|Rates of Bipolar Diagnosis in Youth Rapidly
Climbing, Treatment Patterns Similar to Adults
The number of visits to a doctor's office that resulted in a diagnosis
of bipolar disorder in children and adolescents has increased by
40 times over the last decade, reported researchers funded in part
by the National Institutes of Health (NIH). Over the same time
period, the number of visits by adults resulting in a bipolar disorder
diagnosis almost doubled. The cause of these increases is unclear.
Medication prescription patterns for the two groups were similar.
The study was published in the September 2007 issue of the Archives
of General Psychiatry.
Mark Olfson, M.D., M.P.H., of New York State Psychiatric Institute
of Columbia University, along with National Institute of Mental
Health (NIMH) researcher Gonzalo Laje, M.D., and their colleagues
examined 10 years of data from the National Ambulatory Medical
Care Survey (NAMCS), an annual, nationwide survey of visits to
doctors’ offices over a one-week period, conducted by the National
Center for Health Statistics. The researchers estimated that in
the United States from 1994–1995, the number of office visits
resulting in a diagnosis of bipolar disorder (http://www.nimh.nih.gov/healthinformation/bipolarmenu.cfm)
for youths ages 19 and younger was 25 out of every 100,000 people.
By 2002–2003, the number had jumped to 1,003 office visits
resulting in bipolar diagnoses per 100,000 people. In contrast,
for adults ages 20 and older, 905 office visits per 100,000 people
resulted in a bipolar disorder diagnosis in 1994–1995; a
decade later the number had risen to 1,679 per 100,000 people.
While the increase in bipolar diagnoses in youth far outpaces
the increase in diagnosis among adults, the researchers are cautious
about interpreting these data as an actual rise in the number of
people who have the illness (prevalence) or the number of new cases
each year (incidence).
"It is likely that this impressive increase reflects a recent
tendency to overdiagnose bipolar disorder in young people, a correction
of historical under recognition, or a combination of these trends.
Clearly, we need to learn more about what criteria physicians in
the community are actually using to diagnose bipolar disorder in
children and adolescents and how physicians are arriving at decisions
concerning clinical management," said Dr. Olfson.
The fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) provides general guidelines that can
help doctors identify bipolar disorder in young patients. However,
some studies show that youths with symptoms of mania (over-excited,
elated mood) — one of the classic signs of bipolar disorder — often
do not meet the full criteria for a diagnosis of bipolar disorder.
Other disorders, such as attention-deficit hyperactivity disorder
may have symptoms that overlap, so some of these conditions may
be mistaken for bipolar disorder as well. For example, in a study
conducted in 2001, nearly one-half of bipolar diagnoses in adolescent
inpatients made by community clinicians were later re-classified
as other mental disorders.
Doctors also face tough questions when deciding on proper treatment
for young people. Guidelines for treating adults with bipolar disorder
are well-documented by research, but few studies have looked at
the safety and effectiveness of psychiatric medications for treating
children and adolescents with the disorder. Despite this limited
evidence, the researchers found similar treatment patterns for
Of the medications studied, mood stabilizers, including lithium — which
was the only medication approved at the time of the study by the
U.S. Food and Drug Administration for treating bipolar disorder
in children — were prescribed in two-thirds of the visits
by youth and adults. Anticonvulsant medications, such as valproate
(Depakote) and carbamazepine (Tegretol), were the most frequently
prescribed type of mood stabilizers in both groups.
Doctors prescribed antidepressant medications in slightly over
one-third of visits by youth and adults. Antidepressant medications
include the older classes of antidepressant medications, such as
tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs);
selective serontonin reuptake inhibitors, such as fluoxetine (Prozac)
and paroxetine (Paxil); and also newer types of antidepressants,
including venlafaxine (Effexor). In both age groups, about one-third
of the visits where antidepressant medications were prescribed
did not include prescription of a mood stabilizer. This trend raises
concerns, considering an earlier NIMH-funded study (Thase & Sachs,
2000) which reported that treating adults who have bipolar disorder
with an antidepressant in the absence of a mood stabilizer may
put them at risk of switching to mania. Also, a recent NIMH study
showed that for depressed adults with bipolar disorder who are
taking a mood stabilizer, adding an antidepressant medication was
no more effective in managing bipolar symptoms (http://www.nimh.nih.gov/press/stepbd-medication.cfm)
than a placebo (sugar pill).
Roughly the same percentage of youth and adult bipolar visits
included a prescription for an antipsychotic medication, although
young patients were more likely to be prescribed one of the newer,
atypical antipsychotic medications, such as aripiprazole (Abilify)
or olanzapine (Zyprexa), than other types of antipsychotics. This
finding suggests that doctors may be basing their treatment choices
for bipolar youth on prescribing practices for adults with the
However, one main difference between youth and adult treatment
was that children and teens were more likely than adults to be
prescribed a stimulant medication — usually prescribed for
treating ADHD — and adults were more likely than youth to
be prescribed benzodiazepines, a type of medication used to treat
anxiety disorders (http://www.nimh.nih.gov/healthinformation/anxietymenu.cfm).
More than half of all diagnosed youths and adults were prescribed
a combination of medications. Given the relative lack of studies
on appropriate treatments for youth with bipolar disorder, the
researchers noted the urgent need for more research on the safety
and effectiveness of medication treatments that are commonly prescribed
to this age group.
The study had several important limitations. For example, the
survey relied on the judgment of the treating physicians, rather
than an independent assessment. As a result, the researchers’ findings
reveal more about patterns in diagnosis among office-based doctors
than about definitive numbers of people affected by the illness.
Another limitation is that the survey recorded the number of office
visits instead of the number of individual patients, so some people
may have been counted more than once.
"A forty-fold increase in the diagnosis of bipolar disorder
in children and adolescents is worrisome," said NIMH Director
Thomas R. Insel, M.D. "We do not know how much of this increase
reflects earlier underdiagnosis, current overdiagnosis, possibly
a true increase in prevalence of this illness, or some combination
of these factors. However, these new results confirm what we are
hearing increasingly from families who tell us about disabling,
sometimes dangerous psychiatric symptoms in their children. This
report reminds us of the need for research that validates the diagnosis
of bipolar disorder and other disorders in children and the importance
of developing treatments that are safe, effective, and feasible
for use in primary care."
"This research, performed at a National Center on Minority
Health and Health Disparities Center of Excellence, underscores
the need to fully engage the community with their health care providers
to better understand the actual prevalence of bipolar disease in
children and adolescents," said John Ruffin, Ph.D., Director
Additional study authors were Carmen Moreno, M.D., and Carlos
Blanco, M.D., Ph.D., of New York State Psychiatric Institute/College
of Physicians and Surgeons of Columbia University; Andrew B. Schmidt,
C.S.W., of New York State Psychiatric Institute; and Huiping Jiang,
Ph.D., of Columbia University.
The study was funded by the NIMH Intramural Research Program,
National Institute on Drug Abuse (NIDA), NCMHD, the Agency for
Healthcare Research and Quality (AHRQ), the Alicia Koplowitz Foundation,
and the New York State Psychiatric Institute.
Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National
trends in the outpatient diagnosis and treatment of bipolar disorder
in youth. Arch Gen Psychiatry. 2007 Sep;64(9).
The National Institute of Mental Health (NIMH) mission is to reduce
the burden of mental and behavioral disorders through research
on mind, brain, and behavior. More information is available at
the NIMH website (http://www.nimh.nih.gov).
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Medical Research Agency — includes 27 Institutes and
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and it investigates the causes, treatments, and cures for both
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