Dr. Mark Olfson, TeenScreen National Center’s scientific advisor, is professor of clinical psychiatry and a mental health services researcher and research psychiatrist at Columbia University and the New York State Psychiatric Institute.
He is a leading expert on the impact of increased diagnoses and prescribing of antipsychotic medications on our youth – concerns that have generated serious discussion within the mental health and medical communities. Improving diagnosis and treatment of bipolar disorder in young people will be the focus of our February 29 webinar, Bipolar Disorder in Adolescents: What Primary Care Providers Need to Know, which we are co-hosting with the American Academy of Pediatrics.
Here, Dr. Olfson shares his thoughts on the controversy and discusses how new research findings may help settle it.
Over the past several years, an increasing number of children and adolescents in the U.S. have been diagnosed and treated for bipolar disorder1,2. As part of their treatment, a majority receive psychotropic medications, often a mood stabilizer and an antipsychotic medication. A recent meta-analysis suggests that antipsychotic medications may be more effective than mood stabilizers for the treatment of manic symptoms in bipolar youth3. Yet weight gain and other adverse metabolic side effects associated with antipsychotic medications4 pose important considerations. As compared with adults, children and adolescents may be more vulnerable to antipsychotic-induced weight gain5 and perhaps even to antipsychotic-associated diabetes6,7.
When the diagnosis is clear, than the benefits of these medications often far outweigh the risks. However, there is growing concern over the accuracy of some of these diagnoses8, 9. Symptoms of increased irritability – often interpreted as symptoms of bipolar — also occur in ADHD and disruptive behavior disorders, and may contribute to a tendency among some clinicians to overdiagnose bipolar disorder10. Even among child and adolescent psychiatrists, there is variation in the clinical criteria used to make a bipolar diagnosis. Many are either uncertain or reject the concept that a child must have the primary DSM-IV criterion for a manic episode (at least one week of elevated, expansive, or irritable mood) to receive bipolar disorder diagnosis8.
Concern over high rates of community bipolar disorder diagnosis in young patients has led the DSM-5 Task Force to propose a new diagnosis: disruptive mood dysregulation disorder. This disorder includes youth with recurrent temper outbursts that are out of proportion – both in duration and intensity — to the stressor that provoked them and that are not connected to an existing mood or psychotic disorder. Although the effects of this new disorder on medical practice remain unknown, epidemiological data suggest that disruptive mood dysregulation disorder occurs in approximately 3.3% of children and adolescents11.
Despite substantial progress in combining psychosocial therapies for adults with bipolar disorder, much less research has focused on child and adolescent bipolar patients. Recently, however, family-focused therapy, which emphasizes communication and problem-solving skills training to enhance family functioning, in combination with pharmacotherapy, has been found to contribute to more rapid and complete remission of depression symptoms than a combination of brief psychoeducation and pharmacotherapy12. Support also exists for multifamily group psychoeducational therapy for children with bipolar disorder in reducing mood symptoms13.
Uncertainty and controversy often surround the diagnostic boundaries of bipolar disorder for children and adolescents. In this clinical context, it is important that mental health professionals apply the DSM criteria in a standard and consistent manner, approach pharmacotherapy with an understanding of its efficacy and risks, and seek to take advantage of emerging evidence that interventions that work on family communication and functioning may play an important supporting role in improving the course and outcome of children and adolescents with bipolar disorder.
References
1. Olfson M, Blanco C, Liu L, Moreno C, Laje G: National trends in the outpatient treatment of children and adolescents with antipsychotics. Arch Gen Psychiatry 2006;63:679-685.
2. Blader JC: Acute inpatient care for psychiatric disorders in the United States, 1996 through 2007. Arch Gen Psychiatry 2011; doi:10.1001/archgenpsychiatry.2011.84
3. Correll CU, Sheridan EM, DelBello MP: Antipsychotic and mood stabilizer efficacy and tolerability in pediatric and adult patients with bipolar 1 mania: a comparative analysis of acute, randomized, placebo-controlled trials. Bipolar Disorders 2010;12:116-141.
4. De Hert M, Dobbelaere M, Sheridan EM, Cohen D, Correll CU: Metabolic and endocrine adverse effects of second-generation antipsychotics in children and adolescents: a systematic review of randomized, placebo controlled trials and guidelines for clinical practice. Eur Psychiatry 2011;26:144-158.
5. Correll CU, Lencz T, Malhotra AK: Antipsychotic drugs and obesity. Trends Molec Med 2011;17 (2):97-107.
6. Hammerman A, Dreiher J, Klang SH, Munitz H, et al.: Antipsychotics and diabetes: an age-related association. Ann Pharmacother 2008;42:1316-1322.
7. Andrade SE, Lo JC, Fouayzi H, Connor DR, Penfold RB, Chandra M, Reed G, Gurwitz JH: Antipsychotic medication use among children and risk of diabetes mellitus. Pediatrics 2011;128:1135-1141.
8. Galanter CA, Pagar DL, Oberg PP, Wong C, Davies M, Jensen PS: Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists. J Child Adolesc Psychopharmacol 2009;19:641-647.
9. Pogge DL, Wayland-Smith D, Zaccario M, Borgaro S, Stokes J, Harvey PD. Diagnosis of manic episodes in adolescent inpatients: structured diagnostic procedures compared to clinical chart diagnoses. Psychiatry Res. Feb 14 2001;101(1):47-54.
10. McClellan J, Kowatch R, Findling RL. 2007. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc. Psychiatry 46(1):107–25
11. Brotman MA, Schmajuk BA, Dickstein DP, et al.: Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry 2006; 991-997.
12. Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 2008;65(9):1053–61.
13. Fristad MA, Verducci JS, Walters K, Young ME. Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Arch Gen Psychiatry 2009;66(9):1013-21.
Local Site Sign-in
Mental health advocates say the pain of stigma is as devastating to people with mental disorders as the symptoms of illness. For many centuries mental illness was terribly misunderstood. Individuals afflicted were viewed by society as dangerously demon-possessed, were locked up in prisons and even executed as witches. In our day it is still all too common for mental illness to be treated a joke. Consider how frequently we hear words that mock these serious brain disorders—”wacko”, “nut case”, “schizo”. This constant ridicule marginalizes young people struggling with mental illness and makes it very tough to engage them in treatment. Who wants to acknowledge having a mental health problem if it leads to being the target of name-calling? Adolescents in middle and high school often experience stigma as bullying. They are called “crazy” and “psycho” and are socially isolated and victimized. In a number of recent high profile cases, bullying has apparently led to teen suicides.
