Children With a Prepubertal and Early Adolescent Bipolar Disorder Phenotype From Pediatric Versus Psychiatric Facilities REBECCA TILLMAN, M.S., BARBARA GELLER, M.D., JEANNE FRAZIER, B.S.N., LINDA BERINGER, R.N., BETSY ZIMERMAN, M.A., TRICIA KLAGES, M.S., AND KRISTINE BOLHOFNER, B.S.
ABSTRACT Objective: To examine characteristics between subjects with a prepubertal and early adolescent bipolar disorder phenotype from pediatric versus psychiatric venues. Method: Subjects (N = 93) with a prepubertal and early adolescent bipolar disorder phenotype were obtained through consecutive new case ascertainment from designated pediatric and psychiatric sites from 1995 to 1998. Children needed DSM-IV bipolar I disorder (manic or mixed phase) with elation and/or grandiosity as one criterion to avoid diagnosing mania only by symptoms that overlapped with those of attention-deficit/hyperactivity disorder. Comprehensive assessment included the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia, given separately to parents about their children and to children about themselves by experienced research nurses blinded to subjects’ diagnostic status. Results: Rates of mixed mania (x 2 = 7.1, p = .008) and suicidality (x 2 = 7.2, p = .007) were significantly higher at psychiatric versus pediatric venues. Subjects from pediatric sites were significantly more likely to be living with their intact biological family (x 2 = 5.3, p = .022). Significantly more subjects with a prepubertal and early adolescent bipolar disorder phenotype ascertained at psychiatric sites versus pediatric sites were taking an antimanic medication (x 2 = 9.5, p = .002), while stimulant medication was significantly more common among subjects ascertained at pediatric sites (x 2 = 19.0, p < .0001). Conclusions: These pediatric versus psychiatric site differences suggest that pediatricians may underrecognize mania and thus do not prescribe antimanic mood-stabilizing medications. Moreover, pediatricians may be more likely to refer children to psychiatrists when depression or suicidality is evident. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(8):776–781. Key Words: bipolar, mania, mixed mania, suicide, medication.
Zarin et al. (1998) reported on differences in medication patterns for children with attention-deficit/hyperactivity disorder (ADHD) by whether the treatment was in a nonpsychiatry versus psychiatry setting. Findings included that the medication patterns were far more complex and significantly more likely to include nonstimulant medications at psychiatric sites. The authors interpreted the data to support that gatekeepers refer only the most difficult ADHD cases to psychiatric clinics. Accepted March 15, 2005. From the Department of Psychiatry, Washington University, St. Louis. Supported by NIMH grant R01 MH-53063 to Dr. Geller. Correspondence to Dr. Barbara Geller, Department of Psychiatry, Washington University in St. Louis, 660 South Euclid Avenue, St. Louis, MO 63110; e-mail:
[email protected]. 0890-8567/05/4408–07762005 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000164588.10200.ed
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This seminal work raised the question of whether this referral bias, i.e., most complex cases in psychiatric venues, would also be true for other disorders. To test this paradigm for a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP), baseline data from the National Institute of Mental Health–funded Phenomenology and Course of Pediatric Bipolar Disorders study were used. It was hypothesized that a similar scenario would be found in which nonpsychiatric sites would see less severe cases of PEA-BP and would have less complex medication patterns. METHOD Study Inclusion and Exclusion Criteria Details of the study inclusion and exclusion criteria have been previously reported (Geller et al., 2002a,b). Inclusion criteria were
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males and females, 7–16 years of age, good physical health, and current DSM-IV BP-I (manic or mixed phase) for at least 2 weeks. At least one of the two cardinal symptoms of mania (i.e., elation and/or grandiosity) was required to avoid diagnosing mania only by symptoms that overlapped with those for ADHD (e.g., hyperactivity, distractibility) and to ensure that all subjects exhibited at least one of the cardinal features of mania. Subjects needed to have significant clinical impairment, evidenced by a Children’s Global Assessment Scale (CGAS) score of £60 (Bird et al., 1987; Shaffer et al., 1983). Exclusion criteria were IQ
