The Geography of Pediatric Bipolar Disorder

This is a guest post that will appear in two parts by distinguished Australian child psychiatrist: Peter Parry, M.D., Child and Adolescent Psychiatrist, Senior Lecturer, Flinders University, Australia

PART I

PBD IS GENERALLY NOT DIAGNOSED OUTSIDE THE USA

The diagnosing and medicating of infants, toddlers, pre-schoolers and thousands of primary schoolers with bipolar disorder is a phenomenon virtually confined to the USA.

I am a child & adolescent psychiatrist in Australia. As these 2 posts will make clear, I am highly critical of PBD. However early symptoms of bipolar disorder in some teenagers are sometimes difficult to distinguish from other causes of adolescent emotionality and warrant close monitoring.

In 2002 I and colleagues were perplexed by the cover story of TIME magazine “Young and Bipolar” [ http://www.time.com/time/covers/0,16641,20020819,00.html ]. Thousands of American pre-pubertal children supposedly suffering from mania was so far from our clinical and academic experience that we categorized the article as some kind of passing aberration.

In 2005 an American child psychiatrist perplexed many in the audience at the Australian and New Zealand (ANZ) child psychiatry annual conference by describing a case of PBD. For a couple of years PBD became a hot topic of discussion and many questioned whether our American colleagues were seeing something we should be. But ultimately the vast majority of ANZ child psychiatrists (who I meet regularly at our RANZCP [ www.ranzcp.org ] conferences) have continued in the traditional view and see PBD as a fad diagnosis mostly confined to the USA.

In 2007 we surveyed ANZ child & adolescent psychiatrists [ http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2008.00505.x/abs… ] about PBD. We had 199 responses (60% of the faculty of child & adolescent psychiatrists). A majority (53%) had never seen pre-pubertal cases of bipolar disorder and most of the others who had seen a case had only seen “1 or 2 cases” in their careers.

As to ANZ child psychiatrists’ views of PBD in the USA, 7 (3.5%) of the 199 thought PBD was being underdiagnosed or appropriately diagnosed in the USA, 90% thought it was overdiagnosed or very overdiagnosed by our American colleagues and 6% were unsure. This survey was done near the height of the PBD phenomenon in ANZ and in the ensuing 5 years it seems the short flurry of PBD diagnosing in this part of the world has dwindled. Anecdotally at conferences the talk is that a repeat survey would show even more skeptical responses.

Similarly a German survey [ http://www.ncbi.nlm.nih.gov/pubmed/15383136 ] found minimal support for PBD. Only 7% of 251 German child psychiatrists reported having seen pre-pubertal cases. In the UK, the British National Institute for Health and Clinical Excellence (NICE), a research body similar to the American NIH/NIMH, produced guidelines on bipolar disorder in 2006. These guidelines made clear that PBD was a research hypothesis only, and effectively ruled out using the diagnosis in clinical practice: “the conference was not convinced that evidence currently exists to support the everyday clinical use of bipolar II disorder or bipolar not otherwise specified (bipolar-NOS) disorder (the DSM category where PBD fits) for these age groups” (under 18 years old). Because children can present in “high spirits” and adolescents can be emotionally volatile the NICE guidelines were concerned not only that using criteria for PBD (under bipolar disorder NOS category) but even bipolar-II disorder use would overdiagnose children and teenagers.

Some research centers in Spain, Switzerland, Italy, the Netherlands, Australia, Brazil and India did accept and use the PBD diagnoses. Most were in collaboration with leading American researchers in PBD. Having attended a seminar on PBD in New Delhi and talking with European colleagues it is clear that uptake of PBD by child psychiatrists in clinical practice outside these centers has been minimal. An indication of this is the number of presentations on PBD at 3 official child & adolescent psychiatric associations’ conferences in 2009: there were over 40 presentations on PBD at the American Academy of Child & Adolescent Psychiatry (AACAP) annual convention in Hawaii; in contrast there were zero presentations at the ANZ FCAP conference in New Zealand and also zero presentations at the large European ESCAP conference in Budapest, Hungary. When some conference organizers in Europe were asked why, the reply was words to the effect: “(PBD) is an American fad that shall pass”.

Even in Canada there has been skepticism of PBD diagnoses, at least from discussions I’ve had with Canadian colleagues. The July 2007 editorial in the Canadian Journal of Psychiatry focused on the PBD controversy [ http://publications.cpa-apc.org/browse/documents/243 ] . Two lead articles with diametrically opposing views were juxtaposed: Chang, from California, argued in favor of widespread pre-school age onset; Duffy, in a study sponsored by the Canadian Institute for Mental Health, reported that no cases of bipolar disorder under age 12 had been found in children from high risk families where one or both parents had bipolar disorder. The current editor of the Canadian Journal of Psychiatry, Dr Joel Paris, has a special interest in bipolar disorder. Dr Stuart Kaplan, the host of this blog, heard Dr Paris give a presentation at the recent 2012 American Psychiatric Association conference in Philadelphia where he stated: "When psychiatrists 50 years from now look back on our current era in psychiatry, they will understand that the diagnosis of pediatric bipolar disorder is the greatest scandal to ever befall psychiatry.”

So why has PBD not been accepted by child psychiatry outside the USA? The factors for this will be explored in the next post.