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Antipsychotic drugs for kids raise hope, worry
Erin Allday, Chronicle Staff Writer
Monday, June 22, 2009
(06-21) 19:38 PDT -- Increasingly powerful antipsychotic drugs available on the market, and growing evidence that starting these medications early can help children with conditions like bipolar disorder, is putting doctors under more pressure than ever to diagnose and treat young people with mental illnesses.
As a result, some doctors say, mental illness, especially bipolar disorder, has been overdiagnosed much the same way attention deficit hyperactivity disorder was in the 1980s.
"ADHD was the diagnosis du jour in the '80s. Now it's become bipolar disorder," said Dr. Andrew Giammona, who heads the psychiatry department at Children's Hospital Oakland. "We're in a quick-fix society, and parents want to believe that if we had this treatment, we can get it fixed and move on."
Before the 1990s, bipolar disorder was a rare diagnosis in children under age 19. By 1994, U.S. doctors were reporting about 25 cases per 100,000 young people, and by 2002 that number had jumped to 1,000 cases per 100,000, according to data from the National Center for Health Statistics.
Medication was prescribed for about two-thirds of those patients, according to the National Institute of Mental Health. Antipsychotic medications are among the most popular made by pharmaceutical companies. Earlier this month, a U.S. Food and Drug Administration panel recommended approval of three antipsychotic drugs for use in treating schizophrenia and bipolar disorder in children and teens. The FDA will make a final decision on Geodon, Seroquel and Zyprexa in the coming weeks.
While better drugs and increased diagnoses have been a blessing for many families, at FDA hearings in Washington, doctors and parents voiced concerns that the medication can cause long-term health problems - specifically, extreme weight gain that can lead to metabolic disorders like diabetes.
Not a trivial decision
"It would be controversial enough if it was just a diagnosis, but the diagnosis comes with these very potent medications," said Glen Elliot, chief psychiatrist and medical director of the Children's Health Council in Palo Alto. "My main message is parents need to be apprised that this is a cost-benefit analysis. You don't trivially put somebody on a medication."
As with ADHD, many thousands of children and teens really do have a mental illness that can be treated effectively with medication and therapy. Oakland parent Barbara Carlson said her son was 7 when he started having fits of violent rages, smashing windows and throwing chairs. After several days of testing, he was diagnosed with bipolar disorder - but she was reluctant to put him on medication. "He was just so young," Carlson said. "I thought, 'He has his whole life ahead of him, what if this is the wrong diagnosis?' It was very scary to put him on medications."
Seven years later, she said the drugs have improved his life dramatically. He's had weight problems, but he's excelling in school and is active in sports and making friends.
Many mental health experts said they've felt pressure from families with troubled children to make a diagnosis and start treatment - a reaction that's understandable if the child is clearly having problems. But if doctors don't have the proper training to accurately diagnose a mental illness, children may not get the right treatment, said Dr. Robin Dea, director of mental health services for Northern California Kaiser Permanente.
Depression and mania
"I tell doctors, 'You have to be honest with yourself about your own level of experience with this condition,' " Dey said. "We have to be honest with ourselves about whether the medications are working, and if they're not working you need to keep questioning the diagnosis."
Bipolar disorder is thought to affect about 1 percent of children, although studies vary and some experts believe it affects as many as 5 percent of children.
The disorder in adults is marked by extended cycles of depression and mania, although people can have long periods of time where they have no symptoms at all. During manic periods, adults may get grandiose ideas, feel euphoric and be impulsive and make poor decisions.
Children with bipolar disorder tend to cycle through moods faster than adults, and they are more likely to be extremely irritable than euphoric, said Dr. Kiki Chang, director of the Pediatric Bipolar Disorders Program at Stanford University School of Medicine. Experts note that these children are not just kids with behavior problems.
"An irritable kid is most likely not bipolar, he's probably just upset about something," Chang said. "Bipolar kids may be extremely explosive, extremely angry. But they have to have these other symptoms: they're not sleeping as much, their mind is going faster and they're making poor decisions."
Hard to tell the difference
It's not always easy for doctors to tell the difference between a kid with bipolar disorder and one who's dealing with teenage angst or has some other problem, like post-traumatic stress. Giammona at Oakland Children's Hospital said he once diagnosed a child with bipolar disorder only to discover later that the patient had a food allergy that was making him extremely irritable.
"There's a lot of overlap with other potential diagnoses," he said. "There can be lots of reasons for symptoms that look like bipolar disorder. Just because they have the symptoms of the disorder doesn't mean they have it."
Dale Milfay, vice president of the National Alliance on Mental Illness in San Francisco, said it's crucial that children with mental illness get a correct diagnosis as soon as possible and start treatment right away. There may be medical advantages to early treatment, she said, but children also benefit from staying in school and developing crucial relationships with friends and family.
"The earlier people are diagnosed, the better their chances," Milfay said. "But you wouldn't want these drugs to be overused. There needs to be some real criteria that this is not something a primary care doctor can just diagnose."
E-mail Erin Allday at email@example.com.
This article appeared on page A - 1 of the San Francisco Chronicle