A Randomized Controlled Trial of Cognitive Debiasing Improves Assessment and Treatment Selection for Pediatric Bipolar Disorder

A Randomized Controlled Trial of Cognitive Debiasing Improves Assessment and Treatment Selection for Pediatric Bipolar Disorder

Melissa M. Jenkins University of California San Diego and VA San Diego

Healthcare System, San Diego, California

Eric A. Youngstrom University of North Carolina at Chapel Hill

Objective: This study examined the efficacy of a new cognitive debiasing intervention in reducing decision-making errors in the assessment of pediatric bipolar disorder (PBD). Method: The study was a randomized controlled trial using case vignette methodology. Participants were 137 mental health professionals working in different regions of the United States (M � 8.6 � 7.5 years of experience). Participants were randomly assigned to a (a) brief overview of PBD (control condition), or (b) the same brief overview plus a cognitive debiasing intervention (treatment condition) that educated participants about common cognitive pitfalls (e.g., base-rate neglect, search satisficing) and taught corrective strategies (e.g., mnemonics, Bayesian tools). Both groups evaluated 4 identical case vignettes. Primary outcome measures were clinicians’ diagnoses and treatment decisions. The vignette characters’ race or ethnicity was experimentally manipulated. Results: Participants in the treatment group showed better overall judgment accuracy, p � .001, and committed significantly fewer decision-making errors, p � .001. Inaccurate and somewhat accurate diagnostic decisions were significantly associated with different treatment and clinical recommendations, particularly in cases where participants missed comorbid conditions, failed to detect the possibility of hypomania or mania in depressed youths, and misdiagnosed classic manic symptoms. In contrast, effects of patient race were negligible. Conclusions: The cognitive debiasing intervention outperformed the control condition. Examining specific heuristics in cases of PBD may identify especially problematic mismatches between typical habits of thought and characteristics of the disorder. The debiasing intervention was brief and delivered via the Web; it has the potential to generalize and extend to other diagnoses as well as to various practice and training settings.

What is the public health significance of this article? Study findings increase understanding of clinicians’ cognitive vulnerabilities; they model a new approach for improving clinical decision-making. Greater awareness of faulty heuristics and using cognitive debiasing strategies improve clinicians’ diagnostic reasoning and result in more accurate treatment decisions.

Keywords: cognitive debiasing, decision-making, pediatric bipolar disorder

Supplemental materials: http://dx.doi.org/10.1037/ccp0000070.supp

Pediatric bipolar disorder (PBD) is an extremely challenging diagnosis (Leibenluft, 2011; Marchand, Wirth, & Simon, 2006; Rettew, Lynch, Achenbach, Dumenci, & Ivanova, 2009). There often are long delays in diagnosing youth with PBD, with symp- toms often being misdiagnosed as something else (Marchand et al.,

2006). Paradoxically, bipolar also is often a “false positive” diag- nosis, clinically assigned and treated when the youth actually has a different disorder (Leibenluft, 2011; Rettew, Lynch, Achenbach, Dumenci, & Ivanova, 2009). In short, clinicians miss true cases of bipolar disorder and diagnose PBD in many cases where the youth

This article was published Online First January 4, 2016. Melissa M. Jenkins, Department of Psychiatry, University of California

San Diego and Research Services, VA San Diego Healthcare System, San Diego, California; Eric A. Youngstrom, Departments of Psychology and Neuroscience and Psychiatry, University of North Carolina at Chapel Hill.

Melissa M. Jenkins is now at Child and Adolescent Services Research Center (CASRC), Rady Children’s Hospital San Diego.

Eric A. Youngstrom has received travel support from Bristol-Myers Squibb and consulted with Lundbeck, Otsuka, Western Psychological Services, and Pearson about assessment.

This material is based upon work supported by the North Carolina Translational and Clinical Sciences Institute: National Institutes of Health grant 1UL1TR001111. The funding source did not play a role in the study design, in the collection, analysis, and interpretation of data, in the writing of the manuscript, or in the decision to submit the article for publication.

Correspondence concerning this article should be addressed to Eric A. Youngstrom, Departments of Psychology and Neuroscience and Psychia- try, Center for Excellence in the Research and Treatment of Bipolar Disorder, University of North Carolina, CB #3270, Davie Hall, Chapel Hill, NC 27599-3270. E-mail: eay@unc.edu

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