Criminal Justice Forum

 By BENEDICT CAREY
 Published: September 3, 2007 


The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.

 Most experts believe the jump reflects the fact that doctors are more aggressively applying the diagnosis to children, not that the number of new cases has gone up. But the magnitude of the increase is surprising to many experts, who say it is likely to intensify a debate over the validity of the diagnosis that has shaken the field of child psychiatry in recent years.

 Bipolar disorder is characterized by extreme mood swings and, until relatively recently, it was thought to emerge only in adulthood. Some psychiatrists say that the disorder is too often missed in children, and that increased awareness — reflected in the increasing use of the diagnosis — is now allowing youngsters who suffer from it to get the treatment they need. But others argue that bipolar disorder is over diagnosed. The term, they say, has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain.

 The spread of the diagnosis has been a boon to drug makers, according to these experts, because treatment typically includes medications that can be three to five times more expensive than those prescribed for other disorders, like depression or anxiety.

 “I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder, but the tremendous controversy reflects the fact that we haven’t matured enough,” said Dr. John March, chief of child and adolescent psychiatry at Duke University’s school of medicine, who was not involved in the research.

 “From a developmental point of view, we simply don’t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness,” he said. “The label may or may not reflect reality.”

 Most children who qualify for the diagnosis do not go on to develop the classic features of adult bipolar disorder, like mania, researchers have found. They are far more likely to become depressed.

 But Dr. Mani Pavuluri, director of the pediatric mood disorders program at the University of Illinois, Chicago, said that label is often better than any of the other diagnoses that difficult children often receive. “These are kids that have rage, anger, bubbling emotions that are just intolerable for them, and it is good that this is finally being recognized as part of a single disorder,” to better tailor treatment, she said.

 In the study, researchers from New York, Maryland and Madrid analyzed data from a National Center for Health Statistics survey of office visits, which focused on doctors in private or group practices. The researchers calculated the number of visits in which doctors recorded a diagnosis of bipolar disorder, and found that the numbers went up from roughly 20,000 such diagnoses in 1994 to about 800,000 in 2003

 “I have been studying trends in mental health services for some time, and this finding really stands out as one of the most striking increases in this short a time,” said Dr. Mark Olfson of the New York State Psychiatric Institute at Columbia University, the senior author of the study, which appears in the September issue of Archives of General Psychiatry, which is to be published Tuesday.

 The increase makes bipolar disorder more common among children than clinical depression, the authors said. The study found that psychiatrists made almost 90 percent of the diagnoses, and that two-thirds of the young patients were boys. About half the patients also had been identified as having other mental difficulties, most often attention-deficit disorder.

 The treatment given the children almost always included medication. About half received antipsychotic drugs, like Risperdal from Janssen or Seroquel from Astrazeneca, both developed to treat schizophrenia; a third were prescribed so-called mood stabilizers, most often the epilepsy drug Depakote; and antidepressants and stimulants were also common. Most children were on some combination of two or more drugs, and about four in 10 received some psychotherapy.

 Their regimens were very similar to those of a group of adults with bipolar diagnoses, the study found. “You get the sense looking at the data that doctors are generalizing from the adult literature and applying the same principles to children,” Dr. Olfson said.

 The rise in bipolar diagnoses in children reflects several factors, experts say. Bipolar symptoms do appear earlier in life than previously thought, in teenagers and young children who later develop the full-blown disorder, recent studies suggest. The label also gives doctors and desperate parents a quick way to try to manage children’s rages and outbursts, in an era when long-term psychotherapy and hospital care are less accessible, they say.

 In addition, in recent years drug makers and company-sponsored psychiatrists have been encouraging doctors look for the disorder, ever since several drugs were approved to treat the disorder in adults. Last month the Food and Drug Administration approved one of these medications, Risperdal, to treat bipolar in children — which many experts say they expect will escalate the use of Risperdal and similar drugs in young people.

 “We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that, ‘Omigod, we’re missing bipolar,’ ” said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at Stony Brook University School of Medicine on Long Island. “And if you’re a parent with a difficult child, you go online, and there’s a Web site for bipolar, and you think, ‘Thank God I’ve found a diagnosis. I’ve found a home.’ ”

 Some parents whose children have received the diagnosis say that, with time, the label led to effective treatment. "It’s been a godsend for us," said Kelly Simons, of Montrose, Colo., whose son Brit, 15, was prone to angry outbursts until given a combination of lithium, a mood-stabilizer and Risperdal several years ago. He is now on lithium alone and he is an honor-roll student.

 Others say their children have suffered from side effects of drugs given for bipolar disorder, without getting much benefit.

 Ashley Ocampo, 40, of Tallahassee, Fla., the mother of an 8-year-old boy, Nicholas Ryan, who is being treated for bipolar disorder, said that he had tried several antipsychotic drugs and mood stabilizers, and that he had been better lately.

 But, she said in an interview, “He has gained weight, to the point where we were struggling find clothes for him; he’s had tremors, and still has some fine motor problems that he’s getting therapy for.”

 She added, “But he’s a fabulous kid, and I think, I hope, that we’re close to finding the right combination of medications to help him.”