Childhood Bipolar Disorder: The View From Abroad

Is Pediatric Bipolar Disorder (PBD) a “culture-bound syndrome” of the USA?

The following is a guest post from Dr. Peter Parry, an Australian psychiatrist and senior lecturer at the University of Queensland, who is a co-conspirator of mine in the fight against the pernicious practice of psychiatrists and pediatricians diagnosing acting-out children as having the major psychiatric disorder bipolar disorder (manic depressive illness).

A “culture-bound syndrome” [http://rjg42.tripod.com/culturebound_syndromes.htm]  in psychiatry is used to describe psychiatric disorders that generally occur in exotic indigenous communities and developing countries due to cultural factors.  Examples include “Koro” - a disorder of group hypochondriasis that occurs in epidemics in parts of south-east Asia where men start to believe that their penises are shrinking into their abdomens; “Dhat” - a disorder in India associated with anxiety and fatigue in men related to fear of losing too much semen; “Bebainan” - a disorder where young women from Balinese nobility, who in everyday life must behave with extreme politeness and be very demure, vent their anger in seemingly irrational brief rage attacks.  The last of these can be seen to have a useful function for individuals whose emotional lives are otherwise highly socially constrained.

In a couple of blog posts on “The Geography of Pediatric Bipolar Disorder” [http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder] on Psychology Today  I concluded by posing the question: “is Pediatric Bipolar Disorder (PBD) a culture bound syndrome of the USA?”.  As I explained in the first post, PBD, despite becoming the most common diagnosis for pre-pubertal children in US inpatient units 10 years ago [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001259/], has barely rated in the rest of the world. 

This is not to say that there haven’t been a few academic research centers who have investigated PBD in places like Spain, Switzerland, the Netherlands, Brazil, India and Australia.  These research centers have usually collaborated with prominent American PBD research centers such as Prof Biederman’s center at MGH-Harvard.  In clinical practice outside the USA there have been a few isolated pediatricians and rarely child psychiatrists who have adopted the American clinical practice of diagnosing PBD in pre-pubertal children.  But the vast majority of practicing clinicians and academics in child psychiatry and pediatrics in Britain, Europe, Australia, New Zealand and to lesser extent Canada have simply not accepted PBD as a valid diagnostic entity in clinical practice.

Here in Australia, one group that seriously researched the PBD diagnostic constructs was based in Sydney.  Their follow-up research found that few cases went on to true bipolar disorder.  Prof Philip Hazell who led much of this research was quoted in the Australian media [http://www.theaustralian.com.au/news/health-science/moody-teens-wrongly-diagnosed-with-bipolar-disorder-psychiatrist/story-e6frg8y6-1226191879545] saying “There are about 10 times as many people with 'lookalike' mood dysregulation as there are people with bipolar disorder”.

Now it is true that bipolar disorder often first manifests in adolescence and early manic or hypomanic symptoms can be mistaken for extreme adolescent emotionality, risk-taking or substance abuse.  But until an unequivocal manic episode erupts it is difficult to make the diagnosis.  The “BCOS study” [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract] was a study of 240 adults mostly in their 40s with classical Bipolar-I or Schizoaffective Disorder in Melbourne and Geelong in Australia.  The BCOS study found that the diagnosis was often made years late.  The study asked the adults when their symptoms first began.  The median age of onset for the first hypomanic/manic episode was 24.1 years old.

Yes bipolar disorder is a severe mental disorder that needs to be detected earlier in life than it often is.  But it is still a disorder that doesn’t usually start until late adolescence or young adulthood.

Another study that asked middle aged adults with bipolar-disorder when they thought their first symptoms of bipolar disorder began was published in the British Journal of Psychiatry [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract].  The authors of this study were quite favorably disposed towards PBD.  The remarkable aspect of the study is the discrepancy in recall of symptom onset between the European subjects with adult bipolar disorder (Dutch and Germans) and the American subjects.

Is there something about childhood in the USA that brings on a severe psychotic mental disorder such as bipolar disorder so much earlier than in other countries?  Or is there simply an over-diagnosis fad in operation, one that colors the memory recall of childhood?  Notably the American adults in this study had features more suggestive of milder “bipolar” and more personality and substance use problems than the Europeans who had more classic euphoric manic symptoms.

A 20 year follow-up study [http://www.jaacap.com/article/S0890-8567(09)64566-4/abstract] in New Zealand (NZ) was published in the Journal of the American Academy of Child & Adolescent Psychiatry in 1991 (before the creation of the PBD phenomenon).  It was based on all inpatient admissions to the child and adolescent psychiatric ward for a catchment area of 1 million people.  In those 20 years there were 59 children under age of 18 who presented with a confirmed psychotic illness that included schizophrenia, schizoaffective disorder or mania/bipolar disorder.  Age of diagnosis was based on reports of first symptoms, not date of admission to the inpatient unit.  Of these 59 children and teenagers, only 3 were aged 12 or under at onset of symptoms.  One of these 3 children was reported to have had their first manic episode at age 9, the youngest who later turned out to have schizophrenia was aged 7 at onset of first symptoms.

The lead author of the study is now Emeritus Professor of Child & Adolescent Psychiatry in Auckland, NZ, Prof John Werry.  In a survey that I and colleagues organized of Australian and New Zealand (ANZ) child psychiatrists [http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2008.00505.x/abstract] on PBD that found high levels of skepticism (including that only 3% thought that PBD was not over-diagnosed in the USA), Prof Werry sent a hard hitting comment for public airing:

“I do not see any juvenile bipolar disorder below adolescence and I think that the American view is mostly nonsense as do many of my American colleagues.”

The second author of the NZ study was one of his “American colleagues”, Dr Jon McClellan, a child & adolescent psychiatrist who returned to the USA and is based in Seattle.  Dr McClellan was one of the very few child psychiatrists to have a dissenting article [http://www.jaacap.com/article/S0890-8567(09)61468-4/abstract] on PBD published in the Journal of the American Academy of Child & Adolescent Psychiatry.  With regard to PBD his article concluded:

“the rate of psychotropic agents being prescribed to preschoolers is skyrocketing…Labelling tantrums as a major mental illness lacks face validity and undermines credibility in our profession.”

One very prominent US psychiatrist, Prof Allen Frances who was chair of the DSM-IV task force, has called PBD a “fad” [http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005] diagnosis.

What I found when attending the American Academy of Child & Adolescent Academy (AACAP) meeting in Hawaii in 2009 is that Werry, McClellan and Frances were spot on.  Many US child psychiatrists were very troubled by the PBD diagnostic fad, the bad effects on the children and families of a spurious diagnosis and wrong treatment, and the undermining of credibility in our profession.  I received mainly supportive comments from my US colleagues when I presented my poster of our Australian and New Zealand survey showing high levels of skepticism about PBD in ANZ.  These comments helped to explain what it was about the culture of the USA that had spawned the PBD fad epidemic.

Firstly – the US health system is mainly a private insurance system and much more fragmented than the universal health cover that exists in nearly all other 30 developed nations in the OECD [http://www.oecd.org/dataoecd/24/8/49084488.pdf].  US health insurers are more likely to restrict reimbursements on the basis of diagnosis than health insurers in other countries.  Also pharmacotherapy is favored over the psychotherapies. 

At the Hawaii AACAP conference an American child psychiatrist told me that if she is seeing a boy with emotional and behavioral problems embedded in difficult family dynamics, with some insurers she has to phone the insurer in the first session and is asked to give a diagnosis. If she says she has no diagnosis at that early stage, the insurance clerk says no reimbursement. If she says the diagnosis is a “parent-child relational problem” (which is a non Axis I DSM diagnosis) she may also be told no reimbursement. If she says it is an “adjustment disorder” (an Axis I DSM diagnosis) then she may be allowed 1 or 2 sessions to fix the complex problems. But if she says it is “bipolar disorder” then ongoing sessions are likely to be reimbursed. 

This is effectively diagnosis by medically untrained health insurance clerk.  It is also an expensive system, the USA spends 17% of its GDP on health care whereas other OECD nations spend between 8% and 11%.  A lot of money goes into paying medically untrained clerks and profits to shareholders.

Secondly the pharmaceutical industry has focused its influence on medical research and public opinion more in the USA than elsewhere.  The pharmaceutical industry is globally the most profitable industry on the planet.  In 2002 the 10 Pharma companies in the Fortune 500 had greater profits than the other 490 world’s biggest companies combined.  In 2008 they averaged 18% profits whilst the rest averaged 0.9% profits in the global recession.  Pharma spend 3 times as much on marketing to the medical profession and (mainly in the USA) the public than they do on Research and Development.  The biggest market for medications, particularly psychotropics, is the USA and direct to consumer advertising (DTCA) is only legal in the USA and New Zealand (but NZ has a tiny market).  Thus the American public have been flooded with advertising of psychotropic drugs and often ads about bipolar disorder whereas the public in other nations have not (though the internet is changing this).

Another US child psychiatrist colleague told me at the ANZ child psychiatry conference in 2007 that in working as a locum in NZ he had never had parents come to see him stating their child had “such and such diagnosis” and demanding a related medication, rather they asked him what he thought.   Conversely parents invariably were fixated on a diagnosis and drug or two when they came to consult him in the USA.  He had also trained at an academic child psychiatric unit prominent in PBD research and was trained to ask himself “is it bipolar?” and diagnosed half a dozen cases of PBD, yet in NZ he’d never seen a case of PBD and had started to question his training.

The pharmaceutical industry provides considerable funding to researchers and to academics to provide “continuing medical education” (CME) to other doctors.  Internal industry documents [http://www.healthyskepticism.org/global/news/int/hsin2009-12] revealed that Pharma saw broadening of bipolar diagnoses in adults and children as useful to selling more atypical antipsychotic agents.  Such CME is a global phenomenon and has been harshly criticized [http://www.psychiatrictimes.com/display/article/10168/1570483] in recent years.  However proponents of PBD providing CME were mainly confined to the USA.

A key researcher in neuroimaging children diagnosed with PBD, Dr Mani Pavuluri, presented findings at the Hawaii AACAP meeting.  The research appeared to be of high technical quality.  The findings (overactive right amygdale, underactive right frontal lobe) were identical to findings in children who had suffered attachment trauma and abuse.  I and others in the audience asked why not call such children “affect dysregulated” rather than PBD.  Dr Pavuluri agreed that would be a more neutral term, but stated “if we don’t call them bipolar we don’t get funding for our research”.  Such a dependence on a presumed result favored by funders reverses the scientific process.

Also at the AACAP Hawaii conference I asked Dr Melissa DelBello about attachment trauma in her group’s research, the interchange was recorded by Dr. David Allen on this blog here [http://davidmallenmd.blogspot.com.au/2010/04/attachment-latest-dirty-word-in.html].

I did an extensive review [http://cdn.intechopen.com/pdfs/29393/InTech-Paediatric_bipolar_disorder_are_attachment_and_trauma_factors_considered_.pdf ] of the PBD literature for exploration of attachment, trauma and abuse as possible contextual factors and found that the PBD literature was extremely lacking in consideration of these very obvious markers of distress in childhood. 

Why this is so is a very interesting question.  Denial and repression of trauma is a feature of humanity, be it at individual, family or societal levels.  Whether this is more the case in the USA is unlikely but it is possible that American parents have been more indoctrinated with the neurobiological paradigm for children’s behavioral problems and this helps them avoid “parent blaming”.  As an aside, I find it helpful to discuss with parents how parenting in modern societies is incredibly difficult compared to how parenting evolved in small hunter-gatherer ancestor tribes. 

But other modern societies have similar epidemics to the US PBD epidemic.  Instead of PBD in Europe, Canada and Australasia there is a tendency to also over-diagnose autistic spectrum disorders and ADHD as ways of overlooking more complicated attachment, trauma, family dynamic, learning difficulties, bullying and other contextual problems.  To a great extent I think the simplistic checklist approach to diagnosis fostered since DSM-III plays a role in this [http://www.clinicalpsychiatrynews.com/views/commentaries/single-article/diagnostic-labels-and-kids-a-call-for-context/5783d363fe823984bafbef98b0ffaa75.html]

According to DSM-IV: “Not all (culture-bound syndromes) are considered pathological in their society of origin, and may be seen as "idioms of distress”, a way of communicating distress in a way which is culturally understood and, to varying degrees, accepted.”  Thus for a society that has been “educated” to see mental, emotional and behavioral problems as based in neurochemistry fixable with medications, where “parent blaming” is considered unsociable, where health insurers value pharmacotherapy over more talking therapies and insurance clerks request more serious diagnoses from clinicians before reimbursing sessions, and where funding of research comes largely from pharmaceutical companies – to diagnose the moodiness and rages of distressed toddlers, preschoolers and older children as bipolar disorder has to varying degrees become accepted. 

Prescribing polypharmacy psychotropic cocktails to toddlers can be seen as the ultimate in a Huxleyan “brave new world”, the ultimate end point of “Pharmageddon” [http://www.socialaudit.org.uk/60700716.htm].  The recent book by Dr David Healy expands on how we arrived at such a point [http://www.ucpress.edu/book.php?isbn=9780520270985].  PBD can also be seen as an emblematic diagnosis for an era of “mindless psychiatry” [http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826].

The US is not alone to suffer from these factors, but it seems to suffer more than other jurisdictions and hence PBD can be seen as a culture bound syndrome of the USA.  That is not to say it couldn’t spread to other nations if the same predisposing factors were to arise, and ADHD and Autistic Spectrum Disorders do to some extent represent a similar phenomena outside the USA.