Prevalence Of Bipolarity In Children Underdiagnosis Overdiagnosis Misdiagnosis

Over the past two decades, the underdiagnosis and misdiagnosis of childhood bipolar disorder have been noted by several authors [10].

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Gammon et al. [11] interviewed 17 adolescent inpatients and their mothers using the Schedule for Affective Disorders and Schizophrenia for School-aged Children and Adolescents, Epidemiological Version (K-SADS-E), and found that 5 of the 17 adolescents (29%) satisfied DSM-III criteria for bipolar disorder or atypical bipolar disorder (bipolar II). These teenagers were not clinically diagnosed to have bipolar disorder.

Weller et al. [5] selected 157 case reports of children with severe psychiatric illnesses from English literature dating from 1809 to 1984. They then applied DSM-IIIR criteria to re-diagnose the selected 157 cases and found that mania had been underdiagnosed. In over 50% of the reviewed cases, the children could have easily fulfilled stringent criteria for mania. Instead, the children had been diagnosed to have other disorders such as schizophrenia or a behavioural disorder.

Data from adult studies support the idea of underdiagnosis and mis-diagnosis during childhood. For example, 60% of bipolar adults report that their first symptoms occurred in childhood or adolescence, but there was a delay in diagnosis and treatment. In one report, the initial treatment for bipolar disorder was delayed an average of 10 years from the onset of symptoms [12].

It has been estimated that between one and two thirds of individuals with bipolar disorder do not receive appropriate treatment due to misdiagnosis [13]. Most adults see at least three physicians prior to being correctly diagnosed. Importantly, a misdiagnosis of unipolar depression (now referred to as major depressive disorder in DSM-IV-TR) may lead to induction of mania in depressed patients with bipolar disorder when they are treated with antidepressants [14-16].

Recently, a few investigators noted a tendency to overdiagnose paediatric bipolarity, possibly due to the lack of agreement on diagnostic criteria for bipolar disorder in children [17].

This change in diagnostic practice is reflected in practitioners' prescribing practices. A study conducted by Safer [18] examined the prescribing practices of child and adolescent psychiatrists in Baltimore, Maryland, in 1994. The author reviewed the active (1994) and closed (1988-1992) outpatient records of youths seen in four separate community mental health centres. Inpatient summaries of previously hospitalized youth were also reviewed. There was an increase in the use of medications typically used to treat mood disorders and in the use of multiple medications for both inpatients and outpatients in 1994. This change in practice mirrors that observed in adults.

Other researchers examined differences in the treatment practices for teenagers and prepubescent children in the inpatient setting. Patients under the age of 12 received more stimulants than teenagers, and lithium was prescribed to more patients over the age of 13 than to prepubescent children [19].

The changes in diagnostic trends and practices are reflected in epidemiological studies. Lifetime prevalence rates for bipolar disorder in children are dependent on the diagnostic concepts and the diagnostic instruments tailored to these concepts. For example, Carlson and Kashani [20] reported that 0.6% of 150 adolescents (14-16 years old) were diagnosed manic when severity and duration were both taken into account. However, 13.3% reported periods of at least two days in which they experienced four or more manic symptoms. While none of these adolescents exhibited sufficient impairment to meet criteria for a manic episode, three (1.5%) appeared to qualify for a diagnosis of bipolar II disorder or cyclothymia. These adolescents with manic symptoms exhibited high rates of comorbidity, and 70% were judged by the interviewers to need treatment [20]. In another study, Klein et al. [21] reported that 24% of patients with bipolar parents and 0% of the patients without bipolar parents had cyclothymia as assessed by the General Behavior Inventory, which had excellent correlation with interview-derived diagnosis, according to the authors.

Relatively recent prevalence rates, reported by Lewinsohn et al. [22], are rather similar to those reported in the Epidemiological Catchment Area study [23] and other recent epidemiological studies of adult samples [24]. These investigators studied a large, randomly selected community sample (n = 1705) that received diagnostic assessments during adolescence; a stratified subset was later assessed at the age of 24 (n = 893). In addition, direct interviews were conducted with all available first-degree relatives. Lifetime prevalence of bipolar disorder was 1%, the point prevalence of bipolar disorder was 0.64% and the 1-year incidence rate was 0.13%. Although most of these bipolar cases only met criteria for bipolar II disorder or cyclothymia, they exhibited considerable impairment, as well as high rates of attempted suicide, comorbidity and mental health care utilization, and a relatively chronic course. Less than 1% of adolescents with major depressive disorder ''switched'' to bipolar disorder by the age of 24. In addition, a subgroup was identified who reported distinct periods of elevated, expansive or irritable mood, but did not meet criteria for any form of bipolar disorder. These subjects also had considerable impairment. Lifetime prevalence for sub-syndromal bipolar disorder was approximately 5.7%. This was consistent with the findings of Carlson and Kashani [20], who also reported high rates of comorbidity and impairment (as indicated by the interviewers' judgement of need for treatment) in adolescents with manic symptoms, most of whom did not qualify for a bipolar disorder diagnosis.

These data highlight the clinical significance of even the milder and sub-threshold forms of bipolar disorder in adolescence [22]. Adolescents with bipolar disorder had an elevated prevalence of bipolar disorder on follow-up at ages 19-23 years, while adolescents with sub-syndromal bipolar disorder groups had elevated rates of antisocial symptoms and borderline personality symptoms. Both groups showed significant impairments in psychosocial functioning and had higher mental health treatment utilization at the age of 24. The authors concluded that adolescent bipolar disorder showed significant continuity across developmental periods and was associated with adverse outcomes during young adulthood. Adolescent sub-syndromal bipolar disorder was also associated with adverse outcomes in young adulthood, but was not associated with an increased prevalence of bipolar disorder. Due to high rates of comorbidity with other disorders, definitive conclusions regarding the specific clinical significance of sub-syndromal bipolar disorder must await studies with larger numbers of "pure" cases.

In other recent surveys, the lifetime prevalence of bipolar I disorder among adolescents was estimated to be approximately 0.5% [2]. As of now, no national or international epidemiological study of bipolar disorder in children is available.

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