The bipolar diagnosis is on the rise. You can read it in the media and readily observe it by talking to people you know. More people than ever (and significantly more children than ever) carry the label. According to results of a study published in the Archives of General Psychiatry (September, 2007) entitled, “National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth,” we’ve seen a 40-fold increase in the diagnosis of bipolar disorder in children and adolescents between 1994 and 2003. During this same period, the bipolar diagnosis in the adult population nearly doubled.
Dr. Candida Fink, MD is a board certified child and adolescent psychiatrist who specializes in several areas including mood and anxiety disorders and dual diagnoses of developmental disabilities and mental illness. She treats children, teens, and young adults with a range of concerns including ADHD, anxiety disorders, OCD, autism, pediatric mood disorders, and mental health issues in school settings.Dr. Fink has co-authored two books – The Ups and Downs of Raising a Bipolar Child (with Judith Lederman, Simon and Schuster, 2003) and Bipolar Disorder for Dummies (with Joe Kraynak, John Wiley & Sons, 2005, third edition 2015). She has been featured nationally and locally in broadcast, print, and online media coverage and is a frequent speaker on mental health topics for community and school-based audiences.
Editor: Nadeem Noor
The estimated annual number of youth office-based visits with a diagnosis of bipolar disorder increased from 25 (1994-1995) to 1003 (2002-2003) visits per 100 000 population, and adult visits with a diagnosis of bipolar disorder increased from 905 to 1679 visits per 100 000 population during this period.
This sudden and dramatic increase in the diagnosis of bipolar disorder generates concern as well as questions. Consumers begin to wonder whether bipolar disorder is a real illness or just a diagnosis du jour. Is this increase in diagnosis good or bad? Does it mean more people who need help are getting it or that patients are being mis-diagnosed and receiving the wrong treatment?
Although these questions may ruffle the feathers of anyone who’s had to deal with the often brutal reality of bipolar disorder, they’re important questions to address. Let’s look at factors that could be contributing to the sudden and dramatic rise in the bipolar diagnosis:
- A greater awareness of bipolar disorder among doctors. The idea here is that many doctors simply did not recognize bipolar in the past, so they diagnosed it less.
- A greater awareness of (and perhaps a greater acceptance of) bipolar disorder among consumers allows more people who really need help to feel more comfortable seeking it rather than just trying to deal with it on their own.
- In the past, doctors often missed the bipolar diagnosis – patients often present with depressive episodes before full blown mania, so without careful diagnostic sleuthing, many people with bipolar were being diagnosed as depressed.
- The professional criteria for diagnosing bipolar disorder have expanded with the publication of the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The addition of the Bipolar Disorder Not Otherwise Specified category opened up a much larger range of mood regulation difficulties to being diagnosed as a bipolar variant. (See “Expanding the Bipolar Spectrum – A Potentially Dangerous Game,” on the Bipolar Blog.)
- The highly influential 1994 article published by Joseph Biederman, MD from Massachusetts General Hospital formally introduced the idea that young children could have bipolar disorder and described many (1 out of 60) of his sickest patients with this label. Prior to the publication of this article, bipolar disorder was thought not to occur in pre-adolescent children.
- Diagnosing children with mental illness has become more acceptable.
- Diagnosing older people with mental illnesses has become more acceptable.
- The proliferation of pharmaceuticals to treat both depression and mania have encouraged more doctors to make the diagnosis.
- Health insurance companies tend to pressure doctors to work quickly, encouraging quick diagnostic labels and the quickest possible intervention. This often leads to incomplete evaluations and knee jerk medications rather than taking more time for a comprehensive assessment and recommending more complex and comprehensive treatment interventions that would include various types of therapy and supports in addition to medication. Reimbursement for non-medication interventions has typically been much more restricted than for “medical” treatments.
- While it is just a speculation, it seems quite possible that as more and more anti-depressants (especially SSRI or Selective Serotonin Reuptake Inhibitor) are prescribed for treating depression, amphetamines (such as Adderall and Ritalin) are prescribed for treating ADHD, and other stimulants (including caffeine, nicotine, weight-loss drugs, and energy drinks) are used for various purposes, we’re seeing more emotional and behavioral side effects that can include agitation or sleep disturbances or even classically manic symptoms that may result in a premature bipolar diagnosis.
The question of whether bipolar disorder is over-diagnosed does not presume that bipolar is a phony diagnosis or that people (including children and adolescents) diagnosed with bipolar disorder have something else entirely. Patients and parents who battle this often devastating illness on a daily basis can benefit significantly by receiving an accurate diagnosis and the required medications and therapy to level out their mood fluctuations.
Ultimately for those with classically defined bipolar disorder or a broader problem with mood regulation, heightened awareness and improved understanding by the public – that this is an illness and not just “an excuse” or a moral failing – can only be positive. Shining a light on this range of painful illnesses is the only way to ensure that patients will be more able to seek help comfortably, and professionals will be more likely to make as accurate a diagnosis as possible and provide help to those who are suffering.
On the other hand, if the diagnosis is a misdiagnosis (as I believe it often is in the case of children and adolescents), then it can potentially prevent patients from receiving proper treatment and perhaps expose them unnecessarily to powerful psychotropic medications used to treat bipolar disorder. (Visitors to the Bipolar Blog are already aware of what I see as the potential problems posed by over-diagnosing bipolar in children, as I discuss in “Bipolar Disorder Over-diagnosed in Children?“)
What does this mean for providers and consumers? It simply means that an accurate diagnosis is the key first step in receiving the proper care. Doctors should take care to rule out other possibilities first, and consumers should seek an accurate diagnosis from a psychiatrist experienced in diagnosing and treating bipolar disorder.