard to justify any psychopharmacological approach.

http://www.psychiatrictimes.com/display/article/10168/1551005

 

[eaglepsych]

thanks Suedehead,

it is great that this message is being put out there so much more, in the past couple years especially.

 

[Chimed]

As a child fellow, I approach bipolar disorder in kids in a very similar way as yourself and agree with you. I think the evidence to support early onset bipolar as being more defined by irritability and a bipolar disorder NOS that is being championed by researchers like Kiki Chang is not that strong and has some issues. I think he's argued that in some of the strongest studies where they followed kids with bipolar disorder NOS, ~45% ended up having bipolar as an adult. (Of course that doesn't take into account the negative studies). But I think those studies have some problems AND they treated ALL those kids with mood stabilizers. Since those kids likely had depression and atypicals have anti-depressant properties, how do they know that their depression just isn't improving rather than a subclinical bipolar? Regardless, that also means that potentially 55% of those kids got a potentially harmful medication (atypicals) that didn't need it!?! I find that troublesome and there needs to be a lot more research done. There are a lot of private practice child psychiatrists (and unfortunately some attendings) in our area who diagnosis almost every kids with irritability, mood dysregulation, and depression as bipolar. I think that's a mistake because adolescent depression can present just like that.

I'm more in the camp of Gabrielle Carlson who argues that even pediatric bipolar disorder needs have some "classic" symptoms of mania in order to meet criteria. Also, it seems like the best ground to stand on is a strong family history, some manic symptoms, and/or not responding to or getting worse from anti-depressants.

 

[alina_s]

I continue to be frustrated and amazed by the number of parents who get upset with me when I suggest that their kid has problems, but not bipolar disorder. Several have fired me when I said that I couldn't continue to prescribe antipsychotics for ODD and non-aggressive irritability. I think we're in the middle of an unfortunate diagnostic trend (like MPD was in the 80's and early 90's), combined with highly successful drug marketing. I also think that the broad definition of bipolar disorder is very unfortunate- maybe this will improve with the addition of the temper dysregulation disorder in the DSM-V?

 

[eaglepsych]

definitely agree. it is sad but there has been a ton of money made by pharma and "research" psychiatrists with the overinclusiveness of pediatric bipolar disorder.

 

[nitemagi]

This was one of the main reasons I didn't go into child psych. Pediatric bipolar, plus the excessive use of meds (I've seen cases where 4 year-olds were on heavy polypharmacy) just seems misguided. I think it gives the whole field a bad name, frankly. Many people get into it for the money and they just treat without thinking.

 

[milesed]

You'll just have to get a feel for it as you get to know your patients and families. True BPAD seems to be increasing from what I see and I'm pretty strict about following criteria. I see lots of children of true bipolar parents who eventually follow what's laid out in the 10 year review articles in the AACAP orange journal.

You're treating symptoms not just the diagnosis, so you'll usuaully end up with the same approach no matter what you call it.

 

[whopper]

I'm reiterating what I've seen in other threads, and I'm not a child psychiatrist. I think this area requires a lot more research, and while I'd be open to medicating children, the data better be damned good, and I'd only continue a medication if it provided an objective benefit other than the parents are happy because the kid is now zonked and they don't have to deal with a crying baby.

Some examples I've seen where medications were justified...a colleague of mine had a patient age seven that started grabbing kitchen knives and threatening to kill his family. There was no known environmental factors that could've explained this behavior.

 

[NoNoNoNo]

love this blog post by Allen Frances. He was head of the DSM IV task force. here are his thoughts on childhood bipolar disorder.... to focus on the issue of diagnosis. cause until the diagnostic mess is cleaned up, it's really hard to justify any psychopharmacological approach.

http://www.psychiatrictimes.com/display/article/10168/1551005

Yeah, I really liked that Frances post.

Gary Greenberg also has lots to say ("Inside the Battle to Define Mental Illness"): http://www.wired.com/magazine/2010/12/ff_dsmv/all/1