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    Benefits of Subthreshold BP-NOS Diagnoses
    Robert M. Post | Head, Bipolar Collaborative Network; Professor of Psychiatry, George Washington University
    Safer et al (1) point out the marked increases in the incidence of psychiatric visits for subthreshold diagnoses and conclude that they “lack research reliability and potentially increase the likelihood of off-label prescribing of psychotropic medications”. The findings of increases in bipolar not otherwise specified (BP-NOS) were particularly noteworthy for the 18 fold increases from 1999-2002 to 2007-2010. Visits increased most markedly in younger individuals and BP-NOS is most highly prevalent in the youngest children. The NIMH Roundtable Conference reached consensus in 2000 that BP-NOS should be considered a “working diagnosis”. Therefore increases in the diagnosis would make sense after such agreement was reached. Birmaher et al (2) followed up children with BP-NOS, BP II, and BP I and found that those with BP-NOS were highly impaired in a range not dissimilar from that of the BP II and I children. Moreover, they found that while it took about 9 months to stabilize those with BP I and II, it took more than a year and a half to achieve this result in those with BP-NOS. Thus, one would anticipate that once diagnosed, those with BP-NOS would have increasingly more visits for monitoring and treatment. BP-NOS is often a precursor to BP I and II, and if there is a positive family history of bipolar disorder, the conversion rate is 53% after 5 years of follow up (3). Furthermore in high-risk offspring because of a positive family history of bipolar disorder, more children had BP-NOS (10.2%) than BP I and II combined (8.4%). Even in the comparison control offspring BP-NOS was more common (1.2%) than BP I and II (0.8%). Epidemiological studies that include BP-NOS also show more childhood bipolar disorder in the US (4). Safer et al (1) imply that off label treatment is ill advised. However, there are no FDA approved medications for any children with bipolar disorder under the age of 10, so pharmacological treatment would of necessity be off label. Compared to adult onsets, childhood onset bipolar disorder carries a poorer prognosis and is associated with longer delays to first treatment, and treatment delay itself is independently associated with a more difficult outcome in adulthood (5). Therefore it would appear that treating these children with high degrees of dysfunction with off-label medications would a most appropriate course of action and might yield the desired benefits of acute and long-term illness amelioration.

    1. Safer DJ, Rajakannan T, Burcu M, Zito JM. Trends in subthreshold psychiatric diagnoses for youth in community treatment. JAMA psychiatry. Jan 2015;72(1):75-83.

    2. Birmaher B, Axelson D, Goldstein B, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study. The American journal of psychiatry. Jul 2009;166(7):795-804.

    3. Axelson D, Goldstein B, Goldstein T, et al. Diagnostic Precursors to Bipolar Disorder in Offspring of Parents With Bipolar Disorder: A Longitudinal Study. The American journal of psychiatry. Mar 3 2015:appiajp201414010035.

    4. Van Meter AR, Moreira AL, Youngstrom EA. Meta-analysis of epidemiologic studies of pediatric bipolar disorder. The Journal of clinical psychiatry. Sep 2011;72(9):1250-1256.

    5. Post RM, Leverich GS, Kupka RW, et al. Early-onset bipolar disorder and treatment delay are risk factors for poor outcome in adulthood. The Journal of clinical psychiatry. Jul 2010;71(7):864-872.

    CONFLICT OF INTEREST: Dr. Robert Post has consulted and participated in lecture bureaus for AstraZeneca, Sunovion, and Validus Pharmaceuticals.
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    Original Investigation
    January 2015

    Trends in Subthreshold Psychiatric Diagnoses for Youth in Community Treatment

    Author Affiliations
    • 1Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 2Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 3Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
    JAMA Psychiatry. 2015;72(1):75-83. doi:10.1001/jamapsychiatry.2014.1746
    Abstract

    Importance  Patterns and trends of subthreshold DSM-IV mental health diagnoses for youth within US community treatment settings merit systematic research.

    Objective  To quantify and assess temporal patterns of DSM-IV diagnoses not otherwise specified (NOS) among youth during physician office visits.

    Design, Setting, and Participants  We conducted a retrospective study using psychiatric diagnostic data from the US National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (n = 16 295) from 1999 through 2010, combined in 4-year intervals. Using diagnoses from visits to physicians, we compared trends of the proportional distribution of the major psychiatric diagnoses with subthreshold criteria (coded as NOS) with proportions of diagnoses reaching full criteria.

    Main Outcomes and Measures  Specific common psychiatric diagnoses NOS compared with full-criteria psychiatric diagnoses.

    Results  Between the 1999-2002 and 2007-2010 periods, the proportion of US medical visits reporting DSM-IV NOS psychiatric diagnoses compared with the proportion reporting full psychiatric diagnostic criteria for youth aged 2 to 19 years rose prominently for major mood diagnostic subtypes. Among all visits for mood disorders, NOS visits grew proportionally 1.5-fold from 45.3% in the 1999-2002 period to 68.8% in the 2007-2010 period (P < .001). Among visits for bipolar disorder, NOS visits increased more than 18-fold, from 3.6% in the 1999-2002 period to 72.6% in the 2007-2010 period (P < .001). In addition, anxiety disorder NOS increased from 44.6% in the 1999-2002 period to 58.1% in the 2007-2010 period. Overall, NOS visits constituted 35.0% of the total psychiatric visits in 2007-2010 but represented 55.9% when attention-deficit/hyperactivity disorder codes were excluded.

    Conclusions and Relevance  The expansion of subthreshold (NOS) DSM-IV diagnoses of mood disorder, bipolar disorder, and anxiety disorder in youth that has occurred since 1999 in all likelihood will continue in the DSM-5 era unless administrative efforts are made to alter this practice. Unspecified diagnoses lack research reliability and potentially increase the likelihood of off-label prescribing of psychotropic medication.

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