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To the Editor: The article by Steven R. Pliszka, M.D., et al. (1) raised a number of questions concerning mood disorders—in particular, mania—among juvenile offenders. It is of interest that the rate of major depressive disorder identified in this population was quite similar to those found in two previous studies (2, 3). Although both of these studies characterized the presence of depression, only the former characterized all identifiable affective disorders. With the use of different structured interviews, the authors identified major depressive disorder in 23% of the juvenile delinquents in each study; minor depressive disorder was verified in 15% of the juvenile delinquents in the former study (2). The number of delinquents with affective disorders in these studies was similar to that found by Dr. Pliszka et al.: 38% versus 42%, respectively. The similarity in the frequency of depressive disorder and the correlation of depressive disorder with substance abuse in these studies are quite striking.
However, Dr. Pliszka et al. identified mania in 22% of the delinquents; in our study (2), we identified only 4% with mania. The similarities in the rates of depressive disorder among these studies make the high rate of mania in the study population of Dr. Pliszka et al. not only striking but potentially suspect. In our study, agitation/irritability was not used as the primary mood symptom in the identification of bipolar illness; instead, euphoria of a relatively prolonged nature (over 2 weeks) was used as the defining affect. A total of 36% of the juvenile delinquents with major depressive disorder had agitated subtypes. Could the high rate of mania in the study by Dr. Pliszka et al. be explained by an overuse of agitation as the primary mood symptom to identify mania?
This is an issue that now appears to be vexing child and adolescent psychiatry. There has developed almost a knee-jerk diagnostic reflex in which any anger, agitation, or irritability is immediately labeled "mania" when found among children and adolescents. Is the result an accurate rate of occurrence? The justification offered for this notion appears to be the potential response of these clinical characteristics to treatment with divalproex sodium or lithium. So? Do they really substantiate the diagnostic entity?
Of further significance is the high percentage of juvenile delinquents identified with borderline personality disorder in another of our studies (4). In fact, borderline personality disorder was the most frequent principal psychiatric diagnosis made in this population: 44%. Intense anger, affective lability, and self-injury significantly differentiated the juvenile offenders with borderline personality disorder from those without. I understand that the Diagnostic Interview Schedule for Children does not identify borderline or other types of personality disorders. If so, how many of these youths may have had borderline personality disorder that was not correctly identified? Are all adolescents with borderline personality disorder merely exhibiting bipolar illness?
I wholeheartedly agree that the presence of mood disorders among juvenile offenders is an important finding; however, of greater significance is the correct identification of mood disorders. The implications of high levels of mania in this population are important, especially if this finding is accurate. But before pursuit of this issue is undertaken, it is important that we not attempt to oversimplify complex symptom profiles or use diagnostic instruments that bias either the phenomena identified or the diagnoses derived.
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