Sunday Scribblings' prompt for today is In the news. I chose a magazine article I wanted to read anyway. Here is my post.
In the news
April 9th’s New Yorker caught my eye recently. One of the cover articles is Jerome Groopman’s, “Is your child really bipolar?” I like to keep up with what the public is reading about the illnesses I treat so I put this article on my reading list.
Dr. Groopman is the prolific author of several books (that I have not read) and a number of articles for publications including the New Yorker, New York Times and Lancet. I admire his accomplishments as an author and he seems to be a notable scientist. However, his areas of scientific expertise are in the domains of cancer and AIDS research, not psychiatry.
Mr. Groopman’s article is well-written and informative. It gives some interesting historical background about the diagnosis and treatment of Bipolar Disorder (formerly known as Manic Depression). He provides an adequate introduction to some of the controversies regarding the diagnosis of Bipolar Disorder in children and adolescents.
His article reads like a Who’s Who of Child Bipolar research. Groopman begins the article with reference to Steven Hyman, former director of the National Institute of Mental Health. He mentions respected Child Psychiatric researchers such as Barbara Geller, Joseph Biederman, Janet Wozniak and Eileen Leibenluft and discusses their relevant research.
These psychiatrists along with a few others not mentioned here provide the core of the research-based analysis of what is and is not Pediatric Bipolar Disorder. To give you an example of these researchers stature, a search on the name Barbara Geller on PubMed lists 24 articles in major journals on Bipolar Disorder. Search on Joseph Biederman and you find 220 articles, 45 of which relate to Bipolar Disorder.
These and other scientists do not agree on the exact definition of Bipolar Disorder in children. This is a caution to us all. If the definition is not clear and (as in this case) there are no laboratory exams or body scans to identify an illness, there will be instances of both under and over diagnosis. The diagnosis is even harder in preschool and young-school aged children. As Groopman correctly points out, the medications used to treat Bipolar Disorder are often potentially toxic and should be used with great care. For some people, they may be life-saving as well.
Let us compare treatments for Bipolar Disorder to treatments for Dr. Groopman’s specialties, AIDS and cancer. It is well known that chemotherapy, radiation and AIDS medications can be extremely toxic; however, they are used because they also clearly can save lives. We probably wouldn’t give these treatments to someone if we weren’t sure they had cancer or AIDs, however. What would we do if we believed they had a 50-75% probability of having cancer or AIDS? This is what we are dealing with when we treat presumed Bipolar children.
Some of these children are so severely afflicted that they are at risk of being institutionalized, expelled from school, jailed or placed for adoption (or re-adoption) by their families. Under these circumstances can you afford not to treat? Even if the diagnosis is uncertain, the medication may help, sometimes remarkably so. What do you do when the child is suicidal, violent or so impulsive as to be placing their physical health at risk on a nearly daily basis? I treat these children.
Dr. Groopman is correct. The basis for a bipolar diagnosis, especially in a prepubertal child is difficult and controversial. I tell this to parents I work with. I also discuss medication risks and before I suggest mood stabilizer medications I need to feel confident that the child experiences a serious level of impairment from their mood disorder and that a safer form of treatment is not a viable option. I have indeed seen children that were incorrectly diagnosed with Bipolar Disorder. I have also seen the illness evolve in children I or another health professional had previously diagnosed with ADHD, depression or anxiety disorders.
Like Dr. Groopman, I feel that childhood onset Bipolar Disorder is a bit of a disease du jour and that too many challenging, irritable children are diagnosed with it.
Where I argue with Dr. Groopman is that he trivializes the argument against the diagnosing of children with this illness. He interviews two psychotherapists to make his point. One is April Prewitt, a child psychologist, who apparently spends a good deal of time “undiagnosing” children with were told they had the disorder. What are her qualifications besides a Ph.D.? Hard to tell. She is not cited in PubMed. The only April Prewitt, psychologist, I could find on the internet, works at a health center specializing in women’s health issues. Dr. Prewitt has seen 30 children diagnosed with Bipolar Disorder in three years, according to the article. I doubt this qualifies her as an expert on the illness.
The other therapist interviewed is Phillip Blumberg, “a psychotherapist in Manhattan.” I have no idea what his credentials are. He apparently does not publish in the scientific journals as his name is not mentioned on PubMed. His previous employment as a vice president at ABC Motion Pictures seems irrelevant at best. I cannot even find out what therapy degree he has. In fact, Mr. Blumberg cannot be found at all on a casual internet search. Blumberg seems to blame the drug companies and academic pressure on children for the increase in diagnosis of Bipolar Disorder in children. However, his arguments are vague and not well substantiated.
If Dr. Groopman wants to make a case for the overdiagnosis of Bipolar Disorder in children, more power to him. But let’s have some substantive facts or at least meaningful opinions. Edit out the paragraphs regarding Dr. Prewitt and Mr. or Dr. Blumberg and the argument against the pediatric Bipolar diagnosis is weaker but the article is sounder. We owe it to our kids to accurately portray all sides of the controversy.
Addendum: After writing this article, I decided to edit it and send it to the New Yorker as a letter to the editor. I truly doubt they’ll publish it but why not send it anyway?