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The Spectrum of Agitation Associated with Schizophrenia and Bipolar Disorder

Payers Perspective
Faculty Perspectives: The Spectrum of Agitation Associated with Schizophrenia and Bipolar Disorder

The Affordable Care Act of 2010, with the extension of benefits to individuals aged ≤26 years, has arrived at the intersection of new advances and thinking regarding adolescent mental health and disease management.

Recent technological advances in the diagnosis of mental health disorders and a deeper understanding of the physiologic causes behind various mental health disorders will require managed care organizations and other payers to re-evaluate their standard-of-care assumptions. A cost-effectiveness profile of mental health on total family burden, including absenteeism and associated secondary medical spending, should encourage payers and providers to lower barriers to care and high out-of-pocket costs for those patients with mental health disorders who seek care.

Accurately diagnosing mental health disorders remains a challenge because many of these disorders present with similar symptoms, and there are only a few objective tools to differentiate between them. A large part of the difficulty is that, although many medical diagnoses can be proven or disproven by simple tests, diagnosing mental health disorders relies primarily on comparing lists of symptoms with the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders. Therefore, to establish an accurate diagnosis of the mental disease and to recommend an appropriate treatment regimen, providers require a detailed account of all presenting symptoms.

The main article in this publication discusses 2 complex realms regarding severe mental health conditions: schizophrenia and bipolar disorder. These disorders share similar psychotic features, including hallucinations, mood disturbances, and agitation. The author accurately states that because of the similarities of agitation across these diagnoses, the provider needs to make a careful evaluation of the patient; this underlines the difficulties in differentiating between the 2 disorders, especially when the patient has little or no previous history of psychiatric treatment.1 For example, at the height of an untreated manic episode, the symptom profiles for schizophrenia and bipolar disorder can be nearly identical, reinforcing that active treatment of these psychotic features involves ready access to a combined regimen of costly antipsychotic and anticonvulsant medications, in combination with psychotherapy and constant monitoring.

Another important consideration in the treatment of agitation is the rising incidence of bipolar disorder in children and adolescents. According to a September 2007 report from the National Institute of Mental Health, diagnosis of bipolar disorder in minors increased by a factor of 40 between 1997 and 2007; diagnosis of bipolar disorder in adults approximately doubled in the same time period.1 There are many reasons for this shift. One reason is that bipolar disorder is replacing attention-deficit/hyperactivity disorder (ADHD) as the “diagnosis du jour” for children with behavioral problems.2

Although many children show psychomotor agitation of the types described in the article, they also meet diagnostic criteria for ADHD, anxiety disorders, or even unipolar depression rather than bipolar disorder. The situation is further complicated by the medication used for the treatment of patients with agitation; many of these medications, including anticonvulsants and antidepressants, were found by the US Food and Drug Administration to increase suicidal thoughts and behaviorism among children and adolescents.3,4 It is critical for all providers, payers, and formulary committees to recognize this trend and to be mindful of the diagnosis and barriers to treatment they establish, especially when instituting formulary placement and access to costly psychotropic medications.

Providers in emergency departments, clinics, long-term care facilities, and private practices should examine all symptoms and treatment options carefully. Finally, providers and payers who cover and treat children and adolescents with mental health conditions should recognize that the information provided in this article may not apply equally to every patient, and thus will require flexibility in their thinking and benefit planning.

1. National Institute of Mental Health. Rates of bipolar diagnosis in youth rapidly climbing, treatment patterns similar to adults. September 3, 2007. Accessed November 14, 2014.
2. Carey B. Bipolar disorder cases rise sharply in U.S. children. The New York Times. September 3, 2007. Accessed November 14, 2014.
3. Kowalczyk L. FDA requests anticonvulsants be reexamined. Boston. April 20, 2005. Accessed November 14, 2014.
4. Friedman RA, Leon AC. Expanding the black box—depression, antidepressants, and the risk of suicide. N Engl J Med. 2007;356:2343-2346.

Last modified: August 30, 2021