Pediatric bipolar disorder in an era of "mindless psychiatry"

Recent trends in hospital admission due to bipolar disorder in 10-19-year-olds in Spain: A nationwide population-based study

INTRODUCTION

Bipolar disorder (BD) hospitalization rates in children and adolescents vary greatly across place and over time. There are no population-based studies on youth BD hospitalizations in Spain.

METHODS

We identified all patients aged 10-19 hospitalized due to BD in Spain between 2000 and 2021, examined their demographic and clinical characteristics, and assessed temporal trends in hospitalizations - overall and stratified by age and presence of additional psychiatric comorbidity. We used Joinpoint regressions to identify inflection points and quantify whole-period and annual percentage changes (APCs) in trends.

RESULTS

Of 4770 BD hospitalizations in 10-19-year-olds between 2000 and 2021 (average annual rate: 4.8 per 100,000), over half indicated an additional psychiatric comorbidity, most frequently substance abuse (62.2%), mostly due to cannabis (72.4%). During the study period, admissions increased twofold with an inflection point: Rates increased annually only between 2000 and 2008, for APCs 34.0% (95% confidence interval: 20.0%, 71.1%) among 10-14-year-olds, 10.3% (6.4%, 14.3%) among 15-19-year-olds, and 15.5% (11.5%, 22.7%) among patients with additional psychiatric comorbidity. Between 2009 and 2021, rates decreased moderately among 10-14-year-olds - APC: -8.3% (-14.1%, -4.4%) and slightly among 15-19-year-olds without additional psychiatric comorbidity - APC: -2.6(-5.7, -1.0), remaining largely stable among 15-19-year-olds overall.

CONCLUSIONS

Recent trends in hospitalization due to BD in 10-19-year-olds in Spain indicate salient increases in the early 2000s - especially among (i) patients aged 10-14 (decreasing moderately after 2009 among 10-14-year-olds and plateauing among 15-19-year-olds) and (ii) patients with additional psychiatric comorbidity (i.e., cannabis use disorder). These findings suggest links with recent changes in clinical practices for children and recent trends in substance use among Spanish youth.

Adolescent Depression Screening: Not So Fast

Background:

Screening adolescents for depression has recently been advocated by two major national organizations. However, this practice is not without controversy.

Objective:

To review diagnostic, clinical, and conflict of interest issues associated with the calls for routine depression screening in adolescents.

Method:

The evaluation of depression screening by the US Preventive Services Task Force is compared and contrasted with those of comparable agencies in the UK and Canada, and articles arguing for and against screening are reviewed. Internal pharmaceutical industry documents declassified through litigation are examined for conflicts of interest. A case is presented that illustrates the substantial diagnostic limitations of self-administered mental health screening tools.

Discussion:

The value of screening adolescents for psychiatric illness is questionable, as is the validity of the screening tools that have been developed for this purpose. Furthermore, many of those advocating depression screening are key opinion leaders, who are in effect acting as third-party advocates for the pharmaceutical industry. The evidence suggests that a commitment to marketing rather than to science is behind their recommendations, although their conflicts of interest are hidden in what seem to be impartial third-party recommendations.

Interpersonal functioning, support, and change in early-onset bipolar disorder: a transcendental phenomenological study of emerging adults

BACKGROUND

Early-onset bipolar disorder (EOBD) diagnoses have increased, yet much remains to be understood about its phenomenology. Research and treatment models developed for adult-onset bipolar disorder have largely overlooked qualitative inquiries and adolescent developmental considerations that influence course of illness.

AIM

The purpose of the current study was to obtain an understanding of the lived experience of interpersonal relationships and EOBD during adolescence through the retrospective report of emerging adults.

METHODS

This study utilized a transcendental phenomenological design. A purposive sample of eight participants ages 18-25 participated in semi-structured interviews that explored the experience of interpersonal relationships and EOBD throughout adolescence.

RESULTS

Participants described their experiences across three broad themes: managing and coping with EOBD; effect of EOBD on relationships; and change and uncertainty. Sub-themes include knowledge and denial of illness, involvement of others in treatment, support, difficulty maintaining social functioning, isolation and secrecy, and changes in relationships.

CONCLUSIONS

Participants characterized adolescence as a period of constant, simultaneous challenges in symptom management, maintaining social functioning, and concurrent changes in family and peer relationships that provide interpersonal support. Future qualitative studies should explore the implications of normative social development and family functioning for the course of illness and treatment outcomes.

The geography of a controversial diagnosis: A bibliographic analysis of published academic perspectives on 'paediatric bipolar disorder'

BACKGROUND

The hypothesis that bipolar disorder presents before puberty with atypical mania has proved to be controversial. Published academic perspectives on the validity of Paediatric Bipolar Disorder (PBD) appear to vary between the United States and the rest of the world.

METHODS

We examined the perspectives of articles citing four seminal articles. The citing articles were grouped as either supportive or non-supportive of the PBD hypothesis, and the perspectives of the articles by US authors were compared with those by non-US authors.

RESULTS

There were 787 citing articles commenting on PBD, mostly published in US-based journals. Most authors were affiliated with several US institutions. Among the 624 articles with US authorship, the majority (83%) supported PBD. Of the 163 articles by non-US authors, most (60%) supported the traditional view that bipolar disorders are rare before mid-adolescence. Published academic perspectives in favour of the PBD hypothesis are mostly concentrated in several US institutions.

CONCLUSION

There is majority support for PBD among citing articles from the United States, whereas the traditional perspective predominates in articles from most other countries.

Personalized medicine: evidence of normativity in its quantitative definition of health

Systems medicine, which is based on computational modelling of biological systems, is emerging as an increasingly prominent part of the personalized medicine movement. It is often promoted as 'P4 medicine' (predictive, preventive, personalized, and participatory). In this article, we test promises made by some of its proponents that systems medicine will be able to develop a scientific, quantitative metric for wellness that will eliminate the purported vagueness, ambiguity, and incompleteness-that is, normativity-of previous health definitions. We do so by examining the most concrete and relevant evidence for such a metric available: a patent that describes a systems medicine method for assessing health and disease. We find that although systems medicine is promoted as heralding an era of transformative scientific objectivity, its definition of health seems at present still normatively based. As such, we argue that it will be open to influence from various stakeholders and that its purported objectivity may conceal important scientific, philosophical, and political issues. We also argue that this is an example of a general trend within biomedicine to create overly hopeful visions and expectations for the future.

Paediatric bipolar disorder: international comparisons of hospital discharge rates 2000-2010

BACKGROUND

Controversy surrounds the diagnosis and prevalence of paediatric bipolar disorder, with estimates varying considerably between countries.

AIMS

To determine the international hospital discharge rates for paediatric bipolar disorder compared with all other psychiatric diagnoses.

METHOD

We used national data-sets from 2000 to 2010 from England, Australia, New Zealand, the USA and Germany.

RESULTS

For those aged under 20 years, the discharge rates for paediatric bipolar disorder per 100 000 population were: USA 95.6, Australia 11.7, New Zealand 6.3, Germany 1.5 and England 0.9. The most marked divergence in discharge rates was in 5- to 9-year-olds: USA 27, New Zealand 0.22, Australia 0.14, Germany 0.03 and England 0.00.

CONCLUSIONS

The disparity between US and other discharge rates for paediatric bipolar disorder is markedly greater than the variation for child psychiatric discharge rates overall, and for adult rates of bipolar disorder. This suggests there may be differing diagnostic practices for paediatric bipolar disorder in the USA.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© 2015 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Competent psychopharmacology

There is little doubt that undergraduate and post-graduate training of physicians, pharmacists, and nurses is insufficient to prepare them to use psychotropics safely and effectively, especially in the context of their expanded off-label uses. Therefore, the development of competencies in psychotropic prescribing needs to be approached as a long-term, practice-based learning commitment. Proposed are the abilities and knowledge components necessary for safe and effective use of psychotropics. Typical challenges in prescribing for chronic and recurrent illnesses include highly variable responses and tolerability, drug interactions, and adverse effects that can be serious, irreversible, and even fatal. Prescribing psychotropics is further complicated by negative public and professional reports and growing patient concerns about the quality of care, and questions about the efficacy, safety, and addictive risks of psychotropics. Increased efforts are needed to enhance clinical training and knowledge in psychopharmacology among trainees and practising clinicians, with more comprehensive and sustained attention to the assessment of individual patients, and greater reliance on patient education and collaboration. Improved competence in psychotropic prescribing should lead to more informed, thoughtful, and better-targeted applications as one component of more comprehensive clinical care.

[Bipolar disorder in children and adolescents: a difficult diagnosis]

Bipolar disorder (BD) is a severe mental condition with neurodevelopmental features that clinically results in pathological fluctuations of mood. Whereas it was classically or traditionally considered as an adult-onset disorder, recent findings suggest that BD may occur very early in the life course, thus, determining what is now called Juvenile bipolar disorder (JBD). One of the reasons for which JBD has been so difficult to identify is that JBD primary symptoms vary much from the typical adulthood BD clinical expression. Euphoric mood is rare in JBD, while irritability mood, aggressive temper, mixed manic state onset, rapid cycling, anger outbursts and chronic course of symptoms are much more frequent. This specific clinical presentation makes JBD difficult to differentiate from other diagnoses related to pathological externalizing behaviours, including conduct disorder, oppositional provocative disorder, and attention deficit-hyperactivity disorder.

A comparison of American and English hospital discharge rates for pediatric bipolar disorder, 2000 to 2010

OBJECTIVE

Controversy exists over the diagnosis and prevalence of pediatric bipolar disorder (PBD). Although several small surveys suggest that the rate of the PBD diagnosis in clinical settings is higher in the United States than in other countries, no comprehensive cross-national comparisons of clinical practice have been performed. Here, we used longitudinal national datasets from 2000 to 2010 to compare US and English hospital discharge rates for PBD in patients aged 1 to 19 years.

METHOD

We used the English National Health Service (NHS) Hospital Episode Statistics (HES) dataset and the United States National Hospital Discharge Survey (NHDS) to compare US and English discharge rates for PBD (bipolar I disorder [BP-I], bipolar II disorder [BP-II], bipolar disorder not otherwise specified [BP-NOS], and cyclothymia). We also conducted cross-national comparisons for all other psychiatric diagnoses in youth and for adults with bipolar disorder (BD).

RESULTS

There was a 72.1-fold difference in discharge rates for PBD in youth between the United States and England (United States, 100.9 per 100,000 population, 95% confidence interval = 98.1-103.8, versus England, 1.4 per 100,000 population, 95% CI = 1.4-1.5). After controlling for cross-national differences in length of stay, discharge rates for PBD remained 12.5 times higher in the United States than in England. For all other child psychiatric diagnoses, the discharge rate was 3.9-fold higher, and for adults with BD 7.2-fold higher, in the United States than in England.

CONCLUSION

The disparity between US and English discharge rates for PBD is markedly greater than the disparity for child psychiatric discharge rates overall and for adult rates of BD. This suggests that the difference in discharge rates for PBD may be due to differing diagnostic practices for PBD in the United States versus in England.

Biologism in Psychiatry: A Young Man's Experience of Being Diagnosed with "Pediatric Bipolar Disorder"

Pediatric bipolar disorder is a diagnosis that arose in the mid 1990s in the USA and has mostly remained confined to that nation. In this article a young American man (under a pseudonym) describes his experience of having the diagnosis throughout his adolescent years. His story was conveyed via correspondence and a meeting with the author, an Australian child psychiatrist. The young American's story reveals several issues that afflict contemporary psychiatry, particularly in the USA, where social and economic factors have contributed to the rise of a dominant biomedical paradigm-or "biologism". This focus on the "bio" to the relative exclusion of the "psychosocial" in both diagnosis and treatment can have serious consequences as this young man's story attests. The author explores aspects of his tale to analyze how the pediatric bipolar disorder "epidemic" arose and became emblematic of a dominant biologism. This narrative points to the need, depending on the service and country, to return to or retain/improve a balanced biopsychosocial perspective in child and adolescent mental health. Child psychiatry needs to advocate for health systems that support deeper listening to our patients. Then we can explore with them the full range of contextual factors that contribute to symptoms of individual and family distress.

The place of psychotherapy in contemporary psychiatry

Psychotherapy has long been an essential component of clinical psychiatry and many young physicians choose to train in psychiatry residency programs in order to acquire necessary knowledge and skills, and become competent psychotherapists. Recent advances in psychopharmacology and neuroscience, and growing dominance of managed care and evidence-based medicine have had dramatic impacts on health care delivery systems and clinical psychiatry practice. Despite these changes in the field of mental health, psychotherapy still remains a crucial part of clinical psychiatry and comprises a great proportion of psychiatrists' clinical practice. Hence, accreditation agencies and regulatory bodies determine compulsory minimum requirements for psychiatry residency programs to ensure that residents, at the end of their specialty training, can demonstrate competence in managing their patients through applying different approaches of psychotherapy.

Psychotropic marketing practices and problems: implications for DSM-5

The descriptive diagnostic model since DSM-III has often led to "cookbook" diagnosis and assumptions of "chemical imbalance" for psychiatric disorders. Pharmaceutical companies have exploited this in their marketing. This includes promoting self-diagnosis with online checklists. Significant overprescribing of psychotropics has resulted. DSM-5 will provide new disorders and broader diagnostic criteria that will likely exacerbate this. Most psychotropic prescribing is done by primary care physicians, who are problematically excluded from DSM-5 field trials and are influenced by industry funded key opinion leaders who may promote diagnosis of subthreshold cases. More lax criteria will increase diagnosis of subthreshold cases. Expansion of not otherwise specified (NOS) categories can be used to justify off-label promotion. Pediatric bipolar disorder, constructed within the bipolar disorder NOS category, became an "epidemic" in the United States, fuelled by diagnostic upcoding pressures. Disruptive mood dysregulation disorder may similarly cause overdiagnosis and excessive prescribing, as will other new disorders and lower diagnostic thresholds.