Psychiatry - October 2008 - (Page 38)

Clinical Global Impression scales were compared pre- and posttreatment. Results: Patients with bipolar disorder improved significantly more than mood disorder NOS patients, despite similar levels of care. Meaningful differences in diagnostic and treatment variables were apparent at baseline and at endpoint. Conclusion: Standardized assessments in community clinics are feasible and lead to the identification of meaningful differences between “similar” patient groups. Improving diagnostic practices across different psychiatric settings appears paramount. INTRODUCTION Recently, there has been a significant increase in the diagnosis of bipolar disorder in youth.1 Within the last decade, this diagnosis in children and adolescents has more than doubled.2 There are a number of possibilities explaining this dramatic increase. Perhaps an unknown biological variable, causing an actual increase of bipolarity in the pediatric population, exists. Perhaps this change is due to a more comprehensive understanding of the disorder. Or, perhaps the surge of diagnoses is due to a combination of diagnostic confusion and poor diagnostic practices. Often determining which disorders plague a child can be challenging due to a variety of factors, including comorbidity (i.e., a series of disorders frequently occurring simultaneously, such as attention deficit hyperactive disorder [ADHD], oppositional defiant disorder, and bipolar disorder).3 In community practices today, there seems to be a habit of categorizing a series of similar, yet fundamentally distinct, disorders under the heading of bipolar disorder.4 However, with the advancements of psychiatry in the modern era, including new medications and new diagnostic classifications, it is more important than ever to differentiate between disorders. Conditions in youth can continue into adulthood with 38 Psychiatry 2008 [ O C T O B E R ] complicated symptoms; therefore, it is essential to diagnose properly from an early age. Furthermore, the imperfections of medications and their often serious side effects strengthen the desire to avoid intensive use if not critically necessary. Thus, on these two counts, the correct diagnosis and treatment is vital in psychiatric practice. More specifically, in the case of pediatric bipolar disorder, it is crucial to distinguish between severely mood disordered youth and actual bipolar disordered youth. Data from the National Institute of Mental Health (NIMH) clearly delineate the importance of diagnostic differentiation between these two conditions. The data underscore this necessity by suggesting that severely mood disordered, but not bipolar disordered, youth may be significantly at risk for developing unipolar depression in adulthood, but not adult bipolar disorder.5 Leibenluft describes a series of four phenotypes of “bipolarity” in the pediatric population.6 The phenotypes range from the Diagnostic and Statistical Manual of Mental Disoders, Fourth Edition, Text Revision (DSM-IVTR) definition of bipolar disorder to severely mood disordered youth. These latter patients are characterized by hyper-arousal and severe irritability, but not by core manic symptoms of euphoria, grandiosity, decreased need for sleep, hypersexual behavior, and racing thoughts. Phenotype I matches both the symptomatic and duration criteria of the DSM-IV-TR for bipolar disorder. Phenotype II matches the symptomatic criteria but not the duration criteria. Phenotype III does not match the symptomatic criteria for mania or hypomania, but cycling is present with irritability as the predominant mood. And, finally, phenotype IV references youth without symptomatic criteria and without cycling, but with chronic severe irritability. Patients in the latter groups are considered to be severely mood disordered, yet not bipolar. Often in clinical practice, all of the phenotypes are deduced to be bipolarity, though this certainly may not be the case, as evidenced by the NIMH study. Unfortunately, there is little data in community practice highlighting the differences between bipolar disorder and severely mood disordered pediatric patients. Therefore, this study is an initial pilot study to look at two samples, one with bipolar disorder and one with severe mood disordered symptomatology, to see if any meaningful differences emerge. In this paper, Leibenluft’s phenotypes I and II will be referenced as pediatric bipolar disorder, while phenotypes III and IV will be referenced as mood disorder not otherwise specified (NOS). METHODS A retrospective chart review included all patients, five to 18 years of age, who underwent a psychiatric evaluation between September 2004 and September 2007, and were diagnosed with bipolar disorder or mood disorder NOS. A psychiatric evaluation by a board-certified child and adolescent psychiatrist in this clinic includes the administration of the Mini International Neuropsychiatric Interview for Children and Adolescents7 to the patient and the completion of the Child/Adolescent Symptom Inventory8 by the parent. Patients were diagnosed with bipolar disorder I or II when they fulfilled full DSMIV-TR criteria and with bipolar disorder NOS when they showed discrete episodes of core hypomanic/manic symptom clusters, such as euphoria, grandiosity, decreased need for sleep, hypersexual behavior, and racing thoughts, for at least four hours duration, at least once per week.9 Patients were diagnosed with a mood disorder NOS when they showed a significant mood disturbance of severe irritability, cyclical or not, and did not have discrete episodes of core hypomanic/manic symptoms, even though they may have had

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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