The studies have been done and the consensus is in. Juvenile bipolar disorder (JBD) has probably been overdiagnosed recently, and the DSM-5 will describe a narrower phenotype to qualify for the diagnosis. The 40-fold increase in the diagnosis from 1994/1995 to 2002/2003 (Moreno C et al, Arch Gen Psychiatry 2007;64(9):1032–1039) was an overreaction that will likely be reined in. At this point, it is worth thinking about how we got here, and what it means for clinicians as a cautionary tale for the future.
First, there is a lot to be said about external pressures that have contributed to this increase in diagnosis. The rise of pharmaceutical companies’ economic might and direct-to-consumer advertising have been pointed to as possible culprits, as the explosion in advertising has somewhat destigmatized the use of psychiatric medications. Some have pointed to prominent researchers’ financial relationships with these companies. Congressional investigations into high-profile academic researchers receiving payments from pharmaceutical companies directly related to their research has been damaging to the field’s image.
The fiscal constraints on the mental health care system in general have clearly also played a role. Psychiatrists are pushed into seeing patients in ever-shorter visits, insurance requires diagnoses sooner in the process, and environmental supports like parent partners, well-trained foster parents, small classrooms, quality after school programs, and intermediate level treatment are scarce, favoring pharmaceutical over human intervention. Further, diagnostic labels like JBD may make accessing services like individual education plans easier.
Aside from these bigger questions, there is the question of how and why individual, well-meaning, caring, concerned clinicians were apparently eager to embrace this diagnosis before the science was in. The decision to give a child a label of a serious mental illness is not made lightly, nor out of conscious self-interest. There may be emotional, counter-transferential reasons why this happens that are worth exploring.
It is important to emphasize that the children who have been being diagnosed with juvenile bipolar disorder are as a group very impaired. Indeed, when Dr. Joseph Biederman was caught in the crosshairs of the congressional conflict of interest investigation, the chiefs of child and adult psychiatry at Massachusetts General Hospital wrote a letter to the editor supporting him entitled, “Heroes in Mental Health” pointing out how much these children and families struggle, and how much credit he deserves for being willing and able to offer help and hope to them.
Believing that you know what is happening, giving it a label, and having something to offer is tremendously liberating for both the family and the doctor. However, the drive to feel helpful, and the fear of being powerless, has a downside. Our discomfort with sitting with uncertainty and despair understandably leads us to reach for whatever we can offer.
Sadly, what we feel comfortable offering has been shrinking. It has been clearly documented that the number of psychiatrists doing a significant amount of psychotherapy has been declining markedly (Mojtabai R & Olfson M, Arch Gen Psychiatry 2008;65(8):962–970), and the same study found that those who provide psychotherapy to all their patients prescribe medications less frequently than those who provide psychotherapy less often. As we do less therapy, the old adage, “when all you have is a hammer, everything looks like a nail” may apply. When we don’t have the option to do therapy, or feel less comfortable doing it, we are much more pulled to believe that what we do have to offer—namely diagnostic labels and medications—are useful and meaningful. Our narcissist defenses move us towards accepting ideas that make us feel useful and powerful, sometimes without appropriate credulity.
Often the families of the children who might be diagnosed with JBD are also quite impaired. Whether they are struggling with a purely difficult child, or whether some of the child’s problems may have stemmed from the family milieu, these families present challenging dynamics to the child psychiatrist. There may be a strong push to label the child because it will alleviate parental guilt by seemingly confirming that there is “something wrong” medically with the child and therefore not the parents’ fault. Alternatively, it could mean that the parents do not need to look too closely into their child’s suffering because the answer is a medication adjustment, not a deeper emotional one. Sometimes as providers we are pulled into these dynamics unawares.
Sometimes we consciously react against family dynamics hoping to intervene positively. Parents who see their out-of-control children as all bad, hostile, or manipulative may move us as providers to give an alternative narrative that is less pejorative to the child. In an effort to protect the child, we may feel drawn to giving a label that implies that the child’s behavior is not the child’s fault, and makes the parent more empathic. Parents more easily understand something that has a clear label and a history behind it, than a discussion of why it’s important to be understanding.
Finally, it is worth admitting that as clinicians we are also susceptible to the stigma and uncertainty surrounding mental health care. In the face of societal skepticism and sometimes hostility to mental illness, it is tempting to flee to certainty. It is uncomfortable to say, “I don’t know, and I’m not sure how to help.” The reality in child psychiatry, however, is often that we don’t know. It takes time for illnesses to reveal themselves, and even when they do they often don’t fit clear diagnostic boxes. It takes a tremendous amount of resilience and ego to be able to feel comfortable with that, and meet families where they are (which is often confused, upset, guilt-ridden, scared, and sometimes angry). The temptation to offer a diagnosis, and make ourselves feel smart and useful, is very strong and shouldn’t be ignored.