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
an annual, nationwide survey of visits to doctors' offices over a
one-week period, conducted by the National Center for Health
The researchers estimated that in the United States from 1994-1995,
number of office visits resulting in a diagnosis of bipolar disorder
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
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 (ADHD)
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
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
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
of switching to mania. Also, a recent NIMH study showed that for
depressed adults with bipolar disorder who are taking a mood
adding an antidepressant medication was no more effective in managing
bipolar symptoms http://www.
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 disorder.
However, one main difference between youth and adult treatment was
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
medication used to treat anxiety disorders
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 of NCMHD.
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.
The National Institutes of Health (NIH) -- The Nation's Medical Research Agency -- includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.