The National Institute of Mental Health website
has information about some of the most recent
research on mental health and related issues.  

Click on the logo at left for the NIMH home page.  
Information and Research on Mental Health
Director’s Update
September 3, 2007

NIMH Perspective on Diagnosing and Treating Bipolar Disorder in Children

A recently published research paper (September 2007, Archives of General Psychiatry) reported a 40-fold
increase in the rate of diagnosing bipolar disorder in youth over the past decade. This paper raises several
important questions:

Were physicians under-diagnosing bipolar disorder in the past?
Are they over-diagnosing currently?
Are more children developing behavioral disorders than in the past?
It is unclear exactly what is causing this increase, but current evidence suggests a combination of each of these
and possibly other factors. The following is intended to discuss the paper's findings within the broader context of
what we know about the diagnosis and treatment of bipolar disorder in children and adolescents.

It is important to note that the paper's findings were based on data from a survey conducted annually by the
National Center for Health Statistics. The survey comprises a one-page form that asks a nationally representative
sample of private practice doctors to describe certain characteristics of each patient visit, including children and
adults, over a one-week period. Neither the survey nor the paper provides information regarding:

how common bipolar disorder is (prevalence) within the community;
the annual rate at which new cases are reported (incidence).
practices of other mental health providers, such as psychologists, clinical social workers, and mental health
counselors;
practices of physicians who work for the Federal government (such as the Veterans Administration); or
practices of non-office based health settings where people with bipolar disorder may receive mental health care,
such as community mental health centers and hospital clinics.
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. Because the survey was conducted only over one week, it was not possible
to study the length and progress of treatment. In addition, information on the doses of some medications was not
available. Finally, while a 40-fold increase seems large, the base rate (25 bipolar diagnoses per 100,000 people)
suggests that the diagnosis was rarely used in 1994-1995. The recent rate of 1,003 bipolar diagnoses per
100,000 people is indeed much higher than the 1994-1995 rate, but still well below the rate of bipolar disorder for
adults (1,679 bipolar diagnoses per 100,000 people).

How do physicians currently diagnose bipolar disorder in children? The current edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) lists criteria to define bipolar disorder in children. These criteria
are based on how the disorder typically appears in adults and have not changed over the past decade.1
Research indicates that there are children whose symptoms clearly meet these criteria, as well as a much larger
group of children who show some but not all symptoms. It is in this latter group, who frequently show excessive
irritability and impulsivity, where there is disagreement as to whether these are symptoms of bipolar disorder or of
a broader spectrum of mood disturbances. Such mood disturbances may have been diagnosed differently or may
not have come to a physician's attention a decade ago.

Co-occurring disorders can also make diagnosis more difficult. As many as 60 percent of children diagnosed with
bipolar disorder in most studies also have attention deficit hyperactivity disorder (ADHD),2,3 raising questions
about whether the current diagnostic criteria are specific enough to distinguish symptoms of bipolar disorder from
symptoms of other related illnesses in children.

Recent research has demonstrated that many adult mental disorders begin in childhood. The NIMH-funded
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial found that about 65 percent of
adults with bipolar disorder describe the onset of symptoms before age 19,4 suggesting that the disorder may
have been insufficiently recognized in the past. It is not yet clear, however, that all of the children currently
diagnosed with bipolar disorder will grow up to be adults with bipolar disorder.

A current NIMH supported study is following a group of children and adolescents diagnosed with bipolar disorder
to determine the course of their symptoms over time. In this and other research studies for which having bipolar
disorder is a requirement, only a small fraction of children referred for participation actually meet criteria for the
disorder. It seems likely therefore, that many of the children and adolescents in the community diagnosed as
having bipolar disorder do not have the same illness as adults with bipolar disorder. In this sense, the diagnosis
may be over-used or mis-used in children. This is not to say that these children and their families are not in
distress. While these children may not all have bipolar disorder, it appears that physicians are reporting a true
increase in the number of children and adolescents presenting with severe behavioral problems, including
irritability, aggression, and erratic moods.

NIMH is committed to the development of biological tests that can help validate the diagnosis of bipolar disorder
in children. Recent research advances showed that electroencephalograms (EEGs) and magnetic resonance
imaging (MRI) studies of the brain can reveal differences between bipolar disorder and related behavioral
syndromes which cause some of the same symptoms in children as bipolar disorder causes. In addition, recent
studies have identified novel candidate genes that may increase risk for adults with bipolar disorder.5,6 NIMH
researchers also recently found that parents of children diagnosed with bipolar disorder appear more likely to
themselves have bipolar disorder, compared with the parents of children with severe irritability but without the
classic mood episodes of bipolar disorder. This suggests that genetics should ultimately prove helpful for
validating bipolar diagnoses in children.

Whatever the issues are in diagnosis, the Archives paper also described widespread prescribing of medications
not FDA-approved for children diagnosed with bipolar disorder. Currently, there are no antidepressants
approved by the FDA for treating bipolar disorder in children and adolescents, and only one approved atypical
antipsychotic, risperidone (Risperdal).

More research is needed to determine the safety and effectiveness of the many medications currently used to
treat bipolar disorder in youth, as well as to identify other types of appropriate treatment. Several NIMH-funded
clinical trials seek to accomplish this goal, including the Treatment of Early Age Mania study, involving children
(ages 6-15) who have mania, which is comparing the effectiveness of three medications commonly used to treat
bipolar disorder in adults. An additional study is focusing on teens (ages 13-17) diagnosed with bipolar disorder
to examine the effectiveness of family-focused therapy (FFT) in conjunction with medication treatment. Another
promising area of study lies in the ongoing trials of early diagnosis and interventions for children at risk for
developing bipolar disorder because of a strong family history.

The apparent inaccurate use of the bipolar diagnosis and questions about the safety and effectiveness of
medications being prescribed to young children raise real concerns. These concerns need to be balanced by
recognizing that psychiatric illnesses can cause disabling and sometimes dangerous symptoms during a critical
period of physical and cognitive development, with many potential long-term effects for a child's future. Parents
and physicians concerned about the risk of treatment need to consider the risks of not treating children who may
have impulsive behaviors that can threaten themselves or others and make it difficult or impossible for the child
to function well at home, at school or with peers. Children currently in treatment should not discontinue
medication without consulting a physician.

Information on current trends in mental health care can help to highlight specific areas for further research and to
assess ongoing efforts. Clearly, more studies are needed to determine the best ways to define, diagnose, treat,
and perhaps someday even prevent, the range of mood disorders that affect children and adolescents. By
supporting a broad range of rigorous research in this area, NIMH seeks to ensure that concerns about under-
diagnosis or over-diagnosis can be resolved with valid diagnostic methods and safe, effective treatments.

Press Release: Rates of Bipolar Diagnosis in Youth Rapidly Climbing, Treatment Patterns Similar to Adults

References

1 McClellan J, Kowatch R, Findling RL. Work Group on Quality Issues. Practice parameter for the assessment
and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jan;46
(1):107-25.

2 Scheffer RE, Kowatch RA, Carmody T, Rush AJ. Randomized, Placebo-Controlled Trial of Mixed Amphetamine
Salts for Symptoms of Comorbid ADHD in Pediatric Bipolar Disorder After Mood Stabilization With Divalproex
Sodium. Am J Psychiatry. 2005 Jan;162(1):58-64.

3 Dickstein DP, Nelson EE, McClure EB, Grimley ME, Knopf L, Brotman MA, Rich BA, Pine DS, Leibenluft E.
Cognitive flexibility in phenotypes of pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2007 Mar;46
(3):341-55.

4 Perlis RH, Miyahara S, Marangell LB, Wisniewski SR, Ostacher M, DelBello MP, Bowden CL, Sachs GS,
Nierenberg AA; STEP-BD Investigators. Long-Term implications of early onset in bipolar disorder: data from the
first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol
Psychiatry. 2004 May 1;55(9):875-81.

5 Baum AE, Akula N, Cabanero M, Cardona I, Corona W, Klemens B, Schulze TG, Cichon S, Rietschel M, Nothen
MM, Georgi A, Schumacher J, Schwarz M, Abou Jamra R, Hofels S, Propping P, Satagopan J, Detera-Wadleigh
SD, Hardy J, McMahon FJ. A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and
several other genes in the etiology of bipolar disorder. Mol Psychiatry. 2007 May 8; [Epub ahead of print] *Click
to see NIMH press release*

6 Wellcome Trust Case Control Consortium. Genome-wide association study of 14,000 cases of seven common
diseases and 3,000 shared controls. Nature. 2007 Jun 7;447(7145):661-78.
                                        Brain Maturity May Lag in Children with ADHD

In the Spring, 2008 issue of NAMI Beginnings, Philip Shaw (MD, PhD) reports on research done by the Child
Psychiatry Branch of the National Institute of Mental Health.  According to Dr. Shaw, current research indicates a
delay in the maturation of the cortex of the brain in children diagnosed with ADHD.   For an extended report on this
research at the NIMH website, click
here  
"Anxious and Depressed Teens and Adults: Same Version of Mood Gene,
Different Brain Reactions"  (Dec. 08)   
Read the full  NIMH report here.
Research news from the National Institute of Mental Health website

October 25, 1009:  Significant Weight Gain, Metabolic Changes Associated with Antipsychotic Use in
Children
  To read the article, click here.