of pediatric bipolar disorder (BPD) vary in population-based (Carlson and Kashani 1988
; Lewinsohn et al. 1995
; Costello et al. 1996
; Reich et al. 2005
) and clinical samples (Wozniak et al. 1995
; Youngstrom et al. 2005
). Although much variation can be attributed to differences in study methodology and the conceptualization of BPD, some variation is likely due to clinicians' diagnostic decision making.
Variability in diagnosis is not only of academic concern; misdiagnosis can lead to delayed or inappropriate treatments. Research shows that patients who receive accurate diagnoses are discharged from hospitals more quickly (Miller 2001
) and that when psychiatrists are given accurate diagnoses for their patients, they may change their treatment plans (Basco 2000
). If clinicians miss the diagnosis of BPD, they may risk triggering manic episodes by treating with antidepressant or stimulant medication (Strober and Carlson 1982
; Brisoce et al. 1995
; Strober 1998
; Reichart and Nolen 2004
), although, in their review of the literature, Licht and colleagues (2008
) failed to find evidence of iatrogenic mood effects with selective serotonin reuptake inhibitors (SSRIs). Similarly, if clinicians diagnose BPD where instead a child has another disorder, such as attention-deficit/hyperactivity disorder (ADHD), ADHD with subthreshold manic symptoms, anxiety disorders, or depression, the child and adolescent psychiatrists (CAP) might prescribe unnecessary medication (such as a mood stabilizer or atypical antipsychotic) and fail to prescribe appropriate medication for the correct diagnosis. Reliable and accurate diagnostic reasoning is therefore a necessity.
Although part of diagnostic variability may be due to the shifting conceptualization of pediatric BPD, apart from the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders
, 4th edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000
), there is no other accepted “gold standard” for diagnosing BPD in the community (Setterberg et al. 1991
; National Institute of Mental Health Research Roundtable on Prepubertal Bipolar Disorder 2001
; Youngstrom et al. 2005
). Given the recent rise in BPD diagnoses (Blader and Carlson 2007
; Moreno et al. 2007
), we were interested to determine whether CAPs apply DSM criteria consistently or instead rely on other criteria or their clinical judgment.
A growing body of research has focused on the cognitive aspects of clinicians' decision making, particularly how they elicit and process information (for review, see Galanter and Patel 2005
). Clinicians differ in how they weigh evidence and employ strategies to resolve unclear, incomplete, or inconsistent information (Way et al. 1998). One potential means to facilitate CAP decision-making and improve diagnostic accuracy is to study clinicians' diagnostic practices, determine where additional decision support is needed, and develop tools to support decision making (Poses 1999
Researchers have used survey methodology to study how clinician characteristics influence diagnostic practices. For example, Epstein and colleagues (Epstein et al. 2001
) found that psychiatrists were more likely to diagnose major depressive disorder if they were board certified, younger, had fewer years in practice, and had a greater percentage of patients in managed care or on psychotropic medications. Investigators in Germany (Meyer et al. 2004
) surveyed CAPs and found that while 63.3% had diagnosed BPD in adolescents, only 7.8% had done so in children under 11 years old. Diagnosing BPD was positively associated with younger clinician age and with favoring (versus not favoring) a pharmacological or cognitive–behavioral approach and negatively associated with favoring a psychodynamic approach. In a study comparing the likelihood of CAPs diagnosing BPD in the United Kingdom and the United States (Dubicka et al. 2008
), researchers presented clinicians with written vignettes. U.S. clinicians were more likely to interpret symptoms as indicative of BPD, whereas the British CAPs were more likely to attribute them to ADHD, behavior disorders, or pervasive developmental disorder. No surveys have examined how clinicians weighed symptoms when considering BD or how diagnostic consistency with DSM-IV relates to clinician characteristics.
To further characterize CAPs' diagnostic practices with BD, we surveyed U.S. CAPs about practice patterns, experience with BPD, and which symptoms led them to consider BPD. Specifically, we sought to examine variability in which symptoms guided BPD diagnostic practices and understand how clinician characteristics might correlate with CAP diagnostic decision making.