Evidence-Based Strategies Improve Assessment of Pediatric Bipolar Disorder by Community Practitioners

Generalizability of evidence-based assessment recommendations for pediatric bipolar disorder

Bipolar disorder is frequently clinically diagnosed in youths who do not actually satisfy Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR; American Psychiatric Association, 1994) criteria, yet cases that would satisfy full DSM-IV-TR criteria are often undetected clinically. Evidence-based assessment methods that incorporate Bayesian reasoning have demonstrated improved diagnostic accuracy and consistency; however, their clinical utility is largely unexplored. The present study examines the effectiveness of promising evidence-based decision-making strategies compared with the clinical gold standard. Participants were 562 youths, ages 5 to 17 and predominantly African American, drawn from a community mental health clinic. Research diagnoses combined a semistructured interview with youths' psychiatric, developmental, and family mental health histories. Independent Bayesian estimates that relied on published risk estimates from other samples discriminated bipolar diagnoses (area under curve = .75, p < .00005). The Bayes and confidence ratings correlated at rs = .30. Agreement about an evidence-based assessment intervention threshold model (wait/assess/treat) was κ = .24, p < .05. No potential moderators of agreement between the Bayesian estimates and confidence ratings, including type of bipolar illness, were significant. Bayesian risk estimates were highly correlated with logistic regression estimates using optimal sample weights (r = .81, p < .0005). Clinical and Bayesian approaches agree in terms of overall concordance and deciding next clinical action, even when Bayesian predictions are based on published estimates from clinically and demographically different samples. Evidence-based assessment methods may be useful in settings in which gold standard assessments cannot be routinely used, and they may help decrease rates of overdiagnosis while promoting earlier identification of true cases.

Treatment of Pediatric Bipolar Disorder: A Review

AIM: To review the diagnosis and the pharmacologic and psychosocial interventions for pediatric bipolar disorder (PBD). METHODS: A comprehensive literature review of studies discussing the diagnosis and treatment of PBD was conducted. RESULTS: A context for understanding controversies and difficulties in the diagnosis of PBD is provided. An evidence-based assessment protocol for PBD is reviewed. The evidence for the following three categories of pharmacologic interventions are reviewed: Lithium, antiepileptics, and second generation antipsychotics. Algorithms for medication decisions are briefly reviewed. Existing psychosocial treatments and the evidence for those treatments are also reviewed. CONCLUSION: Despite recent developments in understanding the phenomenology of PBD and in identifying pharmacologic and psychosocial interventions, critical gaps remain.