The sad case of Rebecca Riley

The tragic death of 4-year old Rebecca Riley, who died after an overdose of psychiatric medications, has sparked a lot of discussion and finger pointing. An article in today’s Boston Globe (Bipolar labels for children stir concern) suggests that part of the problem is the overuse of bipolar disorder as a diagnosis.

Riley… was exceptionally young when she was diagnosed, just 2 1/2. But among somewhat older children, the bipolar label has proliferated to the point that some psychiatrists now suspect the diagnosis may be sometimes misused, placing some children at unnecessary risk from the serious medications that usually follow.

I asked Mickey Segal, MD, PhD, CEO of decision support company SimulConsult, for his thoughts. Here’s what he said:

The case is odd because the parents are charged with murder using prescribed drugs, yet the doctor is being investigated by the Board of Registration in Medicine for prescribing the drugs. What scenario is being suggested?

The article also suggests that diagnosis of bipolar disorder is colored by reimbursements:

[Dr. Jennifer Harris , a clinical instructor at Harvard University and supervisor at Cambridge Health Alliance] and others point out that a diagnosis of bipolar disorder is considered more serious than attention deficit hyperactivity disorder or post traumatic stress disorder. A child diagnosed as bipolar thus tends to have much easier access to a range of help, from a spot in a therapeutic school to insurance coverage for hospitalization.

But it is a serious matter to suggest that “up-coding” influences treatment decisions.
Part of the problem is that there is no way to make a definitive diagnosis of either bipolar disorder or attention deficit disorder, since we don’t have genes for either disease yet. Since drugs for both disorders have dangers, we need a deeper understanding of these diseases, hopefully resulting in therapies that are more benign or more effective. Until then, doctors and patients will try different things and there will be some tragedies.

February 15, 2007

One thought on “The sad case of Rebecca Riley”

  1. I’m not sure the bit about upcoding is right. It’s just as easy to code a 99214 for ADHD as for bipolar. I’m not sure I agree with Jennifer Harris’ point either, that it’s easier to access services for more serious diagnoses. This is especially so in this era of an explosion of diagnoses of BPD. There simply aren’t enough providers to see them all.



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