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A dysfunctional mental-health system is why more children are diagnosed with bipolar disorder, doctor argues

Slate magazine ran an interesting article earlier this month on why there’s been an explosion during the past decade in the diagnosis of bipolar disorder in children.

And, no, it’s not because parents would rather drug than discipline their “difficult” children. The article points instead to a “dysfunctional and overburdened mental health care system,” one in which there’s a stronger incentive to give a child a pill than to do the labor-intensive work of cognitive and behavioral therapy for kids with explosive behavior.

The article, written by Dr. Darshak Sanghavi, a pediatric cardiologist and assistant professor at the University of Massachusetts Medical School as well as a columnist for Slate, points out that the number of kids receiving bipolar diagnoses really began to take off in the late 1990s after the publication of a book called “The Bipolar Child” and the establishment of the parent-instigated Child and Adolescent Bipolar Foundation. (Full disclosure: I did some writing for the foundation’s website when it was launched.)

“Pretty soon,” writes Sanghavi, “many easily frustrated and chronically inflexible children were receiving a label previously reserved for adults. From 1994 to 2002, the number of children with the diagnosis increased 40-fold.”

In 2000, while acknowledging that bipolar disorder exists in children, the National Institutes of Mental Health was unable to come up with specific advice on how to diagnose it, a failing that has led to a “mini-industry in ways to identify the condition,” says Sanghavi.

“All this has led to even more diagnoses, a putative epidemic of bipolar among the nation’s children, and a corresponding increased in the pediatric use of antipsychotics, mood stabilizers, and other drugs often used to treat bipolar adults,” he adds. “… That’s worrisome since, according to a British government review, the evidence behind drug treatment for the condition is ‘extremely limited,’ and several drugs cause major weight gain (roughly 20 pounds in two months on average), hormone problems, and other side effects.”

The underlying problem
Sanghavi empathizes with the parents of these children. “Normal families don’t seek out stigmatizing labels and give their kids scary drugs for the hell of it,” he writes. “They do these things because they are at wit’s end.”

Furthermore, the mental health system “is so fragmented, variable in quality, and frankly unfair to those without money” that parents often have no choice than to accept the bipolar label for their children. It’s what will get them care. “Many insurers, for example, won’t cover old-fashioned diagnoses like ‘conduct disorder,’ writes Sanghavi, “but will cover the more serious-sounding bipolar disorder.”

“In addition,” he adds, “there was a strong incentive to expand drug therapy because giving pills is less labor-intensive than cognitive and behavioral therapy. The perverse result: Kids get more and more disturbing labels and medications.”

The huge shortage in pediatric psychiatrists (1 for every 11,000 children in this country) is contributing to the problem. “There simply aren’t enough doctors around to provide the key treatment for explosive behavior: face-to-face time for cognitive and behavioral therapy. Just getting an appointment with a good child psychiatric expert in many parts of the country can take six to eight months.”

“Much of the debate around bipolar disorder in kids is fixated on quixotic attempts to shoehorn complex behaviors into neat labels instead of studying and treating the various complex symptoms themselves, like inflexibility, irritability, and anxiety,” Sanghavi concludes. “We now have great behavioral tools for relieving those symptoms. But so long as the right resources are only deployed for those children who can score a label like ‘bipolar disorder,’ we’re doomed to an endless cycle of coming up with new names for old problems.”

You can read Sanghavi’s article here.

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Comments (4)

There is a horrific shortage of pediatric psychiatrists and psychologists in the US. And I agree - many children diagnosed with bipolar disorder may have some other mental health or behavioral issue that is too difficult to identify in young children. Many of the parents I know in my CABF and other support groups have children who have had multiple diagnoses, that get refined and more succinct over time, as the child matures. The same can be said for the incredibly high rates of diagnosis of Autism Spectrum Disorders.

However - some children truly do have childhood onset mental illnesses like bipolar disorder.

Take my child. He was diagnosed with an Autism Spectrum disorder at age 4, a mood disorder "not otherwise specified" at age 6, bipolar disorder at age 8, bipolar disorder with psychotic features at 11, and at 14, with schizoaffective disorder. Now, at 16, his battery of doctors - that I sought out to get third and fourth opinions from - he still seems to be a textbook case of it. But there would have been very little chance to know that at age 4.

The Child and Adolescent Bipolar Foundation does not press the diagnosis of children with bipolar disorder. CABF helps all parents with children like mine - with some severe, organic brain disorder that impacts mood and/or behavior - find resources and get support.

What happened to the not-so-labor-intensive of running lab tests of children's blood, urine, stool, hair and nails to determine whether one or more underlying environmental toxins is the causal agent of mental illnesses?

All the psych time and behavior therapy in the world won't treat an underlying physical ailment. To have psychologists and psychologists bypassing basic medical diagnostics and instead relying on psychotropic band-aids is a disgraceful retrograde practice.

It's amazing to see children improve mentally and physically once nutritional deficiencies are addressed, or toxic heavy metals removed, or sources of environmental toxins are eliminated.

There is a dangerous industry that has grown up around parents' fears over the behaviors of teenagers, and many, many teens with mental illness and learning disabilities are caught up in its web.

The so-called "troubled teen industry" uses high-pressure sales to persuade parents to enroll their children in expensive "therapeutic" or "emotional growth" boarding schools, wilderness challenge programs, and teen boot camps. The parents are told of dire consequences if they do not sign an enrollment contract immediately. There is documentation of widespread abuse, maltreatment and death of youth in these isolated, for-profit facilities.

The Federal Trade Commission and the Goverment Accountability Office have both issued warnings about the troubled teen industry. FTC's list of questions to ask (warning signs) can be found here: http://www.ftc.gov/bcp/edu/pubs/consumer/products/pro27.shtm

While it is difficult to find qualified help close to home, these troubled teen facilities are no help at all.

It's interesting to see this issue getting addressed but several things about the doctor's analysis seem deeply uninformed. He laments the lack of child psychiatrists for providing CBT when CBT really doesn't work with children and psychiatrists are not trained to provide it anyway; they give out drugs, period. He doesn't mention research showing that the diagnosis coincides with lower SES, indicating a social control diagnosis. Worse, Sanghavi seems to have missed the elephant in the living room -- the role of the drug industry in promoting the diagnosis of "the bipolar child," a diagnosis and treatment that may one day end up looking to medical historians like a barbaric treatment that ultimately served a the purposes of social control and the generation of profits more than health. He does not mention that Joseph Biederman, a Harvard psychiatrist in his own back yard, did more to promote the diagnosis of a "bipolar child" than any other clinician, and over a million dollars from the drug industry for his work. Why is a drug for such a rare condition the most profitable class of medications in our society today? Does this trouble anyone?

He does not mention that the drugs come on the heels of children getting stimulants and antidepressants, which, as David Healy has written, could clearly produce these "bipolar" symptoms (drugs which were all going off patent and/or becoming harder to work with, due to their capacity to cause suicidal thinking.) He does not mention that clinicians like Wozniak had to radically change the symptom profile of what it means to be bipolar in order for physicians to diagnose it in children (essentially, once a person had to cycle over a period of weeks to be seen as bipolar, but now you could do assign such cycling to a child over a matter of minutes). He does not mention that children as young as 18 months have been diagnosed as "bipolar" and that in one book on the topic, mothers were encouraged to recall if their bipolar child was especially over-active BEFORE THEY WERE BORN! He does not mention the wrongful death lawsuits for children who died on the drugs, the highest profile such case in Boston (Read Mania, A Short History of Bipolar Disorder by Healy). Astoundingly, his primary source for the problem is Judith Warner -- a parenting blogger.