Author: Peter Parry
Parry, Peter, 2021 ‘Paediatric Bipolar Disorder’: Why did it occur, the iatrogenic consequences, and the implications for medical ethics and psychiatric nosology, Flinders University, College of Medicine and Public Health
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This doctoral thesis examines a major controversy in the field of child psychiatry: the diagnosis and treatment of bipolar disorder among prepubertal children. Part I presents the development of ‘paediatric bipolar disorder’ (PBD), which became a frequent diagnosis in the US. Part II contains three new studies on critical areas of PBD research. Part III discusses the implications of the PBD phenomenon for psychiatric ethics and nosology.
The PBD controversy began in the mid-1990s when US child psychiatric researchers from two prestigious universities hypothesised that bipolar disorder frequently presented with atypical mania among prepubertal children. PBD was rapidly translated into clinical practice in the US, as probably over a million children and young adolescents were diagnosed and treated for PBD over the next two decades. The most contentious aspect was the off-label prescription of medications, typically reserved for adults with bipolar disorder, including second- generation antipsychotics.
Part I describes how the media, restrictive health insurance, parent support groups, pharmaceutical industry funding of research, continuing medical education, direct to consumer advertising, and the dominant biomedical paradigm within US psychiatry combined to rapidly translate the PBD hypothesis from academia into clinical practice.
My original contribution to knowledge enfolds the published studies that form the three chapters of Part II. The methodology for Part II is a re-examination of the peer-reviewed research. The first study examined a highly cited meta-analysis that claimed that bipolar disorder is prevalent in community epidemiological studies of children and adolescents. This crucial claim was used to argue that the high diagnostic rates of PBD in the US were consistent with the high community prevalence, and PBD was underdiagnosed internationally. However, re-examination of the individual studies found bipolar disorder to be exceedingly rare before mid-adolescence. The published findings precipitated a nine-article debate in a later issue of the journal, the largest debate on the PBD topic (Chapter 4.8.8.2).
The second study examined whether academic psychiatrists outside the US supported the PBD hypothesis of atypical prepubertal mania. Using bibliometric methods, the study found that authors from a few US academic centres wrote most of the articles supporting PBD, but the majority of non-US authors were sceptical of the PBD hypothesis.
The third study examined whether studies of PBD investigated alternative causes of childhood mood lability such as attachment disorganisation, maltreatment and trauma. This bibliometric analysis found that very few PBD studies investigated these contextual factors. This is a significant oversight; given these factors are proximal and frequent causes of childhood mood lability.
Finally, Part III – the Discussion – explores the implications of the PBD phenomenon, and the three new studies. The findings suggest that PBD was prematurely translated into clinical practice in the US, despite lacunae in the research. The translation was not firmly based on science but was related to unique aspects of the US health system and sociocultural dynamics involving the influence of the pharmaceutical industry. The Discussion outlines the iatrogenic consequences of the rise of PBD, and the implications for medical ethics and psychiatric nosology and training.
Keywords: bipolar disorder, disorder, bipolar, paediatric, psychiatry, paediatrics, child, adolescent, medical ethics, ethics, iatrogenic harm, iatrogenic, harm, psychiatric nosology, nosology, diagnosis, DSM, literature review, epidemiology,
Subject: Psychiatry thesis
Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Medicine and Public Health
Supervisor: Professor Tara Brabazon