Nassir Ghaemi M.D., M.P.H.

Mood Swings

Banning Childhood Bipolar Illness

The 400 percent solution

Posted Feb 13, 2014

We hear it over and over: one of our colleagues has an entire blog on this website devoted to the topic.  Your child is not bipolar! It’s all a conspiracy of those evil pharmaceutical companies, seeking profits (how dare they, in America of all places?).

This new religion takes a special aspect outside the borders of the freest country in the world. I recently experienced how it is in the most prestigious psychiatric institution in England, our cousin nation, at the Maudsley Hospital. I was present as an invited consultant to a case conference on a 14-year-old adolescent, diagnosed with ADHD, who then developed clear mania some months after treatment with methylphenidate. The diagnosis wasn’t in doubt: bipolar illness was admitted. But the British consultant, who gave a formal presentation, spent some time pointing out how bipolar illness is overdiagnosed in the United States. He showed a slide in adults: the bipolar diagnosis has risen 58 percent in a decade. Stirrings in the audience. He showed a slide in children: the bipolar diagnosis rose 400 percent in children. Audible gasps. The speaker, a specialist in childhood mood disorders, ended in his broad British accent: overdiagnosis has occurred. We must compensate by diagnosing bipolar illness less. 

Thinking that carelessness is not generally proposed by anyone, I rose for my brief informal remarks. I had hoped to discuss the case, but obviously the background state of knowledge was more in debate. 

I started by citing a great British statesman, Benjamin Disraeli, who noted the relationship between lies, damn lies, and statistics. So I added statistics to statistics.

Adult bipolar diagnosis has increased 58 percent. What hadn’t been described was research, including my own, which showed that bipolar illness not diagnosed in about 30-40 percent of persons who have the illness, as confirmed by research diagnostic interviews. After the first manic episode, our research found that it takes about a decade for a person to be accurately diagnosed with the illness. On average, 3.3 psychiatrists are seen before it is diagnosed correctly.

No audible gasps in the audience. Complete silence.

Now to children: This 400 percent claim is so often repeated, and so falsely interpreted, that it should be taught in statistics courses as the prime example of how to lie with statistics. It is based on a the commonly-cited study where there was a 40-fold increase (hence 400 percent) in bipolar diagnosis in children and adolescents in the US.  

Here are the statistics: This 40-fold, 400 percent, increase is a relative change. What is never stated is the absolute change. What was the baseline bipolar diagnosis rate in children and adolescents before this awful overdiagnosis happened: 0.1 percent. That’s one in 10,000 children. What is the true bipolar rate in children and adolescents? Based on the best epidemiological studies, replicated in different nations, and not based on clinical practice patterns: 0.5 percent. That’s one in 200. 

What does the 400 percent increase produce? A change from 0.01 percent to 0.4 percent. That one in 250, which is slightly below the actual prevalence of this illness.

How is this overdiagnosis?

No audible gasps.

(I’ve said this before, at conferences and on this blog. But the truth bears repeating, especially when the world doesn’t want to hear it.) 

Time for the panel discussion. My colleague replies: Childhood bipolar illness is overdiagnosed; there was a NIMH conference that said so; the American Psychiatric Association said so. (My thoughts went to Thoreau: Truth is not a matter of popular vote). His voice rose passionately: Children were killed in the US with overmedication of anti-bipolar medications because of overdiagnosis!

I interrupted my colleague: How many children were killed? How many cases? Two cases, he replied. Oh, I muttered. Two cases. Okay, not 200 cases, not 2000 cases. Two cases. And that proves overdiagnosis. (My thoughts turned to research on sudden cardiac death with amphetamines: How many children have died from amphetamine treatment for ADHD? More than two cases? And does that prove overdiagnosis of ADHD?)

We didn’t get a chance to comment on the fact that my colleague had recommended quetiapine, an antipsychotic, plus an amphetamine for the ignored case of the poor 14-year-old British girl, exactly the kind of medication combinations that so bother those who oppose the bipolar diagnosis in children, and which, by the way, led to the two deaths (along with anticonvulsants). I would have recommended low-dose lithium, and nothing else, but no one asked my opinion.

This is the paradox: the child bipolar haters are mad because they don’t like using drugs for the bipolar diagnosis; yet they use worse drugs for ADHD (amphetamines are  the most clearly neurotoxic psychotropic drugs, in repeated clear results of decades of animal research; unlike lithium, which is the most neuroprotective psychotropic agent in neurobiological research on animals). They especially hate antipsychotics, but they prescribe those agents frequently, as in this case, for agitation. They don’t worry about antidepressants, which, based on our best randomized evidence,  cause increased suicidal ideation in about one percent of children, which statistically leads to suicide in about 10 percent, or about 1 in 1000 children. Given that millions of children have received antidepressants, this produces many more than two cases of death. Hence the Food and Drug Administration (FDA) warning on this matter. Amphetamtines, by the way, are antidepressants. 

Many child psychiatry colleagues seem completely unconscious about this anger about using drugs for bipolar illness in children, combined with the complete apathy toward their use for ADHD or depression or the myriad childhood labels (oppositional defiant disorder, mood dysregulation disorder, conduct disorder).  

The British are punctual. So the case conference ended without much further discussion, just dangling disagreement, and a sense, I heard from a friend, that I sounded like a patriot defending American psychiatry. I wish I could defend American psychiatry. I noted that America gets blamed a lot; I should have added: frequently justifiably. But this anti-bipolar attitude is as common within our dear old nation’s borders as without.

If I’m a patriot, my nation is bounded by the rules of science: which means telling all the statistics, not half.   

(A request: anti-child bipolar extremists shouldn’t bother commenting harshly or personally, as they’ll be deleted. Polite comments, focused on content, are welcome, as always.) 

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