MINI-THREAD, and you have to bear with me:

"One of the Worst (Titled) Papers in Child Psychiatry"

#meded #psychtwitter #psychiatrychat #medtwitter #somepsych

(and I'm sorry if I offend anyone who knows or works with these authors, or the authors themselves. Sorta.)
/1

The paper purports to be a RCT of Bipolar I Disorder treatment in Children and Adolescents

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/1151487

And, reading the abstract, it looks solid.

However, its awfulness is why YOU SHOULD ALWAYS READ THE POPULATION DEMOGRAPHICS.

/2

They took 279 medication-naive subjects, and randomized them to:
* Risperidone (avg dose 2.5mg)
* Lithium (1.0 mEq/L level)
* Divalproex Sodium (113 ug/mL level)

Their conclusion?

/3

"Risperidone was more efficacious than
lithium or divalproex sodium for the initial treatment of
childhood mania but had potentially serious metabolic
effects."

So why did I call this one of the WORST Titled Papers ever? Well... let's get to it.

/4

First off, how the hell did they get 712 patients eligible to study? Bipolar I Disorder in kids should be exceedingly rare. But, no matter... the meat of the problem comes with the dreaded TABLE 2: Baseline Demography.

Look at something here:

/5

Why on earth would there be almost 4x more 6-12 year olds than 13-15 year olds - the incidence of bipolar disorder peaks at 22!

Average age of 10? That's kinda young...

But here's the kicker.

Check this stuff out. Hey psychiatrists, what do you think of this?

/6

The AVERAGE age of mania onset was FIVE YEARS OLD. The AVERAGE duration of MANIA was FIVE YEARS. 99.3% of these 10-year-old subjects were FIVE YEARS into their first MANIA episode.

MANIA?!

Bipolar Mania does not last 5 years. Ever.
Like ever ever.

/7

272 (97.5%) of their subjects had MIXED EPISODE, and 277 (99.3%) had DAILY RAPID CYCLING.

THEYARENOTDESCRIBINGBIPOLARDISORDER!

They are doing a trial of behavioural disruption, incorrectly diagnosing Bipolar I disorder, with NO CONCEPT of BD at all. /8

This comes from a group of kids that I call ("American Bipolar") ... there seems to be a NE US trend (Eye of Sauron centered over Harvard) , where in some weird disconnected-from-reality-ivory-tower move, they believe that 6y.o.'s with 5years of disruption have BD-1!

/9

Unsurprisingly, for this general pattern of behavioural disruption, risperidone outperformed lithium/divalproex... BECAUSE THESE KIDS AINT BIPOLAR!

Risperidone, a major antipsychotic, with TONS of side effects, can be used for general severe aggression control, cautiously.

/10

This paper could have been titled "Management of Pediatric Agitation" without the Bipolar label.

And now, in 2019, we are seeing the effects of this horrible title. This study is being included in meta-analyses of BD-1 in kids, and due to its high population, it dominates.

I have respect for many of the authors here, including Barbara Geller, who currently is an author for NEJM's Journal Watch. I'm not trying to throw stones at them, but I recognize that in criticizing one of their landmark studies, it may seem this way.

/12

I can't help it though. This paper is too important an example of horrible diagnostic procedure and knowledge, and too important an example of why reading the abstract isn't enough.

/13

So the next time you are reading a RCT, and you're skimming the abstract, remember this study. It would have fooled you.

* read the demographics and baseline characteristics and ask yourself "which population did they really study here?

/14

How would that have helped?

In this study:
* 5 years of mania
* 99% rapid cycling
* 97% mixed state
Comorbidities:
* 92% ADHD
* 90% Oppositional Defiant d/o

In child psychiatry, we have all treated these kids many times. THEY DO NOT HAVE BIPOLAR DISORDER.

/15

That is a horrendous label to give to these kids.

And now, and forever, as educators, we have to battle against the inevitable journal searches and meta-analyses that will include this study to comment on bipolarity.

/16

If I sound a little angry, its because the overdiagnosis of pediatric Bipolar Disorder, ESPECIALLY in NE United States, has lead to extreme over-prescription of medications in kids, and anti-psychotics are not messing around.

/End THREAD/RANT.

(I have heard that some of the authors now claim that this would be called "Disruptive mood dysregulation disorder (DMDD)", formerly "Disruptive Behaviour Disorder NOS")

Cool.

GO UPDATE YOUR PUBLICATIONS.

You're ruining the science of child & adolescent bipolar disorder.