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Letter From The Editor
In this issue we are pleased to bring you the exciting news that Dubai Healthcare City will launch a world-class tertiary care teaching hospital. This story has been developing for several months, as faculty from HMI, health care leaders in Dubai, a team of architects from a top firm, and clinical and administrative experts from throughout the Harvard medical community have worked together to design every component of the University Hospital.
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This article originally appeared in the December 2007 Harvard Mental Health Letter and is provided courtesy of Harvard Health Publications.
Making the most of psychiatric advance directives
Potential benefits, controversies, and why a team approach is best.
Few medical situations are as difficult as a psychiatric emergency. The fundamentals of providing quality care — talking about symptoms, reviewing medical history, making a diagnosis, prescribing treatment — may be impossible when a patient is delusional, psychotic, or otherwise incapacitated. Clinicians may find themselves wanting to elicit a patient’s treatment preferences, but having to make quick decisions in order to provide emergency (and often lifesaving) care.
In theory, psychiatric advance directives provide a way to consider patient choice even during a medical crisis. These legal documents provide a mechanism for individuals to stipulate, in advance, what types of psychiatric treatments they prefer or to appoint a health care agent to make such decisions for them, should they become incapacitated.
The basics
Psychiatric advance directives evolved from more general advance care directives, but differ from them in two key ways. First, people filling out general health care directives are often making decisions about end-of-life treatments they have never actually experienced. In contrast, psychiatric patients are generally dealing with chronic illnesses and therefore are likely to have experience with the treatments they are describing. (A patient with schizophrenia, for example, may well have opinions about which antipsychotic is most effective and which ones have not worked in the past.) Second, the goal of a general advance care directive is usually to increase the chances that life ends in comfort and dignity; the goal of a psychiatric advance directive is often to maximize the chances of recovery, while minimizing unwanted interventions.
Psychiatric advance directives, like general advance care directives, are governed by state law. Currently 25 states have specific provisions regarding the creation of psychiatric advance directives. People living elsewhere can adapt their state’s general advance care directives for use in psychiatric hospitals by designating a health care agent to make decisions for them if they become incapacitated.
Although state laws vary, psychiatric advance directives often consist of two types of documents. The first includes specific instructions and treatment preferences; the second appoints a health care agent. To create a valid psychiatric advance directive, a patient should obtain the applicable state forms and follow the instructions. All state forms are available online, free of charge, through the National Resource Center on Psychiatric Advance Directives.
Issues to consider
Although clinicians may worry that psychiatric advance directives will contain a laundry list of unreasonable demands, and patients may worry that their instructions will not be followed, preliminary studies suggest otherwise. One study involving 106 outpatients at a community mental health center found that 95% of the advance directives they prepared contained instructions that were reasonable and consistent with standard care. Another analysis of the same cohort, which examined how the psychiatric advance directives were actually used during 90 crisis situations, found that actual care was consistent with advance instructions 67% of the time.
Nevertheless, for psychiatric advance directives to be useful, people need to carefully consider the following issues.
Competence. To be valid, a psychiatric advance directive must be completed by an adult — as defined by state law — who is competent to make medical decisions. (Some states treat emancipated minors as adults.) The law assumes that a person is competent unless a court has determined otherwise. Therefore a person drafting a psychiatric advance directive is generally not required to have a clinical assessment of competency. However, if a dispute arises about the validity of a psychiatric advance directive, a person’s competence may be questioned after the fact, so it may be useful to have a psychiatrist determine capacity ahead of time.
Incapacity. A psychiatric advance directive goes into effect when someone is deemed legally incapacitated and therefore unable to make treatment decisions. State laws define incapacity in different ways (and some do not define it). The determination is usually made by one or more clinicians, a judge, or some combination of professionals. Those considering using an advance directive should understand their state’s legal definition of incapacity, who makes the determination, and what options patients have for challenging the decision.
Health care agents. Not all states require that a patient designate a health care agent, but in practical terms, this may determine whether the psychiatric advance directive is useful. No written document can anticipate every medical situation, and in some situations advance directives may be too vague to provide clinicians with the guidance they need. Appointing a health care agent therefore provides valuable flexibility.
The health care agent can be a friend, a relative, or a clinician who is not providing the patient’s health care (this last proviso is to avoid any conflict of interest). Designating one or more “backup” agents is wise, in case the primary agent is unavailable when a psychiatric advance directive goes into effect. The health care agent is supposed to follow the instructions in a psychiatric advance directive and make decisions in keeping with the patient’s values and preferences — so it’s important that the patient find an agent who knows his or her preferences well enough and can be trusted with this responsibility.
Accessibility. The psychiatric advance directive is useful only if clinicians can access it during an emergency. A patient may want to file one copy with his or her medical record (at all relevant facilities) and distribute additional copies to members of the health care team, family, and friends. Electronic versions can be stored online, although a fee may apply, at the U.S. Living Will Registry. Some states also have online registries.
Some patients carry a copy of their psychiatric advance directive with them at all times, but a less cumbersome alternative is a wallet card alerting clinicians that a psychiatric advance directive exists and where to find it. The U.S. Living Will Registry provides an official registration card, but some patients make their own wallet cards.
Updates. Because patient preferences and treatment options change periodically, it’s important to keep the psychiatric advance directive up to date. The easiest way to do this may be to have a reminder placed in the patient’s medical record to review and update a directive periodically.
Key controversies
Two of the most controversial issues regarding psychiatric advance directives concern when clinicians can override these documents and when patients may revoke them.
Overriding a directive. Most state laws give clinicians broad discretion to override a psychiatric advance directive. The laws stipulate that clinicians may disregard advance treatment instructions when a patient is involuntarily committed to a facility, or when a patient’s wishes are not feasible or conflict with the current standard of care. However, even in these circumstances, clinicians are expected to honor other preferences expressed in the psychiatric advance directive.
Only one federal court so far has ruled on the validity of overriding an advance directive for psychiatric care, in a case known as Hargrave v. State of Vermont. Because Vermont does not have a law specifically authorizing a psychiatric advance directive, patients there adapt general advance care directives. Nancy Hargrave, the plaintiff, was involuntarily medicated for a mental illness in spite of her wishes to the contrary, which she had stipulated in her durable power of attorney for health care.
At issue was whether the state of Vermont could enforce a law to override her directive and provide medication. At the time, state law allowed doctors to nullify advance care provisions related to psychiatric treatment, but not other sorts of medical treatment. The court decided this provision violated the Americans with Disabilities Act.
This case continues to generate debate, with clinicians worrying that they will be sued if they override a psychiatric advance directive. However, it’s important to note that, at least for now, the Hargrave decision applies only in Vermont. In other states, the law generally allows doctors to override psychiatric advance directives when, in their clinical judgment, it is necessary to do so. But it is possible that other legal challenges will arise in the future.
Revoking a directive. A legally competent individual can revoke a psychiatric advance directive at any time. The controversy arises when a patient tries to revoke the document during a crisis. Some patients decide to insert a “Ulysses clause” into the directive, which explicitly states that its treatment directions should not be revoked during a period of incapacity. (The term recalls a strategy by the mythical hero Ulysses, who was so afraid he would fall under the spell of the beautiful music of the Sirens that he would sail his ship into the rocks of their island. He instructed his sailors to bind him to the mast and keep sailing straight, no matter how strongly he protested.)
Some clinicians view a Ulysses clause as a way to increase the chances that instructions given while a patient is competent are honored during a period of incapacity. But others believe these clauses place them in the unwelcome and ethically charged position of honoring choices a patient made in the past, while ignoring or overriding those a patient is currently expressing.
Resources
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Team approach best
Studies indicate that patients are more likely to complete a psychiatric advance directive when they receive assistance in filling out the forms. In 2007, for example, investigators from Duke University reported that 61% of patients who worked with a facilitator completed a psychiatric advance directive or authorized a health care agent, compared with only 3% of those given instructions but left to complete the forms on their own. In separate analyses of the data, the researchers concluded that the intervention itself increased some patients’ ability to actually fill out the forms or make treatment decisions — or what a lawyer might term their legal competence.
Legalities aside, most observers agree that in the ideal situation, both clinicians and patients will use psychiatric advance directives as a way to have a forthright discussion about treatment preferences in the event of an emergency. Filling out the document provides an opportunity for the patient and clinician to anticipate hard times, think things through, and talk openly — all of which enhance treatment. In this way, a psychiatric advance directive can help foster a therapeutic relationship that can accomplish more than any legal document ever could.
Srebnik DS, et al. “The Content and Clinical Utility of Psychiatric Advance Directives,” Psychiatric Services (May 2005): Vol. 56, No. 5, pp. 592–98.
Swanson JW, et al. “Superseding Psychiatric Advance Directives: Ethical and Legal Considerations,” Journal of the American Academy of Psychiatry and the Law (2006): Vol. 34, No. 3, pp. 385–94.
For more references, please see www.health.harvard.edu/mentalextra.
Helping teens stop smoking
A number of options exist, but many challenges remain.
Despite widespread efforts at education and prevention, roughly one-quarter of U.S. teenagers are smoking cigarettes at least occasionally by the time they graduate from high school. Sadly, about three-fourths of those who smoke on a regular basis will continue smoking into adulthood.
In part, this is because adolescents are more vulnerable than adults to becoming hooked on cigarettes. When researchers compared people of different ages who smoked the same number of cigarettes per day, they found that young people ages 12 to 17 demonstrated higher levels of nicotine dependence than any other age group. Adolescents are also more likely to become addicted after smoking fewer cigarettes per day than adults.
It is well known by now that smoking is the leading behavioral cause of premature death in the United States. Cigarettes are implicated in one in five deaths in Americans each year, including approximately one-third of deaths due to cancer. Smoking can also cause disabling health problems, including heart disease, stroke, and chronic obstructive pulmonary disease.
Although there are plenty of evidence-based guidelines for adults who want to quit smoking, until recently there’s been a dearth of research about how to help adolescents quit. Initially, the advice was simply to adapt adult stop-smoking strategies for teens. But more recent analyses have concluded that teens are not just “little adults” when it comes to quitting, so different approaches may be in order.
A number of options are available — in medical clinics, at schools, and on the Internet — to help teens quit smoking. A meta-analysis found that such stop-smoking programs aimed at teens increased the probability of quitting: Roughly 9% of teens participating in a stop-smoking program quit, compared to about 6% of controls. However, another review, which analyzed only studies that followed teens longer than six months, found there is no evidence as yet that any program improves abstinence rates for a prolonged period.
Even so, some guidance is emerging about which approaches work best for teens and which are not effective.
Progress and challenges
Several public health initiatives are aimed at preventing teens from smoking. These include raising taxes on cigarettes, which makes them more expensive; passing laws to restrict exposure to secondhand smoke and tobacco advertising and to prevent young people from purchasing cigarettes; and launching mass media campaigns to encourage prevention. In addition, a number of school-based prevention programs are offered nationwide.
These efforts seem to be having an impact. Data collected by the Centers for Disease Control and Prevention indicate that the proportion of teens who smoked in any given month fell from a high of 36% in 1997 to 23% in 2005. But that still means nearly one in four teens are smoking cigarettes.
Teens may begin smoking for any number of reasons. Many are copying behavior modeled by parents or peers. Girls in particular may hope that smoking cigarettes will help them lose weight. Some evidence indicates that media exposure to smoking may also influence teens. Although cigarette advertising on television is prohibited, ads continue to appear in print, on billboards, and on the Internet. And an analysis of top box office hits in the United States found that three in four movies contained some depiction of people smoking.
Once hooked, many teens do try to quit. Anywhere from 55% to 65% of smokers ages 12 to 18 have attempted to stop smoking, according to surveys. But most teens (like most adults) need help to kick the habit.
Clinical approaches
The most current clinical practice guideline encourages physicians, nurses, and other clinicians to ask teens about smoking behavior during office visits, and then use age-appropriate methods to help teens to quit. The guideline recommends that clinicians do the following:
- Regularly screen adolescents and their parents to determine whether they smoke and, if so, provide encouragement and suggest interventions to stop smoking.
- Use behavioral and counseling interventions. (For some tips, see discussion below.)
- If an adolescent has become dependent on nicotine and expresses a desire to quit smoking, consider prescriptions for bupropion (Zyban) or nicotine replacement therapy. (Be aware, however, that a review published since this recommendation was published indicates bupropion may not be effective for teens.)
Although more specific advice is hard to come by, case reports provide the following practical tips, which may help make a clinical intervention more effective.
Ask specific questions. Adolescents may not consider themselves smokers even if they use cigarettes on a regular basis. Concrete questions may better elicit smoking status. Ask, for example, if a teenager has smoked even one cigarette in the past 30 days, or ask specifically how many cigarettes he or she has smoked in the past week.
Keep confidences. Adolescents may be more open to talking about smoking behavior if they are assured the information is kept confidential. To ensure confidentiality, a clinician may have to ask about cigarette use when a parent is not in the room.
Understand how teens think. Adolescents tend to spend less time than adults mentally preparing to quit smoking, which may reduce the chances that they will succeed. They are also less able to plan for the future, partly because human brain circuitry is not yet fully developed until the early 20s.Therefore teens are more likely than adults to act on impulse and discount long-term consequences.
For these reasons, a clinician may need to spend extra time educating a teen about why it’s important to stop smoking, and then provide specific instructions about how to avoid situations where peers might be smoking, or what to do when the temptation to smoke occurs. Offering concrete tips for how to deal with cravings and find other habits to substitute may also help.
Leverage teen motivations. Because teen girls may be smoking in order to stay thin or lose weight, clinicians may have to provide information about nutrition and exercise as well as offer stop-smoking strategies. Some research indicates that teen boys are more likely to try to quit smoking if they want to participate in school sports. Emphasizing the physical benefits of quitting may help in such cases.
School-based programs
The meta-analysis mentioned earlier concluded that school-based smoking cessation programs aimed at teens work better than clinic-based interventions. The authors concluded that the most effective programs last for at least five sessions and use motivational enhancement, cognitive behavioral techniques, or social influence approaches.
Two model programs endorsed by the Substance Abuse and Mental Health Services Administration meet these criteria: the Not on Tobacco (NOT) program and Project EX. Though they differ in some respects, both use an approach that combines the following three elements:
- motivational enhancement, so that teens are encouraged to quit
- coping skills instruction, so that teens learn to deal with nicotine withdrawal, stress, and relapse triggers
- goal setting, so that teens make a personal commitment to quitting.
The NOT program involves a series of weekly group sessions held separately for teenage boys and girls — on the assumption that the reasons for smoking and motivations to quit vary by sex in this age group. The program helps the students understand why they started to smoke, learn about nicotine addiction and the deadly effects of smoking, and then identify social supports that will help them to quit. At various points, the students engage in role playing, learn relaxation techniques, and write about thoughts and emotions in journals.
Project EX covers some of the same areas, such as coping with nicotine withdrawal and finding ways to avoid relapse. However, it differs from the NOT program in that it encourages teens to take up yoga or begin meditating to deal with stress, instead of smoking, and it also includes a number of interactive games.
Both programs involve expenses for classroom materials and training of facilitators, although exact costs may depend on the school district and what state subsidies are available. The NOT program is endorsed and promoted by the American Lung Association.
ResourcesNot on Tobacco (NOT) and Project EX |
Additional options
Clinicians, school officials, and public health leaders who want to explore other programs may find it useful to consult a guide published by the U.S. Department of Health and Human Services in 2004. Youth Tobacco Cessation: A Guide for Making Informed Decisions provides detailed and practical steps for evaluating programs and putting them into practice in a particular community or other setting. It also provides case studies about how one state health department and one rural school system chose and implemented a smoking cessation program for young people. The guide is available free.
Additional guidelines and options are likely to become available in the future, as research on how to better target smoking cessation programs for adolescents continues. The culture may also move further towards making smoking socially unacceptable. In the meantime, the fact that smoking rates among youths have been falling since the late 1990s is something to be celebrated — because the easiest way to kick a habit is to avoid developing it in the first place.
Grimshaw GM, et al. “Tobacco Cessation Interventions for Young People,” Cochrane Database of Systematic Reviews (2006): Issue 4, Article No. CD003289.
McVea KL. “Evidence for Clinical Smoking Cessation for Adolescents,” Health Psychology (September 2006): Vol. 25, No. 5, pp. 558–62.
“NIH State-of-the-Science Conference Statement: Tobacco Use: Prevention, Cessation, and Control,” Annals of Internal Medicine (December 5, 2006): Vol. 145, No. 11, pp. 839–44.
Sussman S, et al. “A Meta-Analysis of Teen Cigarette Smoking Cessation,” Health Psychology (September 2006): Vol. 25, No. 5, pp. 549–57.
For more references, please see www.health.harvard.edu/mentalextra.
Postconcussion syndrome
Why this diagnosis is controversial and what treatments may help.
More than one million Americans suffer head injuries each year that are serious enough to send them to hospitals. The vast majority of these injuries — anywhere from 75% to 90% — are concussions. Although bicycle accidents and other sports injuries are often to blame for concussions in children, the most common causes in adults are falls and motor vehicle accidents.
Defined broadly, the term concussion is used to describe an injury that results from a blow or other
impact to the head. The person may briefly become dazed or lose consciousness. Dizziness or headache may follow. Other symptoms include neck pain, nausea or vomiting, sensory disturbances (problems with hearing, vision, or taste), fatigue, and confusion. Concussions can also cause either anterograde amnesia (inability to remember new information) or retrograde amnesia (forgetting what happened just before or during the accident).
These symptoms develop because a head impact that significantly jolts the brain can disrupt brain cell function. Most people recover within a few hours, although headache and irritability may persist for a day or more.
Persistent symptoms
In some people, however, symptoms of concussion persist. Case reports indicate that as many as 90% of people continue to experience headaches or dizziness one month after a concussion, and as many as 25% experience these symptoms for a year or more. Anywhere from 4% to 59% of people experience memory problems at various times following concussions.
Postconcussion syndrome is usually diagnosed when several symptoms persist for a prolonged period after a concussion, although diagnostic criteria vary and the diagnosis itself is controversial. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) has proposed diagnostic criteria (see sidebar). Adding to the challenge is the fact that risk for developing postconcussion syndrome isn’t related to any quantifiable measure, such as brain damage detected on a CT scan, neurological test findings, or other objective clinical assessments. It’s also not clear how many people actually experience postconcussion syndrome, with different researchers estimating that anywhere from 15% to 30% of people who suffer a concussion will develop postconcussion syndrome.
Many of these patients will be referred to a mental health clinician for care. Although no official guidelines exist about how to treat postconcussion syndrome, case reports and surveys reveal some options.
Medication options
The medications prescribed depend on the underlying problem.
Headaches. Analgesics help relieve headache pain in many people, although antidepressants may help those who develop chronic daily headaches.
Mood and other problems. Anxiety and depression affect more than one-third of people with persistent postconcussive symptoms, although it is not clear whether these mood disorders were present before the injury or developed as a result of it. (Some patients may well become anxious about the possibility of brain damage, for example.) Antidepressants are usually prescribed to treat anxiety or depression, as well as sleep disturbances, fatigue, irritability, or poor concentration.
Psychological counseling
Psychological counseling can improve outcomes for some people with postconcussion syndrome. Some research indicates that basic patient education — explaining what symptoms to expect, how long they may endure, and that these are part of the normal recovery process and not signs of permanent brain damage — can reduce the incidence and duration of postconcussion symptoms, especially if offered early on.
Another helpful tool, cognitive restructuring, teaches a patient to identify and cope with symptoms that might not be caused by the concussion. Practical guidance about how to gradually resume normal activities after a concussion, rather than trying to rush back into the daily routine, can help people manage fatigue and problems in cognition and concentration.
Although much remains to be learned about postconcussion syndrome, it seems clear that many factors contribute to persistence of symptoms. The best treatment strategy will therefore involve several different approaches.
Mittenberg W, et al. “Treatment of Post-Concussion Syndrome Following Mild Head Injury,” Journal of Clinical and Experimental Neuropsychology (December 2001): Vol. 23, No. 6, pp. 829–36.
Ropper AH, et al. “Clinical Practice: Concussion,” New England Journal of Medicine (January 11, 2007): Vol. 356, No. 2, pp. 166–72.
For more references, please see www.health.harvard.edu/mentalextra.
In Brief
Study finds ADHD is diagnosed and treated less than half the time
Researchers who analyzed survey results for a nationally representative sample of U.S. children ages 8 to 15, from 2001 to 2004, found that less than half who met the diagnostic criteria for attention deficit hyperactivity disorder (ADHD) had actually been diagnosed with it, and an even smaller proportion were being treated for the disorder.
Researchers from the Cincinnati Children’s Hospital Medical Center telephoned the parents or caregivers of more than 3,000 children originally identified through the National Health and Nutrition Examination Survey to determine how many children had ADHD. They concluded that 8.7% of the children had symptoms that met the diagnostic criteria for ADHD, a prevalence rate similar to that reported earlier by the National Survey of Children’s Health.
But only 48% of the children with symptoms had actually been diagnosed with ADHD by a clinician, and only 32% of these children had been consistently treated with medication during the previous year. Although the study had limitations — most significantly, it relied on a parent’s recall rather than objective medical or pharmacy records — the authors conclude that many children with clinically significant symptoms of ADHD are not getting the treatment they need.
Froehlich TE, et al. “Prevalence, Recognition, and Treatment of Attention-Deficit/Hyperactivity Disorder in a National Sample of U.S. Children,” Archives of Pediatrics and Adolescent Medicine (September 2007), Vol. 161, No. 9, pp. 857–64.
In Brief
Mice provide new clues about obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) affects about one in 50 people, and although symptoms vary, it is characterized by recurrent or persistent thoughts, impulses, or images, as well as repetitive actions such as washing hands compulsively. The condition is often disabling.
Duke University researchers did not set out to study OCD. Instead, they wanted to study a protein encoded by a gene known as SAPAP3. They applied a classic research technique: knocking out the gene to determine what happens when the protein is not produced.
To their surprise, the researchers found that although the knock-out mice seemed normal at first, by the age of four to six months old they had begun to groom and scratch themselves compulsively. The mice not only created bald patches and rubbed their skin raw, but also displayed the type of anxiety sometimes seen in people with OCD. When the scientists gave the mice a selective serotonin reuptake inhibitor, a medication used to treat OCD, the obsessive grooming behavior decreased.
Researchers are excited about the findings for two reasons. First, by implicating a previously unsuspected biologic pathway, this study suggests new targets for OCD drug development. Second, the mice may offer the first good animal model for OCD, which could pave the way to future discoveries about the biology of this disorder and how best to treat it.
Welch JM, et al. “Corticostriatal Synaptic Defects and OCD-like Behaviours in SAPAP3-Mutant Mice,” Nature (August 23, 2007), Vol. 448, No. 7,156, pp. 894–900.
In Brief
Research suggests why stress may add pounds
Everyone indulges in a little “comfort food” once in a while, sometimes to deal with stress. But people under chronic stress who habitually consume junk food may find themselves packing on the pounds, especially in the abdominal region, thus increasing their risk of diabetes and heart disease.
A study has identified one possible culprit: neuropeptide Y (NPY). Scientists already knew that this body chemical increases appetite, especially for carbohydrate-rich food, and that certain types of stress increase NPY levels. In the latest research, investigators from Georgetown University showed that NPY stimulates the growth of abdominal fat cells in mice under conditions of chronic stress. When the researchers inhibited NPY and subjected the mice to two types of stress, they were able to prevent fat accumulation. The report may point to a new target for weight loss drug development.
For now, the research provides one more reason why people dealing with stress should try to find healthier ways of coping with it: Although chronic stress may increase the desire to overeat comfort foods, it may also increase the likelihood that doing so will lead to unhealthy weight gain.
Kuo LE, et al. “Neuropeptide Y Acts Directly in the Periphery on Fat Tissue and Mediates Stress-Induced Obesity and Metabolic Syndrome,” Nature Medicine (July 2007), Vol. 13, No. 7, pp. 803–11.
Commentary
The rise of pediatric bipolar disorder
An article published in the September 2007 issue of the Archives of General Psychiatry provides strong evidence that the diagnosis of bipolar disorder is rising in popularity, especially in children. Analyzing survey data from the National Center for Health Statistics, the authors identified trends in the diagnosis and treatment of bipolar disorder by measuring visits to physicians.
Office visits by children diagnosed with bipolar disorder multiplied 40-fold from 1994 to 2003. The number of office visits per 100,000 children went from a quite rare 25 to a much more common 1,003 in that period. Adult office visits during the same period almost doubled (905 to 1,679), which would be impressive on its own if the childhood increase were not so stunning.
Few can agree about what this means. Some see the shift as progress, pointing out that a problem that had previously gone unnoticed is now being identified and treated, with consequent improvements in symptoms and quality of life. Others, however, see in these numbers rampant overdiagnosis. They say thousands of children — in some cases as young as two or three — are receiving too many medications they don’t need and that cause uncomfortable and sometimes dangerous side effects.
Bipolar disorder is very hard to diagnose in children, in part because so many of its symptoms overlap with other disorders. The prime example is attention deficit hyperactivity disorder (ADHD). Two of the symptoms presumed to be evidence of a mood disorder — irritability and hyperactivity — are also key criteria for an ADHD diagnosis.
There is also no consensus on how to measure symptom severity. If a child is perceived to be disruptive, it could mean that his or her behavior deviates wildly from the mean, or it could be that the person describing the child is unusually intolerant of unruly behavior.
Cynics say that drug company profits motivate the rush to this diagnosis. Certainly, the promise of quick relief is easy to sell. But many researchers and clinicians would argue that the rise in diagnosis is a normal evolution in scientific inquiry.
Understanding that mood disorders have genetic and biological underpinnings, adults with bipolar disorder and the clinicians who treat them reasonably assume that the disorder starts relatively early in life. Catching and treating the disease early could diminish suffering.
Unfortunately, we are still at an early stage in defining this disorder for children. We don’t know yet how well symptoms like irritability will predict who will develop the adult form of bipolar disorder. No matter how widely or narrowly we cast the net today, too many will end up being diagnosed when they shouldn’t be (false positives) or will not be diagnosed even though they should be (false negatives).
Yet there is some good news.
Childhood distress of all types is getting much more attention than it did in the past. Rising diagnosis means rising interest in this problem, which will inevitably lead to more scientific discovery, better treatment, and maybe even additional resources directed to the treatment of pediatric mental illness.
Also, listening to concerned debate about statistics does not prevent clinicians and families from considering each child as an individual. In the future, we expect the contentiousness of the debate could be moderated by geneticists when they discover some of the root causes for painful symptoms. The diagnostic labels will then diminish in importance, because we’ll have tools to better predict not only who should be treated, but also which treatments to try and which to avoid.
— Michael Craig Miller, M.D.
Editor in Chief, Harvard Mental Health Letter
