Sunday, April 08, 2007

And now for something completely serious

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?


sister AE said...

A common problem is that good intentions to air "both" or "all" sides of an issue sometimes result in false impressions of the relative weight of a those sides.

The majority is not always right. But then again, it is not always wrong either.

sarala said...

Ah, but neither of us was arguing whether the majority was right or even who was the majority. I'm just arguing in favor of applying the scientific method.

Jillian said...

To Sister ae- I think you meant err, not air. Not that I am a language expert. In fact I will probably spell something wrong in my comment.

I found this blog because I too was searching for April Prewitt in the hopes of discovering who this psychologist that finds herself qualified to practice psychiatry really is. I am currently reading "The Bipolar Child" book that was mentioned in the article, and all I can say is that it is a very complicated topic. I have recently been diagnosed with bipolar 2, and my kids are a heck of a lot like me. Do I plan to get them on the meds I take? Not until the last possible moment.

lagata said...

At the crux of that article and the struggle to define what is and what is not a mental illness in a CHILD, is our inability to define what is and what is not the best way to parent. The line between mental illness and what society defines as a behavioral 'norm' for a CHILD only gets more blurred. Boys are traditionally more active and 'disorderly' than girls when they are young. I had a pediatrician tell me that almost all of her toddler patients taking medication for ADHD are boys. Is that wrong? Where do we allow for the spirit of a child to come through. Many of our great geniuses were not 'normal', but accomplished great things because of their 'abnormalities'. While I'm certainly not advocating the torture of untreated lifelong mental illness or making light of those who have suffered, it seems that we are in a rush to "normalize" many children who do not 'fit'.

sarala said...
This comment has been removed by the author.
Snail said...

Interesting post, Sarala. I visit your blog to enjoy the photography and your views on art and life but the posts that give your professional insight are fscinating. Just my 2c worth.

Uneasy Rider said...

A colleague recently referred me to Groopman's article because I had mentioned we were having some really serious problems with our 6 year-old boy. Our boy has had difficulties at least since he as 2½ and we had him enrolled in an early intervention program. And getting professional psychiatric help is a tremendous challenge because so few child psychiatrists take new patients... and if they do, they do not carry the health insurance (Aetna) provided by my employer.

To make a long story short, after exhausting all our options, my wife sought to get him enrolled in an ADHD study at Mass. General Hospital (we live west of Boston). The study was under the direction of the same Dr. Biederman mentioned in the article... only we did not realize at the time he was recognized as an authority on the topic. But after a thorough screening - comprised of like 3 solid days of testing - they came back with a diagnosis of childhood bipolar with ADHD being a factor as well. Our boy was moved to a bipolar study using a medication called Equetro.

This was basically the price we had to pay to even get our boy in front of any doctors who could help us. We worked with both Drs. Biederman and Wozniak that were mentioned in the article, as well as another one named Gagan Joshi.

After the Equetro study ended, we were given the opportunity to keep our boy under the care of Dr. Joshi at a cost of $200 per visit - and they don't take any health insurance. But since no other doctors even came close to helping us at all, we realized we really had to pay the $200 per visit because the alternative was.... well, no care at all.

Our boy came off of Equetro and has been thriving with the help of Abilify. And he is still under the care of Dr. Joshi at MGH.

What the article did not mention was just how devastating this illness can be to a family. It is very easy to view the malady as a behavior issue instead of a mood disorder. And lack of proper treatment can pit one parent against the other in how to handle the child. My wife and I came very close to a divorce because the stress level in the house just got to be too much for us to handle. I could not understand the difficulties my wife was having with this boy, and the constant demands for 'help' around the house... sitters, nannys, and cleaning help, put even more stress on us because I could not understand why my wife could not handle these chores herself. And we basically found ourselves pointing fingers at each other... and it was all basically rooted in the extraordinary demands placed on the parents by this one needy child. People who haven't lived this nightmare truly cannot comprehend just how this can tear a family apart.

To tell you the truth, I really don't know if our boy has been accurately diagnosed with childhood bipolor or ADHD or not. What I DO know is that when the medication is working, our boy can be the most charming kid anyone ever met. But the dosage levels need to be carefully monitored, and even bi-weekly visits with the doctors may prove to be inadequate.

Parents like us are basically left grasping for any hope at all that can bring relief to the child and, consequently, to the rest of the family. I can believe that childhood bipolar may be mis-diagnosed because the symptoms may be very broad somewhat fuzzy in nature. And I would be much more skeptical if it were a pediatrician making such a diagnosis. With us, we had Biederman's team making the diagnosis. So far, we have been very happy with the care we have gotten from the MGH team headed by Biederman... my only gripe is the $200 per visit that is not covered by insurance. But that's a lot cheaper than a divorce, which is what was being discussed before our boy was diagnosed with bipolar.

sarala said...

Thanks Easy Rider for sharing your story. I think you illustrate the demands on parents of raising such a child, whatever the diagnosis actually is, and the compromises you have to make. I too wish there were more child psychiatrists and that insurance was more readily available to cover the care. We all need to keep fighting for improvements in mental health care and coverage.

BendingPeak said...

The first time I read this I nodded my head in aggreance and moved on.
Now working with children ages 5-12 I see loads of Bipolar diagnosis with a comorbidity of ADHD, or came in (inpatient) with ADHD and leave with a dx of bipolar.
I understand insurance will pay for bipolar inpatient stays more so than a priamary dx of ADHD for inpatient. But they seem to present many of the same issues with children.
Thanks for writing about this,

Lydia Dustin said...

1/30/12 I just met Dr. Joshi today. He is a doll! He is working at the Bresslin Center on a Anxiety study that I am trrying to get my daughter into. He actually does take insurance. I am looking forward to working with him. I was very impressed.