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Treatment of depressed children questioned
Bipolar disorder and other illnesses may be missed
Record numbers of U.S. children are being treated for depression and receiving prescriptions for antidepressants. Some mental health experts, however, fear many of these patients actually suffer from more severe illnesses and are being misdiagnosed.
According to researchers at Washington State University in Pullman, the rate of diagnosis of depression in children has more than doubled from the early 1990s to 2001. And the rate of prescriptions of antidepressants for them has more than tripled during the same time period.
The Washington researchers used information from the U.S. National Ambulatory Medical Care Survey, an annual survey of office visits to physicians, grouping the survey data into three time periods: 1990-1993; 1994-1997; and 1998-2001. In the final period, researchers found that diagnoses of depression in children 5 to 18 years of age rose to 31.1 per 1,000 office visits from the initial level of 12.9 diagnoses per 1,000 office visits in the first four-year period.
The information was presented in May at the annual meeting of the American Psychiatric Association in New York City.
While it is true that many children may suffer from depression, some experts fear that the increase — and similar increases in the number of adults using antidepressants — are largely driven by the number of general practitioners diagnosing and prescribing treatment for patients with mood and behavior problems.
Often primary care providers do not have the appropriate training to distinguish clinical depression from other mental illnesses, such as bipolar disorder, which may leave large numbers of people treated inappropriately, says Thomas W. Brown, MD, assistant professor of psychiatry and behavioral science at Wake Forest University Baptist Medical Center in Winston-Salem, NC.
"When one (particularly a nonpsychiatrist) promiscuously puts people on antidepressants, a certain number of [the patients] will actually be dysphoric bipolars," Brown says. "The abnormal high-energy mood is irritability, unhappiness, and the sense of nothing’s right; nobody’s pleasing me, etc.’ If given an antidepressant, this mood is intensified — not alleviated."
Understanding bipolar disorder
Specialists in psychiatry and neuroscience are just beginning to understand that bipolar disorder manifests itself in many different ways besides the "classic" cycling of extreme high-energy euphoric mania followed by deep depression, he says.
"In the area of bipolar disorder, one of the things that is true (or we are now finding to be true) is that any combination of abnormal affect, either the depressed side or the elevated side, is how bipolar can present," he explains. "On the elevated side, it can be euphoric, or it can be irritable, or it can be happy, or it can be anxious. And any combination in terms of being purely euphoric, depressed; partially depressed, partially euphoric; extremely irritable, partially depressed — any combination you can imagine occurring however it might over time — either cycling slowly or rapidly is how bipolar can present. There are no rules."
Diagnosing bipolar disorder is extremely difficult and requires a complex and lengthy evaluation — something for which primary care providers have little time.
General practitioners attempt to stay abreast of new treatments for a variety of chronic ailments — from diabetes and rheumatoid arthritis to heart disease. Understanding the complexities of mental illness in sufficient detail to differentiate between them is too difficult a task for the generalists, Brown notes. And diagnosing patients with dysphoric bipolar disorder (irritable bipolar disorder) is particularly difficult.
Patients may feel that they are depressed because they feel in a negative mood all of he time, he says. Thus, they may present in a physician’s office and say they believe they are depressed.
However, it’s important to distinguish the classic symptoms of clinical depression (exhaustion, lack of sleep, inability to function, extremely sad or negative thoughts) with the higher energy negativity of dysphoric manic episodes.
"This is a very subtle diagnosis. If you are not seeing these types of patients a lot of time, it is not an inherently obvious diagnosis," Brown explains. "One of the things I do to help my patients is I say, Let me understand really clearly what this misery is in your life. Are you in the kind of depression where you sit there like all the air has been let out of the balloon, there is no energy, can’t move? Or, are you in the kind of misery where, although you are miserable, your thoughts are jumping around, you are jumping around, the sky is the wrong color of blue, everything makes you angry, you are frustrated, you are miserable, but you are not sitting there like a sad sack?’ And, they say, Oh, believe me, Doc, I can’t sit there. Everything upsets me; I am not sitting there doing [absolutely] nothing!’
"The thing that really distinguishes depression from an irritable dysphoria is that the person is unhappy as all get out, but they are mentally energized," Brown concludes. "When someone is pulling a lot from the manic side, even when there is no euphoria, it is a mentally energized thing, even if at that moment, they are so unhappy they are crying. They have a mood abnormality, though, but it is not depression. But that may be the best word that person knew to describe their symptoms."
Misdiagnosis can lead to tragedy
Judith S. Lederman, the author of The Ups and Downs of Raising a Bipolar Child: A Survival Guide for Parents, knows all too well the difficulty primary care providers have accurately diagnosing mental illness in children.
Her son, Eric, was misdiagnosed as having attention-deficit hyperactivity disorder (ADHD) at the age of 8.
"His first suicide attempt was when he was 5 years old," Lederman recalls. "Initially, the psychologist said to me, He just likes attention, and he is a very clever, manipulative child. Just ignore these behaviors.’ That was the first practitioner who really fell down on the job, and we ended up in a very dangerous situation."
Her son’s behavior problems continued off and on for the next three years, with periodic episodes or raging and erratic behavior at school, home, and his pediatrician’s office, she continues. When he was 8, he suddenly stopped sleeping for days at a time and exhibited threatening behavior to his siblings and parents.
At the end of her rope, Lederman agreed to hospitalize her son for a 72-hour psychiatric evaluation. The result was the diagnosis of ADHD, a prescription for Ritalin and Luvox, and discharged home.
The situation got much worse.
"The Ritalin and Luvox really sent him into psychosis," Lederman recounts. "For two weeks, we lived in hell. He was completely unaware of what he was doing. He threatened to kill us. He took knives and threatened his siblings. He tried to burn the house down."
Finally, Lederman and her husband were able to get in to see a psychiatrist who had been recommended to them. After examining him and taking a careful family history, her son was diagnosed with bipolar disorder and treated appropriately.
"When you are monitoring children for mood disorders like bipolar, you really need to take account of their energy levels, and their moods. You have to look at the whole picture," Lederman notes. "It presents so weirdly in children — it is not classic at all. It is not happy, happy, happy, for three months, then sad, sad, sad. You can be looking at a child with immense energy who is irritable and depressed and in a terrible state, and an hour later it has switched. They often have rapid cycling and you see very strange fluctuations in energy and mood."
Lederman’s pediatrician never attempted to address her son’s altered moods, she notes, usually simply refusing to examine him when he was manic and behaving erratically.
The therapists and psychologists who performed the initial evaluation on her son also did not take a careful family history, which would have revealed a paternal grandfather with a history of similar behavior and a diagnosis of involutional melancholia.
Bipolar disorder frequently runs in families — and children with a family history of severe depression or other mental illness are at higher risk for being bipolar.
"Child and adolescent psychiatrists I talked to all know about bipolar disorder and can recognize it. It was these practitioners along the way [who misdiagnosed the problem] and even psychologists and therapists that are not really on board in terms of making the correct diagnosis or getting the patient to someone who can make the diagnosis," Lederman says. "That is where our medical system is falling down on the job."
Managed care and advertising play a role
Primary care providers need to become more educated about bipolar disorder and other mental illnesses, so they will understand when a situation is so complex that they need to make a referral to a specialist, Lederman says.
"They wouldn’t try to do brain surgery on someone, but they feel comfortable prescribing mind-altering medications with no problem," she says. "Most pediatricians will step back at the right point on other issues. [For example,] I had a pediatrician look at my daughter’s chin injury, which needed stitches, and say, I can’t do this. She needs to go to a plastic surgeon. I could do it, but it is not going to look as good.’ They need to know when to step back and say, You know, it may be ADHD, or it may be something else, and even though I took this history, I’d like you to get to someone who can look at it a little more.’"
Managed care organizations have pressured primary care providers to see more patients, to see them in quick office visits, and not to refer to specialists, Brown says. All of these factors are leading to more missed diagnoses of mental disorders.
"More people in general medicine need to, in more instances say, Look, I am an internist [or] I am a family practitioner. This is not what I specialize in. You, in fact, need to see someone who does specialize in this area,’" he says.
This does not mean that every patient needs to be in talk therapy or that every patient will have to continue seeing a psychiatrist. But a psychiatrist is the best clinician to appropriately screen patients with mood and behavioral disturbances, he adds.
Because some patients may be reluctant to see a psychiatrist initially, the general practitioner can encourage them by making it clear that he or she (the primary care provider) will continue to cooperate with the specialist in providing care.
"In the same way that they take someone who has arthritis and say, I think you may have rheumatic illness, and I am not a specialist in differential diagnosis of rheumatoid arthritis. You need to go see the rheumatologist,’" Brown explains. "Then you say, When the rheumatologist does the work-up and decides the course of treatment, [he or she] will send you back with a report, and I will be glad to follow you.’"
In the same way, the physician can tell the patient that the psychiatrist needs to perform an examination to ensure the patient is actually suffering from clinical depression, can adequately be treated with medication, and appropriately monitored by the primary care provider.
The current controversy over use of the class of antidepressants that are selective serotonin reuptake inhibitors (SSRIs) is indicative both of the number of people placed on these medications inappropriately, and in the difficulty general physicians may have in adequately monitoring patients who take them, Brown adds.
"I think this is where folks are getting [into] trouble and what is hitting the antidepressants with an undeserved bad name," he says. "If you take people who are depressed and put them on antidepressants, I simply refuse to believe that those people, because of the antidepressants, are in fact developing suicidal thoughts."
However, in its warnings issued to providers about the use of SSRIs in children, the U.S. Food and Drug Administration asked providers to watch for signs of agitation, anger, and irritability, Brown notes.
"They are describing classic signs of somebody hitherto undiagnosed with bipolar disorder who, when introduced to an antidepressant, could be stimulated into something that resembles hypomania, but doesn’t look like it," he says.
Increased drug company marketing of antidepressants and other psychiatric drugs to both primary care physicians and to the public is also to blame for many of the mistaken diagnoses. This could ultimately land many physicians in trouble, Brown adds.
There is an emerging trend toward developing formulations that combine antidepressant and antipsychotic medications, and then marketing these formulations to primary care providers, but not psychiatrists. This is particularly frightening, Brown explains, because some antipsychotic medications carry risks of serious side effects, such as hypercholesterolemia, diabetes, or nerve disorders.
"They are [marketing] this to primary care physicians as a way to cover all of the bases," he says. "If the patient is depressed, they have the antidepressant. And if the patient also has schizophrenia or other severe psychosis, that would be covered as well."
For someone with schizophrenia, the risks might be justifiable, but to give the drug without knowing it is the patient’s only alternative could do that patient serious harm and leave the physician open to legal action.
Someone with coexisting psychosis and depression should be under the care of a specialist — not a general practitioner, Brown notes.