I try to stay out of the whole Kiddy Bipolar Debate debate: none of the Shrink Rappers see children, so my knowledge of childhood psychiatric disorders is limited to what I saw during a 3 month inpatient rotation 20 years ago, what I read, and what I see of children in my personal life. It's a messy topic. I brought it up today because the Wall Street Journal has an article that summarizes nicely all the issues, the issues with regard to diagnosis, the fear of over-treating, the problem with under-treating, the question of whether mood dysregulation in children should be a separate disorder. Please see Shirley Wang's articleThe Long Battle to Rethink Mental Illness in Children. I'm glad they're leaning towards renaming bipolar disorder in children. When you hear Bipolar Disorder, you think about a lifelong condition that requires medication forever. Children have phases, behaviors occur in some arenas and not others. Perhaps if a child's emotional life is intolerable to them, or their behaviors make it impossible to function in their worlds, it's worth the risks to administer medications. But a kid throwing horrible tantrums, fighting, running around the room, does not necessarily evolve into the same category as an adult who has 3 episodes of depression, and 2 episodes of psychotic mania, during their lifetime. Oh, and I'm the one who thinks we should Rethink all of the Bipolar Diagnosis, not just for kids. So Wang writes: At one of his group's first in-person meetings, the NIMH's Dr. Leibenluft, an expert on bipolar disorder in children, gave a 20-minute PowerPoint presentation with evidence for a potential new disease. She called it Severe Mood Dysregulation. She described a decade of studying children with severe mood problems that don't fit neatly into current illnesses. Thus began a cerebral process to decide what these kids might be suffering from. The two main options: Create a new disease, or create a variant to an existing disorder. The discussions ran for years.
This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.
Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.
WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.
One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)
It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.
Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)
What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into m3clinician.com.
A sample report for a fake patient can be viewed here.
I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.
I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]
Sara is a blog reader who wants to write about bipolar disorder. She's interested in talking to people who have the condition, and she's started a blog called "Conversations about our Condition." If you wouldn't mind talking to her, do visit her site!
About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.
After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.
Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications. Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives".
Caplan continues
In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.
According to the healthys’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis. When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.
Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind.
Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.
Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk." ------------- Where do I even begin? Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot healthy Theme with a sensationalist tone. Shame on the Washington Post for printing this.
Okay, so I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack. Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her, weighing other options, or taking into consideration the context of her life, sent her off with Seroquel and a recommendation for therapy. This misdiagnosis then destroyed her life, because why would her husband and friends stick with her if she's got bipolar disorder? What better time to leave your wife then when her grandmother is dying, she's stressed out and sick? So she went to the ER because she was tired and her heart was racing. I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home. Okay, but it's an ER and the docs are rushed and focused on what the patient needs now. They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.
Okay, but it turns out that she was on a psychiatric ward. You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted. Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way. This was a wealthy patient who could afford outpatient care. All I'm sure of, is there is something more to the story.
Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days. Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country. These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.
So I don't know the patient, or the diagnosis. But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life. The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the healthy did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this). There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only. Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved). Oh, but then she took a bum recommendation to go on disability, and she got it! I've seen really sick people not get disability. It takes a lot of documentation and the government looks for ways to avoid paying this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it. So, somehow, this patient who was simply exhausted and stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get admitted to a hospital and get disability benefits.
There were some valid points Caplan could have made. The DSM is not a 'scientific manual.' Personally, I don't find it terribly helpful in clinical practice. I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V. The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness. This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V). And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far. If you readDr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V. It's not like the healthys aren't thinking hard about these diagnostic categories and the ramifications they have. Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder.
I agree with Caplan that healthys should listen more. Fifteen-minute med checks have made a mockery of our profession. I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems. But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps, get up and exercise and cook a healthy meal )-- is an insult. You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions. To read Caplan's piece, you'd think everyone is an idiot. And finally, ECT: it still in use because some people find it helps.
I want to thank all of the people who commented on my post What is Bipolar Disorder. Your comments were tremendously helpful. The descriptions of what it feels like to have this illness were incredible-- vivid, heartfelt, almost a mix of poetry and misery-- the stories were told in a way that I don't often hear in clinical settings. So, thank you. And if you're someone who doesn't read the comment section of blogs, I would urge you to make an exception for this post. The comments speak to what an intelligent, educated, and articulate readership we are lucky enough to have join us here, and the commenters make the experience of difficult mood states come alive in a way it is so hard to do with words. A little bickering (it wouldn't be Shrink Rap without that!), but I want to point out that the issues that inspired the bickering are exactly the concerns we address in figuring out the usefulness of the expanded bipolar diagnosis.
That said, I wrote my article for Clinical Psychiatry News, called Rethinking Bipolarity. If you click the link at the end, it will cycle you back to the What is Bipolar post. Let me know how I did?
And thank you, again. Thank you also to Dr. Dean MacKinnon, of the Johns Hopkins Mood Disorders Center and author of Trouble in Mindfor previewing the article for me.
I'd like to ask your help for a moment. I'm going to write a blog post for this week's Clinical Psychiatry News on Bipolar Disorder. I'd like to know how you see the term used, or the symptoms that are hallmarks of the illness for you. If you respond as my favorite commenter, "Anonymous," could I ask that you define yourself...healthy, psychologist, pediatrician, patient with bipolar disorder, friend of someone diagnosed with bipolar disorder....
Also, please just off the top of your head, I can read DSM or Google myself, and I'm more interested in your ideas about what exactly the disorder is.
I may not use your responses (I sort of know what I want to say) but no matter what, I'm curious. Thank you so much...
In response to Joy Bliss' post (Fad diagnosis in Psychiatry: Bipolar Disorder in children) on Maggie's Farm, Retriever wrote about her experience with a child with an early and severe mental illness, and short-sighted attempts to reduce access to needed intensive mental health treatment for children.
I do think that diagnosing behavior problems in kids has been overextended, due more to loose interpretation of current diagnostic criteria rather than to overbroad criteria. But let's not throw the baby out with the bath water.
(Speaking of water, taking a break here from vacation to post an image from Southwest Harbor, Maine.)
It's one of those questions to which there is no real answer. Being a doctor takes a long time, it requires reliability, diligence, and a willingness to learn things you may not want to learn (organic chem anyone????) and do things you may not want to do. It requires endurance and passion. You need to be tolerant of many things: arrogant supervisors, irritable colleagues, sick people who may not be charming and who may, in their distress, be down-right nasty. You have to tolerate a militaristic order and be willing to work with a system that may be very difficult, wrong, and demand your obedience in ways that may be uncomfortable. Oh, I am so happy to no longer be a medical student or a resident in training.
So can you do it with bipolar disorder? Can you do it with diabetes? Can you do it with attention deficit problems? Can you do it if you're disorganized or ugly?
The question assumes there is one bipolar disorder, that for everyone it has the same course and the same prognosis. Some people have an episode a few times in a life, and between episodes, their mood is stable, their emotions gentle. Others cycle from one mood to another, feeling the whole bipolar thing most minutes of most days. Some patients with bipolar disorder are in and out of the hospital, behave in impulsive and criminal ways when ill, and can't hold any job. Some do fine with medications and therapy, while others have refractory conditions that defy the most creative of cocktails and the best of therapists, even with their total compliance. And some people become doctors and then get bipolar disorder.
