‘Pediatric Bipolar Disorder’ rates are still lower than claimed: a re-examination of eight epidemiological surveys used by an updated meta-analysis

Abstract

Background ‘Pediatric bipolar disorder’ (PBD) is a controversial diagnosis with varying rates of clinical diagnosis. A highly cited meta-analysis (Van Meter et al. 2011) of a dozen epidemiological surveys suggested a global community prevalence of PBD of 1.8%. This was updated to 3.9% with eight additional surveys (Van Meter et al. 2019a). In terms of the Cochrane Handbook for Systematic Reviews of Interventions, the heterogenous community surveys were arguably unsuitable for statistical meta-analysis and warranted a narrative analysis. A narrative analysis (Parry et al. 2018) of the original 12 surveys concluded rates of PBD were substantially lower than 1.8% and led to a nine-article debate on the validity, arguable overdiagnosis and iatrogenic aspects of the PBD diagnosis (e.g. Carlson and Dubicka Child Adolesc Mental Health 21:86–87, 2019). This article extends the narrative analysis to include the eight newer community surveys. Methods A narrative analysis of the methodologies and the prevalence rates reported by the epidemiological surveys. Results Across all twenty surveys there was significant variation in methodologies and reported prevalence rates. Of the eight newer surveys, five (two Brazilian, one English, one Turkish, one United States) provided information of pre-adolescent prevalence rates of bipolar spectrum disorder. These pre-adolescent rates were zero or close to zero. Rates of adolescent hypomania and mania were higher, but follow-up data in two studies suggested hypomania might sometimes achieve prolonged remission or not lead to adult bipolar disorder. Limitations Methods in the original surveys vary and criteria used for various bipolar diagnoses were not always fully described. This limitation applies to a narrative analysis but also to a statistical meta-analysis. Conclusion Bipolar disorder is very rare in childhood and rare in adolescence. PBD as a diagnostic construct fails to correlate with adult bipolar disorder and the term should be abandoned. Hypomanic syndromes in adolescence may not always progress to adult bipolar disorder. Early diagnosis of bipolar disorder is important, but over-diagnosis risks adverse iatrogenic consequences.

Paediatric bipolar disorder and its controversy

“…A separate meta-analysis focusing on children aged 12 or younger in community samples identified only a single case of bipolar disorder worldwide, yielding a prevalence of <0.02% and challenging claims of its ubiquity (Douglas & Scott, 2014). Reexamination of Van Meter et al's data focusing on children and younger adolescents similarly showed very low rates, albeit slightly higher in the USA (Parry et al, 2018(Parry et al, , 2021. A further limitation of the Van Meter et al papers was that analyses grouped different types of bipolar disorder together, despite the diverse diagnostic criteria used across studies, likewise complicating interpretation of their findings (Carlson, 2018;Parry et al, 2018;Duffy, 2019;Parry et al, 2019aParry et al, , 2021.…”

“…Many studies classed it within 'bipolar disorder not otherwise specified' using DSM IV criteria (Axelson et al, 2011), which can be met in various ways and so is more ill-defined. Other studies (Wozniak et al, 2017) diagnosed children with ultradian cycling as having 'bipolar I' despite this not being standard DSM criteria, representing a further blurring of diagnostic boundaries (Parry et al, 2021). Adopting strict DSM criteria, however, does not solve these problems: DSM 5 field trials were unsuccessful for the diagnosis of bipolar disorder in children and unable to obtain an accurate estimate of inter-rater reliability due to large variability (Regier et al, 2013).…”

The diagnosis of bipolar disorder in children and adolescents: Past, present and future

“…3 Van Meter and colleagues furnished their detractors a robust rebuttal, 4 but the exchange also prompted them to conduct a further meta-analysis in 2019 that updated their findings. 5 However, their findings and arguments were once again comprehensively critiqued by Parry and colleagues 6 and no compromise was achieved. Thus this important debate concerning the definition of PBD-the issue at the heart of its prevalence-remains unresolved and the seemingly simple question lacks a satisfactory answer.…”

“…In their review, Parry et al 6 identify and systematically address key problems within epidemiological research that, in our view, are at least in part due to the fundamental flaws in our current diagnostic criteria.…”

Patterns of Neural Network Functional Connectivity Associated With Mania/Hypomania and Depression Risk in 3 Independent Young Adult Samples

“…Studies in familial at-risk populations (eg, offspring of individuals affected by BD) and youth affected by BD similarly reported altered amygdala, striatal, CEN, and VAN or SN activity and altered amygdala-VAN and amygdala-SN functional connectivity during emotion processing and emotional regulation . Yet, although childhood-onset BD is a more severe form of BD, it is less common than adult-onset BD . Thus, there remains a critical need for studies to examine young adults at risk of mania/hypomania .…”