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Abstract
OBJECTIVES Paediatric bipolar disorder - bipolar disorder occurring in prepubertal children - is a diagnosis subject to considerable controversy. Whilst historically considered to be very rare, proponents since the 1990s have argued that mania can present differently in children and, as such, is much more common than previously thought. Such proposals raise questions about the validity of proposed phenotypes and potential risks of iatrogenic harm. METHODS I critically examine the construct of paediatric bipolar disorder using Robins and Guze's (1970, American Journal of Psychiatry126, 983-987) influential criteria for the validity of a psychiatric diagnosis. I review, in turn, evidence relating to its clinical description, delimitation from other conditions, follow-up studies, family studies, laboratory studies, and treatment response. RESULTS Across domains, existing research highlights significant challenges establishing the diagnosis. This includes significant heterogeneity in operationalising criteria for children; variable or poor inter-rater reliability; difficulty distinguishing paediatric bipolar disorder from other conditions; large differences in rates of diagnosis between the United States of America and other countries; limited evidence of continuity with adult forms; and a lack of evidence for proposed paediatric phenotypes in children at genetic high-risk of the condition. Laboratory and treatment studies are limited, but also do not provide support for the construct. CONCLUSIONS Evidence for the more widespread existence of paediatric bipolar disorder and its various proposed phenotypes remains weak. The ongoing popularity of the diagnosis, most evident in America, may reflect social pressures and broader limitations in psychiatric nosology. The uncertainty around the diagnosis highlights the need for careful longitudinal assessment of children potentially affected.
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Elsayed OH, Pahwa M, El-Mallakh RS. Pharmacologic Treatment and Management of Bipolar Disorder in Adolescents. Expert Opin Pharmacother 2022; 23:1165-1179. [PMID: 35621334 DOI: 10.1080/14656566.2022.2083954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The importance of the appropriate therapeutic interventions in children and adolescents with bipolar disorder (BD) cannot be overstated since treatment choices and their consequences may have effects into adulthood. AREAS COVERED Randomized clinical trials (RCTs) investigating treatment of mania, bipolar depression, and maintenance in adolescents with BD are reviewed. When RCTs are not available or are inadequate, naturalistic data or open studies are also reviewed. EXPERT OPINION Efficacy and safety of pharmaceutical agents in adolescents with BD appear to mirror adults with BD. Lithium/mood stabilizers are preferred first line agents over antipsychotic medications, but the latter are second line agents particularly in bipolar depression. When lithium is used, serum levels approaching 1.0 mEq/L are reasonable since younger people appear to require/tolerate higher levels. Among the antipsychotics, quetiapine appeared to be minimally better than risperidone while risperidone was associated with greater adverse events. Antipsychotics with antidepressant activity in adults, also appear to have antidepressant effects in youths. Use of antidepressants in bipolar depression is generally not recommended although it may be reasonable in specific clinical situations. The similarities between adolescent and adult outcomes suggest that it is reasonable to utilize adult data to aid with clinical decision making in adolescents with BD, especially when pediatric-specific data are unavailable.
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Affiliation(s)
- Omar H Elsayed
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Kentucky USA
| | - Mehak Pahwa
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Kentucky USA
| | - Rif S El-Mallakh
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Kentucky USA
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3
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Sherwood SN, Carlson GA, Freeman AJ. Decreasing rate of inpatient pediatric bipolar disorder diagnosis in the US between 2004 and 2010. Bipolar Disord 2022; 24:149-160. [PMID: 34664344 DOI: 10.1111/bdi.13145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/05/2021] [Accepted: 10/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Diagnosis of bipolar disorder (BD) increased substantially among youth between the mid-1990s and mid-2000s in the United States. This dramatic increase in diagnosis resulted in concern regarding the potential for misdiagnosis of BD among youth. However, the rate of BD diagnosis in the United States had not been evaluated nationally since the mid-2000s. It was unclear whether changes in diagnostic rates continued to occur. Therefore, the present study aimed to assess the pattern of longitudinal trends in the rate of national inpatient BD diagnosis subsequent to 2004. METHODS Data included a nationally representative dataset of inpatient hospitalizations between 1996 and 2010. De-identified data were obtained from the National Hospital Discharge Survey (NHDS) conducted annually by the National Center for Health Statistics. RESULTS The proportion of BD diagnoses relative to all psychiatric diagnoses increased between 1996 and 2004 among children and adolescents. The proportion of BD diagnoses then decreased between 2004 and 2010 among children but continued to increase for adolescents. However, population-adjusted rates of BD diagnosis per 10,000 individuals in the general population initially increased until the mid-2000s and then decreased until 2010 for both children and adolescents. CONCLUSIONS Rates of BD diagnosis substantially decreased for youth between the mid-2000s and 2010. This decline coincided with recommendations for more conservative diagnostic practices due to concerns about overdiagnosis and increasing awareness of the side effects of front-line medications used to treat BD in youth. Findings provide insight into changing trends in inpatient service utilization for BD in the United States.
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Affiliation(s)
| | - Gabrielle A Carlson
- Psychiatry and Pediatrics, State University of New York at Stony Brook, East Setauket, New York, USA
| | - Andrew J Freeman
- Department of Psychology, University of Nevada, Las Vegas, Nevada, USA.,Division of Child and Family Services, Nevada Department of Health and Human Services, Las Vegas, Nevada, USA
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4
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Abstract
OBJECTIVE Bipolar disorder (BD) is a chronic mental health disorder with significant morbidity and mortality. Age at onset (AAO) may be a key variable in delineating more homogeneous subgroups of BD patients. However, no known research has systematically assessed how BD age-at-onset subgroups should be defined. METHODS We systematically searched the following databases: Cochrane Central Register of Controlled Trials, PsycINFO, MEDLINE, Embase, CINAHL, Scopus, Proquest Dissertations and Theses, Google Scholar and BIOSIS Previews. Original quantitative English language studies investigating AAO in BD were sought. RESULTS A total of 9454 unique publications were identified. Twenty-one of these were included in data analysis (n = 22981 BD participants). Fourteen of these studies (67%, n = 13626 participants) found a trimodal AAO distribution: early-onset (µ = 17.3, σ = 1.19, 45% of sample), mid-onset (µ = 26.0, σ = 1.72, 35%), and late-onset (µ = 41.9, σ = 6.16, 20%). Five studies (24%, n = 1422 participants) described a bimodal AAO distribution: early-onset (µ = 24.3, σ = 6.57, 66% of sample) and late-onset (µ = 46.3, σ = 14.15, 34%). Two studies investigated cohort effects on BD AAO and found that when the sample was not split by cohort, a trimodal AAO was the winning model, but when separated by cohort a bimodal distribution fit the data better. CONCLUSIONS We propose that the field conceptualises bipolar disorder age-at-onset subgroups as referring broadly to life stages. Demarcating BD AAO groups can inform treatment and provide a framework for future research to continue to investigate potential mechanisms of disease onset.
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Affiliation(s)
- Sorcha Bolton
- Department of PsychiatryUniversity of OxfordWarneford HospitalOxfordUK
| | - Jeremy Warner
- University of Oxford Medical SchoolJohn Radcliffe HospitalOxfordUK
| | - Eli Harriss
- Bodleian Health Care LibrariesUniversity of OxfordOxfordUK
| | - John Geddes
- Department of PsychiatryUniversity of OxfordWarneford HospitalOxfordUK,Oxford Health NHS Foundation TrustWarneford HospitalOxfordUK
| | - Kate E. A. Saunders
- Department of PsychiatryUniversity of OxfordWarneford HospitalOxfordUK,Oxford Health NHS Foundation TrustWarneford HospitalOxfordUK
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5
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Sherwood SN, Greenway J, Freeman AJ. Decreasing rate of inpatient pediatric bipolar disorder diagnosis between 2005 and 2015. J Affect Disord 2020; 274:859-863. [PMID: 32664026 DOI: 10.1016/j.jad.2020.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 04/22/2020] [Accepted: 05/10/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The rate of bipolar disorder (BD) diagnosis in youth increased between the mid-1990s and mid-2000s in the U.S. and remained low in other countries. The discrepancy resulted in concerns regarding misdiagnosis of BD. However, the longitudinal trajectory of BD diagnosis subsequent to the mid-2000s was unclear. Therefore, the current study assessed longitudinal changes in the rate of inpatient BD diagnosis in the state of Nevada between 2005 and 2015. METHODS Data included Medicaid administrative billing claims (n = 48,108 unique admissions) for youth 5-17 hospitalized at one of five psychiatric inpatient hospitals in Nevada. Regressions assessed changes in the rate of diagnosis over time for BD and compared to depressive disorders (DD). RESULTS The rate of BD diagnosis declined between 2005 and 2015. The rate of DD diagnosis remained stable for boys and increased substantially for girls during the same time period. LIMITATIONS Some individuals may have been repeatedly hospitalized throughout the study period and contribute more than one unique admission. Findings from this study were limited to a sample of Medicaid-insured youth in a single state. CONCLUSIONS The rate of mood disorder diagnosis in inpatient units is changing. The use of BD as a diagnosis is decreasing in Nevada which may reflect US trends nationally, though still high by international comparison. In contrast, DD increased for girls but not boys. Awareness of the current diagnostic trends for BD may assist inpatient administrators and clinicians in preparing for anticipated service utilization and planning allocation of resources.
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Affiliation(s)
- Samantha N Sherwood
- Department of Psychology, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, Nevada, USA
| | - Joseph Greenway
- Center for Health Information Analysis at the University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, Nevada, USA
| | - Andrew J Freeman
- Department of Psychology, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, Nevada, USA.
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6
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Duffy A, Carlson G, Dubicka B, Hillegers MHJ. Pre-pubertal bipolar disorder: origins and current status of the controversy. Int J Bipolar Disord 2020; 8:18. [PMID: 32307651 PMCID: PMC7167382 DOI: 10.1186/s40345-020-00185-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/17/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Evidence from epidemiological, clinical and high-risk studies has established that the peak period of risk for onset of bipolar disorder spans late adolescence and early adulthood. However, the proposal of the existence of a pre-pubertal form of bipolar disorder manifesting in early childhood created substantial debate. In this narrative review, the literature and contributing factors pertaining to the controversy surrounding the proposed pre-pubertal bipolar disorder subtype are discussed. The resolution of the debate and lessons learned are highlighted. MAIN BODY In the mid 1990s US researchers proposed that chronic irritability and explosive temper in pre-pubertal children with pre-existing ADHD and/or other learning and developmental disorders might represent a variant of mania. A number of factors contributed to this proposal including severely ill children with no diagnostic home given changes in the ADHD DSM diagnostic criteria and over-reliance on symptoms and structured interviews rather than on a clinical assessment incorporating developmental history, social context and clinical course. Prospective studies of children at high familial risk did not support the proposed pre-pubertal bipolar phenotype; but rather provided convergent evidence that bipolar disorder onset in adolescence and early adulthood not uncommonly preceded by sleep and internalizing symptoms and most often debuting as depression in adolescence (after puberty). Epidemiological studies of population and hospital discharge data provided evidence that the pre-pubertal bipolar phenotype was largely a US driven phenomenon. CONCLUSIONS Psychiatric diagnosis is particularly challenging given the current lack of objective biomarkers. However, validity and utility of clinical diagnoses can be strengthened if all available predictive information is used to formulate a diagnosis. As in other areas of medicine, critical information required to make a valid diagnosis includes developmental history, clinical course, family history and treatment response-weighed against the known trajectories of classical disorders. Moreover, given that psychiatric disorders are in evolution over childhood and adolescence and symptoms, in of themselves, are often non-specific, a thorough clinical assessment incorporating collateral history and psychosocial context is paramount. Such an approach might have avoided or at least brought a more timely resolution to the debate on pre-pubertal mania.
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Affiliation(s)
- A. Duffy
- Queen’s University, Kingston, Canada
- Department of Psychiatry, University Oxford, Oxford, UK
| | - G. Carlson
- Renaissance School of Medicine, Stonybrook University, Stony Brook, NY USA
| | - B. Dubicka
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M. H. J. Hillegers
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, The Netherlands
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Parry P, Allison S, Bastiampillai T. The geography of a controversial diagnosis: A bibliographic analysis of published academic perspectives on 'paediatric bipolar disorder'. Clin Child Psychol Psychiatry 2019; 24:529-545. [PMID: 30905170 DOI: 10.1177/1359104519836700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The hypothesis that bipolar disorder presents before puberty with atypical mania has proved to be controversial. Published academic perspectives on the validity of Paediatric Bipolar Disorder (PBD) appear to vary between the United States and the rest of the world. METHODS We examined the perspectives of articles citing four seminal articles. The citing articles were grouped as either supportive or non-supportive of the PBD hypothesis, and the perspectives of the articles by US authors were compared with those by non-US authors. RESULTS There were 787 citing articles commenting on PBD, mostly published in US-based journals. Most authors were affiliated with several US institutions. Among the 624 articles with US authorship, the majority (83%) supported PBD. Of the 163 articles by non-US authors, most (60%) supported the traditional view that bipolar disorders are rare before mid-adolescence. Published academic perspectives in favour of the PBD hypothesis are mostly concentrated in several US institutions. CONCLUSION There is majority support for PBD among citing articles from the United States, whereas the traditional perspective predominates in articles from most other countries.
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Affiliation(s)
- Peter Parry
- 1 School of Clinical Medicine - Children's Health Queensland Clinical Unit, University of Queensland, Australia.,2 College of Medicine and Public Health, Flinders University, Australia
| | - Stephen Allison
- 2 College of Medicine and Public Health, Flinders University, Australia
| | - Tarun Bastiampillai
- 2 College of Medicine and Public Health, Flinders University, Australia.,3 Mind and Brain Theme, South Australian Health and Medical Research Institute, Australia
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8
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Affiliation(s)
- Philip Hazell
- Thomas Walker Hospital, University of Sydney School of Medicine, Concord West, NSW, Australia
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9
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Findling RL, Stepanova E, Youngstrom EA, Young AS. Progress in diagnosis and treatment of bipolar disorder among children and adolescents: an international perspective. EVIDENCE-BASED MENTAL HEALTH 2018; 21:177-181. [PMID: 30327338 PMCID: PMC10270441 DOI: 10.1136/eb-2018-102912] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/29/2018] [Accepted: 08/20/2018] [Indexed: 11/04/2022]
Abstract
Bipolar disorder (BPD) is a potentially lifelong condition characterised by extreme changes in mood that may begin in childhood and cause substantial impairment. Over the past decades, BPD has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in children and adolescents. This report addresses these controversies by reviewing the extant evidence base, providing clinicians with a summary of the literature on diagnosis, phenomenology and treatment of paediatric BPD. The debate regarding diagnosing children with BPD based on severe irritability and aggression is mostly resolved. The current data support utilising the diagnostic criteria based on episodic changes of mood polarity. Therefore, longitudinal course of illness should be explored in detail when diagnosing BPD. Given high rates of genetic predisposition for BPD, assessment of youth should focus on obtaining accurate family history of this condition. Additionally, there has been a substantial increase in randomised placebo-controlled clinical trials evaluating pharmacological agents for mood stabilisation in children and adolescents, which we summarise in this review. Despite significant progress being made in the field of paediatric BPD, more research is needed in the areas of phenomenology, pathophysiology, course and treatment of this condition in youth.
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Affiliation(s)
- Robert L Findling
- Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ekaterina Stepanova
- Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric A Youngstrom
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrea S Young
- Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore, Maryland, USA
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10
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Duffy A, Malhi GS, Carlson GA. The challenge of psychiatric diagnosis: Looking beyond the symptoms to the company that they keep. Bipolar Disord 2018; 20:410-413. [PMID: 30009578 DOI: 10.1111/bdi.12686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Anne Duffy
- Department of Psychiatry, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Gin S Malhi
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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11
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Carlson GA. Commentary: Bipolar disorder in youth - what is it and where is it? - a commentary on Parry et al. (2018). Child Adolesc Ment Health 2018; 23:23-25. [PMID: 32677371 DOI: 10.1111/camh.12243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 11/28/2022]
Abstract
Parry and colleagues reexamine the 12 articles that comprise a widely cited, 2011 meta-analysis of community studies of pediatric bipolar that stated no differences exist between rates in the United States and other countries. This reexamination concludes not only are there in fact considerable differences in rates of bipolar disorder (both bipolar I disorder and bipolar spectrum disorder) but also the rates overall are lower than the meta-analysis stated. This editorial explains some of the reasons behind the overly enthusiastic reports of bipolar disorder rates in youth including definitional (what is pediatric and what is bipolar) and assessment ambiguities and the bona fide effort to explain the psychopathology underpinning explosive children. Although the questions of what prepubertal bipolar disorder is have themselves been polarizing, common ground is being increasingly found.
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Affiliation(s)
- Gabrielle A Carlson
- New York State University, Department of Psychiatry and Behavioural Science, Putnam Hall State University of New York, Stony Brook, NY, 11794-8790, USA
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12
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Parry P, Allison S, Bastiampillai T. 'Paediatric bipolar disorder' rates are lower than claimed - a reexamination of the epidemiological surveys used by a meta-analysis. Child Adolesc Ment Health 2018; 23:14-22. [PMID: 32677365 DOI: 10.1111/camh.12231] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND 'Paediatric bipolar disorder' (PBD) is a controversial diagnosis where often prepubertal children as well as adolescents, who may have a range of psychiatric disorders or symptoms, are diagnosed with a severe mental illness requiring lifelong medication. Clinically, it has often been applied in the United States but rarely in most other countries. A meta-analysis (Van Meter et al., Journal of Clinical Psychiatry, , 72, 1250) claimed that the prevalence of PBD was similar to adults at 1.8% with no difference between the United States and other countries. This conclusion has been highly cited. METHODS The heterogeneous nature of the original 12 epidemiological surveys warrants a qualitative analysis, rather than statistical meta-analysis as performed by Van Meter et al. (Journal of Clinical Psychiatry, 2011, 72, 1250). Thus, the meta-analysis and each of the 12 studies (six from the United States; six from other countries) were reexamined. RESULTS Most of the 12 surveys predated the emergence of the PBD hypothesis. The 12 surveys were mainly of adolescents and at times young adults with few prepubertal children. Prevalence rates in the 12 studies suggest a lower rate of bipolar disorder, especially in non-US samples. For example, the Van Meter et al. (Journal of Clinical Psychiatry, 2011, 72, 1250) meta-analysis chose a rate of 2.8% by summation of adolescent and parent responses in a Dutch survey, however the rate fell to 0% if requiring concordance of adolescent and parent responses. Indeed, it could be argued that four of the non-US studies show 0% rates of PBD. CONCLUSIONS Rates of PBD were generally substantially lower than 1.8%, particularly in non-US surveys, and if both parent and adolescent reports were required to meet the diagnostic threshold they fell to close to zero. The reanalysis suggests that bipolar disorder is rare before the expected age of onset in later adolescence.
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Affiliation(s)
- Peter Parry
- Department of Psychiatry, Royal Brisbane & Women's Hospital, University of Queensland, Herston, Brisbane, QLD, 4006, Australia.,School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Stephen Allison
- School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Tarun Bastiampillai
- School of Medicine, Flinders University, Adelaide, SA, Australia.,Mind and Brain Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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Ryles F, Meyer TD, Adan-Manes J, MacMillan I, Scott J. A systematic review of the frequency and severity of manic symptoms reported in studies that compare phenomenology across children, adolescents and adults with bipolar disorders. Int J Bipolar Disord 2017; 5:4. [PMID: 28155204 PMCID: PMC5289931 DOI: 10.1186/s40345-017-0071-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 01/04/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In the last two decades, there has been a significant increase in the diagnosis of Bipolar Disorder (BD) in children. The notion of prepubertal onsets of BD is not without controversy, with researchers debating whether paediatric cases have a distinct symptom profile or follow a different illness trajectory from other forms of BD. The latter issue is difficult to address without long-term prospective follow-up studies. However, in the interim, it is useful to consider the phenomenology observed in groups of cases with different ages of onset and particularly to compare manic symptoms in children diagnosed with BD compared to cases presenting with BD in adolescence and adulthood. This review systematically explores the phenomenology of manic or hypomanic episodes in groups defined by age at onset of BD (children, adolescents and adults; or combined age groups e.g. children and adolescents versus adults). METHODS Literature reviews of PubMed and Scopus were conducted to identify publications which directly compared the frequency or severity of manic symptoms in individuals with BD presenting with a first episode of mania in childhood, adolescence or adulthood. RESULTS Of 304 studies identified, 55 texts warranted detailed review, but only nine studies met eligibility criteria for inclusion. Comparison of manic symptoms across age groups suggested that irritability is a key feature of BD with an onset in childhood, activity is the most prominent in adolescent-onset BD and pressure of speech is more characteristic of adult-onset BD. However, none of the eligible studies made a direct comparison of phenomenology in children versus adults. Assessment procedures varied in quality and undermined the reliability of cross-study comparisons. Other limitations were: the scarcity of comparative studies, the geographic bias (most studies originated in the USA), the failure to fully consider the impact of psychiatric comorbidities on recorded symptoms and methodological heterogeneity. CONCLUSIONS Despite frequent discussion of similarities and differences in phenomenology of mania presenting in different age groups, systematic research is lacking and studies are still required to reliably establish whether the frequency and severity of manic symptoms varies. Such information has implications for clinical practice and the classification of mental disorders.
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Affiliation(s)
- Faye Ryles
- Early Intervention in Psychiatry Hub, NTW NHS Trust, Newcastle upon Tyne, UK
| | - Thomas D. Meyer
- Department of Psychiatry and Behavioral Sciences, University of Texas, Houston, TX USA
| | | | - Iain MacMillan
- Early Intervention in Psychiatry Hub, NTW NHS Trust, Newcastle upon Tyne, UK
| | - Jan Scott
- Academic Psychiatry, Wolfson Unit, Institute of Neuroscience, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK
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Goldstein BI, Birmaher B, Carlson GA, DelBello MP, Findling RL, Fristad M, Kowatch RA, Miklowitz DJ, Nery FG, Perez‐Algorta G, Van Meter A, Zeni CP, Correll CU, Kim H, Wozniak J, Chang KD, Hillegers M, Youngstrom EA. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disord 2017; 19:524-543. [PMID: 28944987 PMCID: PMC5716873 DOI: 10.1111/bdi.12556] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/14/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Over the past two decades, there has been tremendous growth in research regarding bipolar disorder (BD) among children and adolescents (ie, pediatric BD [PBD]). The primary purpose of this article is to distill the extant literature, dispel myths or exaggerated assertions in the field, and disseminate clinically relevant findings. METHODS An international group of experts completed a selective review of the literature, emphasizing areas of consensus, identifying limitations and gaps in the literature, and highlighting future directions to mitigate these gaps. RESULTS Substantial, and increasingly international, research has accumulated regarding the phenomenology, differential diagnosis, course, treatment, and neurobiology of PBD. Prior division around the role of irritability and of screening tools in diagnosis has largely abated. Gold-standard pharmacologic trials inform treatment of manic/mixed episodes, whereas fewer data address bipolar depression and maintenance/continuation treatment. Adjunctive psychosocial treatment provides a forum for psychoeducation and targets primarily depressive symptoms. Numerous neurocognitive and neuroimaging studies, and increasing peripheral biomarker studies, largely converge with prior findings from adults with BD. CONCLUSIONS As data have accumulated and controversy has dissipated, the field has moved past existential questions about PBD toward defining and pursuing pressing clinical and scientific priorities that remain. The overall body of evidence supports the position that perceptions about marked international (US vs elsewhere) and developmental (pediatric vs adult) differences have been overstated, although additional research on these topics is warranted. Traction toward improved outcomes will be supported by continued emphasis on pathophysiology and novel therapeutics.
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Affiliation(s)
- Benjamin I Goldstein
- Centre for Youth Bipolar DisorderSunnybrook Health Sciences CentreTorontoCanada,Departments of Psychiatry and PharmacologyUniversity of TorontoTorontoCanada
| | - Boris Birmaher
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Gabrielle A Carlson
- Department of PsychiatryStony Brook University School of MedicineStony BrookNYUSA
| | - Melissa P DelBello
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | - Robert L Findling
- Department of Psychiatry & Behavioral SciencesThe Johns Hopkins UniversityBaltimoreMDUSA
| | - Mary Fristad
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | - Robert A Kowatch
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | | | - Fabiano G Nery
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | | | - Anna Van Meter
- Ferkauf Graduate School of PsychologyYeshiva UniversityBronxNYUSA
| | | | - Christoph U Correll
- The Zucker Hillside HospitalDepartment of PsychiatryNorthwell HealthGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineHofstra Northwell School of MedicineHempsteadNYUSA
| | - Hyo‐Won Kim
- Department of PsychiatryUniversity of Ulsan College of MedicineAsan Medical CenterSeoulKorea
| | - Janet Wozniak
- Clinical and Research Program in Pediatric PsychopharmacologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Kiki D Chang
- Department of PsychiatryStanford UniversityPalo AltoCAUSA
| | - Manon Hillegers
- Department of Child and Adolescent Psychiatry and PsychologyErasmus Medical Center‐SophiaRotterdamThe Netherlands
| | - Eric A Youngstrom
- Department of Psychology and NeuroscienceUniversity of North CarolinaChapel HillNCUSA
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15
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Post RM, Altshuler LL, Kupka R, McElroy SL, Frye MA, Rowe M, Grunze H, Suppes T, Keck PE, Leverich GS, Nolen WA. More childhood onset bipolar disorder in the United States than Canada or Europe: Implications for treatment and prevention. Neurosci Biobehav Rev 2017; 74:204-213. [PMID: 28119069 DOI: 10.1016/j.neubiorev.2017.01.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 01/18/2017] [Indexed: 02/05/2023]
Abstract
Evidence of a high or increasing incidence of childhood onset bipolar disorder in the United States (US) has been viewed skeptically. Here we review evidence that childhood onsets of bipolar disorder are more common in the US than in Europe, treatment delays are longer, and illness course is more adverse and difficult. Epidemiological data and studies of offspring at high risk also support these findings. In our cohort of outpatients with bipolar disorder, two of the major vulnerability factors for early onset - genetics and environmental adversity in childhood - were also greater in the US than in Europe. An increased familial loading for multiple psychiatric disorders was apparent in 4 generations of the family members of the patients from the US, and that familial burden was linked to early onset bipolar disorder. Since both early onset and treatment delay are risk factors for a poor outcome in adulthood, new clinical, research, and public health initiatives are needed to begin to address and ameliorate this ongoing and potentially devastating clinical situation.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, Bethesda, MD, USA; Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, D.C., USA.
| | - Lori L Altshuler
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Psychiatry, VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Los Angeles, CA, USA
| | - Ralph Kupka
- Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Biological Psychiatry Program, University of Cincinnati Medical College, Cincinnati, OH, USA
| | - Mark A Frye
- Department of Psychiatry, Mayo Clinic, Rochester, MI, USA
| | - Michael Rowe
- Bipolar Collaborative Network, Bethesda, MD, USA
| | - Heinz Grunze
- Paracelsius Medical University, Salzburg, Austria
| | - Trisha Suppes
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA; V.A. Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paul E Keck
- Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Lindner Center of HOPE, Mason, OH, USA
| | | | - Willem A Nolen
- University Medical Center, University of Groningen, Groningen, The Netherlands
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16
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Merten EC, Cwik JC, Margraf J, Schneider S. Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child Adolesc Psychiatry Ment Health 2017; 11:5. [PMID: 28105068 PMCID: PMC5240230 DOI: 10.1186/s13034-016-0140-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 12/11/2016] [Indexed: 11/22/2022] Open
Abstract
During the past 50 years, health insurance providers and national registers of mental health regularly report significant increases in the number of mental disorder diagnoses in children and adolescents. However, epidemiological studies show mixed effects of time trends of prevalence of mental disorders. Overdiagnosis in clinical practice rather than an actual increase is assumed to be the cause for this situation. We conducted a systematic literature search on the topic of overdiagnosis of mental disorders in children and adolescents. Most reviewed studies suggest that misdiagnosis does occur; however, only one study was able to examine overdiagnosis in child and adolescent mental disorders from a methodological point-of-view. This study found significant evidence of overdiagnosis of attention-deficit/hyperactivity disorder. In the second part of this paper, we summarize findings concerning diagnostician, informant and child/adolescent characteristics, as well as factors concerning diagnostic criteria and the health care system that can lead to mistakes in the routine diagnostic process resulting in misdiagnoses. These include the use of heuristics instead of data-based decisions by diagnosticians, misleading information by caregivers, ambiguity in symptom description relating to classification systems, as well as constraints in most health systems to assign a diagnosis in order to approve and reimburse treatment. To avoid misdiagnosis, standardized procedures as well as continued education of diagnosticians working with children and adolescents suffering from a mental disorder are needed.
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Affiliation(s)
- Eva Charlotte Merten
- Department of Clinical Child and Adolescent Psychology of the Faculty of Psychology, Ruhr-Universität Bochum, Massenbergstraße 9-13, 44787 Bochum, Germany
| | - Jan Christopher Cwik
- Department of Clinical Psychology and Psychotherapy of the Faculty of Psychology, Ruhr-Universität Bochum, Massenbergstraße 9-13, 44787 Bochum, Germany
| | - Jürgen Margraf
- Department of Clinical Psychology and Psychotherapy of the Faculty of Psychology, Ruhr-Universität Bochum, Massenbergstraße 9-13, 44787 Bochum, Germany
| | - Silvia Schneider
- Department of Clinical Child and Adolescent Psychology of the Faculty of Psychology, Ruhr-Universität Bochum, Massenbergstraße 9-13, 44787 Bochum, Germany
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17
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Oedegaard CH, Berk L, Berk M, Youngstrom EA, Dilsaver SC, Belmaker RH, Oedegaard KJ, Fasmer OB, Engebretsen IM. An ISBD perspective on the sociocultural challenges of managing bipolar disorder: A content analysis. Aust N Z J Psychiatry 2016; 50:1096-1103. [PMID: 27742913 DOI: 10.1177/0004867416668790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Clinical management of bipolar disorder patients might be affected by culture and is further dependent on the context of healthcare delivery. There is a need to understand how healthcare best can be delivered in various systems and cultures. The objective of this qualitative study was to gain knowledge about culture-specific values, beliefs and practices in the medical care provided to patients with bipolar disorders from a provider perspective in various areas of the world. SAMPLING AND METHODS The International Society for Bipolar Disorders (ISBD) network provided the framework for this qualitative study. An electronic interview with open-ended questions was administered to 19 international experts on bipolar spectrum disorder representing the International Society for Bipolar Disorders chapter network in 16 countries and six continents. In addition, there were two in-depth interviews with bipolar spectrum disorder experts done prior to the survey. The data were analysed using content analysis, and the information was structured using the software NVivo by QSR International Pty Ltd. FINDINGS All participants described sociocultural factors as important in healthcare delivery to bipolar patients in their part of the world, both in accessing healthcare and in providing culturally appropriate care. Factors that affected the provider's ability to supply good clinical management of patients were access to treatment options and long-term follow-up, as well as general strategies to combat stigma. In some societies, the patients' use of alternative treatments, gender issues and religion were also important factors. Understanding the impact of such culturally specific factors was overall regarded as essential for proper treatment interventions. CONCLUSION Sociocultural factors clearly affect the nature and quality of medical services delivered to bipolar patients. Financial, social and cultural factors affect patients' health-seeking behaviour, and this highlights the need for knowledge about such factors in order to adequately identify and treat bipolar patients globally. Culturally adapted training and psychoeducation programmes are particularly warranted.
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Affiliation(s)
- Christine H Oedegaard
- Global Mental Health Research Group (GMHRG), Centre for International Health, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Lesley Berk
- IMPACT Strategic Research Centre, School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia.,Melbourne School of Population and Global Health and Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia.,Department of Psychiatry, The University of Melbourne, Orygen, The National Centre of Excellence in Youth Mental Health and the Centre for Youth Mental Health, Parkville, VIC, Australia.,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | | | - Eric A Youngstrom
- Department of Psychology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Robert H Belmaker
- Beersheva Mental Health Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ketil J Oedegaard
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Norway .,Division of Psychiatry, Haukeland University hospital, Bergen, Norway
| | - Ole B Fasmer
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Norway.,Division of Psychiatry, Haukeland University hospital, Bergen, Norway
| | - Ingunn M Engebretsen
- Global Mental Health Research Group (GMHRG), Centre for International Health, Faculty of Medicine and Dentistry, University of Bergen, Norway
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18
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Youngstrom EA, Van Meter A. Empirically Supported Assessment of Children and Adolescents. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2016. [DOI: 10.1111/cpsp.12172] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Eric A. Youngstrom
- Department of Psychology and Neuroscience; University of North Carolina at Chapel Hill
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19
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Algorta GP, Dodd AL, Stringaris A, Youngstrom EA. Diagnostic efficiency of the SDQ for parents to identify ADHD in the UK: a ROC analysis. Eur Child Adolesc Psychiatry 2016; 25:949-57. [PMID: 26762184 PMCID: PMC4990620 DOI: 10.1007/s00787-015-0815-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 12/23/2015] [Indexed: 02/06/2023]
Abstract
Early, accurate identification of ADHD would improve outcomes while avoiding unnecessary medication exposure for non-ADHD youths, but is challenging, especially in primary care. The aim of this paper is to test the Strengths and Difficulties Questionnaire (SDQ) using a nationally representative sample to develop scoring weights for clinical use. The British Child and Adolescent Mental Health Survey (N = 18,232 youths 5-15 years old) included semi-structured interview DSM-IV diagnoses and parent-rated SDQ scores. Areas under the curve for SDQ subscales were good (0.81) to excellent (0.96) across sex and age groups. Hyperactivity/inattention scale scores of 10+ increased odds of ADHD by 21.3×. For discriminating ADHD from other diagnoses, accuracy was fair (<0.70) to good (0.88); Hyperactivity/inattention scale scores of 10+ increased odds of ADHD by 4.47×. The SDQ is free, easy to score, and provides clinically meaningful changes in odds of ADHD that can guide clinical decision-making in an evidence-based medicine framework.
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Affiliation(s)
- Guillermo Perez Algorta
- The Spectrum Centre, Lancaster University, Furness Building, C73, Bailrigg, Lancaster, LA1 4YT, UK.
| | - Alyson Lamont Dodd
- The Spectrum Centre, Lancaster University, Furness Building, C73, Bailrigg, Lancaster, LA1 4YT, UK
| | - Argyris Stringaris
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King's College London, London, UK
| | - Eric A Youngstrom
- Department of Psychology and Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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20
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Joslyn C, Hawes DJ, Hunt C, Mitchell PB. Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review. Bipolar Disord 2016; 18:389-403. [PMID: 27530107 DOI: 10.1111/bdi.12419] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 06/30/2016] [Accepted: 07/02/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To identify clinical characteristics and adverse outcomes associated with an earlier age of onset of bipolar disorder. METHODS A comprehensive search yielded 15 empirical papers comparing clinical presentation and outcomes in individuals with bipolar disorder grouped according to age of onset (total N=7370). The following variables were examined to determine odds ratios (ORs) and 95% confidence intervals (CIs): presence of Axis I comorbidity, rapid cycling, psychotic symptoms, mixed episodes (DSM-IV), lifetime suicide attempts, lifetime alcohol and substance abuse, symptom severity, and treatment delay. RESULTS Early age of onset was found to be associated with longer delay to treatment (Hedges' g=0.39, P=.001), greater severity of depression (Hedges' g=0.42, P<.001), and higher levels of comorbid anxiety (OR=2.34, P<.001) and substance use (OR=1.80, P<.001). Surprisingly, no association was found between early age of onset and clinical characteristics such as psychotic symptoms or mixed episodes as defined by DSM-IV. CONCLUSIONS Earlier age of onset of bipolar disorder is associated with factors that can negatively impact long-term outcomes such as increased comorbidity. However, no association was found between early onset and indicators of severity or treatment resistance such as psychotic symptoms. Clinical features found to have the strongest relationship with early age of onset were those potentially amenable to pharmacological and psychological treatment. Results highlight the importance of early identification and provide potential areas of focus for the development of early intervention in bipolar disorder.
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Affiliation(s)
| | - David J Hawes
- School of Psychology, University of Sydney, Sydney, Australia
| | - Caroline Hunt
- School of Psychology, University of Sydney, Sydney, Australia
| | - Philip B Mitchell
- School of Psychiatry, University of New South Wales, Sydney, Australia
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21
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Jenkins MM, Youngstrom EA. A randomized controlled trial of cognitive debiasing improves assessment and treatment selection for pediatric bipolar disorder. J Consult Clin Psychol 2016; 84:323-33. [PMID: 26727411 DOI: 10.1037/ccp0000070] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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22
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Clacey J, Goldacre M, James A. Paediatric bipolar disorder: international comparisons of hospital discharge rates 2000-2010. BJPsych Open 2015; 1:166-171. [PMID: 27703743 PMCID: PMC4995564 DOI: 10.1192/bjpo.bp.115.001933] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/31/2015] [Accepted: 10/16/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Controversy surrounds the diagnosis and prevalence of paediatric bipolar disorder, with estimates varying considerably between countries. AIMS To determine the international hospital discharge rates for paediatric bipolar disorder compared with all other psychiatric diagnoses. METHOD We used national data-sets from 2000 to 2010 from England, Australia, New Zealand, the USA and Germany. RESULTS For those aged under 20 years, the discharge rates for paediatric bipolar disorder per 100 000 population were: USA 95.6, Australia 11.7, New Zealand 6.3, Germany 1.5 and England 0.9. The most marked divergence in discharge rates was in 5- to 9-year-olds: USA 27, New Zealand 0.22, Australia 0.14, Germany 0.03 and England 0.00. CONCLUSIONS The disparity between US and other discharge rates for paediatric bipolar disorder is markedly greater than the variation for child psychiatric discharge rates overall, and for adult rates of bipolar disorder. This suggests there may be differing diagnostic practices for paediatric bipolar disorder in the USA. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © 2015 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Joe Clacey
- Joe Clacey, BM, BCh BA (Hons), Highfield Unit, Warneford Hospital, Oxford
| | - Michael Goldacre
- Michael Goldacre, FFPH, FRCP, BM BCh, BA (Hons), Unit of Health-Care Epidemiology, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anthony James
- Anthony James, MBBS, MRCP, MRCPsych, MPhil, MA (Oxon), Department of Psychiatry, University of Oxford, and Highfield Unit, Warneford Hospital, Oxford, UK
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23
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Ratheesh A, Berk M, Davey CG, McGorry PD, Cotton SM. Instruments that prospectively predict bipolar disorder - A systematic review. J Affect Disord 2015; 179:65-73. [PMID: 25845751 DOI: 10.1016/j.jad.2015.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Identification of earlier stages of Bipolar Disorder (BD), even prior to the first manic episode, may help develop interventions to prevent or delay the onset of BD. However, reliable and valid instruments are necessary to ascertain such earlier stages of BD. The aim of the current review was to identify instruments that had predictive validity and utility for BD for use in early intervention (EI) settings for the prevention of BD. METHODS We undertook a systematic examination of studies that examined participants without BD I or II at baseline and prospectively explored the predictive abilities of instruments for BD onset over a period of 6 months or more. The instruments and the studies were rated with respect to their relative validity and utility predicting onset of BD for prevention or early intervention. Odds ratios and area under the curve (AUC) values were derived when not reported. RESULTS Six studies were included, identifying five instruments that examined sub-threshold symptoms, family history, temperament and behavioral regulation. Though none of the identified instruments had been examined in high-quality replicated studies for predicting BD, two instruments, namely the Child Behavioral Checklist - Pediatric BD phenotype (CBCL-PBD) and the General Behavioral Inventory - Revised (GBI-R), had greater levels of validity and utility. LIMITATION Non-inclusion of studies and instruments that incidentally identified BD on follow-up limited the breadth of the review. CONCLUSION Instruments that test domains such as subthreshold symptoms, behavioral regulation, family history, and temperament hold promise in predicting BD onset.
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Affiliation(s)
- Aswin Ratheesh
- Orygen The National Centre of Excellence in Youth Mental Health, Parkville, Australia; Centre For Youth Mental Health, University of Melbourne, Australia.
| | - Michael Berk
- Orygen The National Centre of Excellence in Youth Mental Health, Parkville, Australia; Centre For Youth Mental Health, University of Melbourne, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Australia; Impact Strategic Research Centre, Deakin University, Australia
| | - Christopher G Davey
- Orygen The National Centre of Excellence in Youth Mental Health, Parkville, Australia; Centre For Youth Mental Health, University of Melbourne, Australia
| | - Patrick D McGorry
- Orygen The National Centre of Excellence in Youth Mental Health, Parkville, Australia; Centre For Youth Mental Health, University of Melbourne, Australia
| | - Susan M Cotton
- Orygen The National Centre of Excellence in Youth Mental Health, Parkville, Australia; Centre For Youth Mental Health, University of Melbourne, Australia
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24
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Parry PI, Richards LME. Stark discrepancy in pediatric bipolar diagnoses between the US and UK/Australia. J Am Acad Child Adolesc Psychiatry 2014; 53:1234-5. [PMID: 25440313 DOI: 10.1016/j.jaac.2014.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/16/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Peter I Parry
- School of Medicine, Royal Brisbane Clinical School, University of Queensland, Brisbane, QLD, Australia.
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25
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Stringaris A, Youngstrom E. Unpacking the differences in US/UK rates of clinical diagnoses of early-onset bipolar disorder. J Am Acad Child Adolesc Psychiatry 2014; 53:609-11. [PMID: 24839878 DOI: 10.1016/j.jaac.2014.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
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26
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A comparison of American and English hospital discharge rates for pediatric bipolar disorder, 2000 to 2010. J Am Acad Child Adolesc Psychiatry 2014; 53:614-24. [PMID: 24839880 PMCID: PMC4473258 DOI: 10.1016/j.jaac.2014.02.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 01/31/2014] [Accepted: 03/05/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Controversy exists over the diagnosis and prevalence of pediatric bipolar disorder (PBD). Although several small surveys suggest that the rate of the PBD diagnosis in clinical settings is higher in the United States than in other countries, no comprehensive cross-national comparisons of clinical practice have been performed. Here, we used longitudinal national datasets from 2000 to 2010 to compare US and English hospital discharge rates for PBD in patients aged 1 to 19 years. METHOD We used the English National Health Service (NHS) Hospital Episode Statistics (HES) dataset and the United States National Hospital Discharge Survey (NHDS) to compare US and English discharge rates for PBD (bipolar I disorder [BP-I], bipolar II disorder [BP-II], bipolar disorder not otherwise specified [BP-NOS], and cyclothymia). We also conducted cross-national comparisons for all other psychiatric diagnoses in youth and for adults with bipolar disorder (BD). RESULTS There was a 72.1-fold difference in discharge rates for PBD in youth between the United States and England (United States, 100.9 per 100,000 population, 95% confidence interval = 98.1-103.8, versus England, 1.4 per 100,000 population, 95% CI = 1.4-1.5). After controlling for cross-national differences in length of stay, discharge rates for PBD remained 12.5 times higher in the United States than in England. For all other child psychiatric diagnoses, the discharge rate was 3.9-fold higher, and for adults with BD 7.2-fold higher, in the United States than in England. CONCLUSION The disparity between US and English discharge rates for PBD is markedly greater than the disparity for child psychiatric discharge rates overall and for adult rates of BD. This suggests that the difference in discharge rates for PBD may be due to differing diagnostic practices for PBD in the United States versus in England.
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Renk K, White R, Lauer BA, McSwiggan M, Puff J, Lowell A. Bipolar disorder in children. PSYCHIATRY JOURNAL 2014; 2014:928685. [PMID: 24800202 PMCID: PMC3994906 DOI: 10.1155/2014/928685] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 12/21/2013] [Indexed: 12/31/2022]
Abstract
Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.
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Affiliation(s)
- Kimberly Renk
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Rachel White
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Brea-Anne Lauer
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Meagan McSwiggan
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Jayme Puff
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
| | - Amanda Lowell
- University of Central Florida, P.O. Box 161390, Orlando, FL 32816, USA
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Abstract
BACKGROUND The existence of bipolar disorder (BP) in youth is controversial. METHODS The current evidence regarding the diagnosis of BP in youth was reviewed. RESULTS BP is a recurrent familial disorder that occurs in 1-3% of youth, particularly in adolescents. Except for subsyndromal BP, the prevalence of BP-I is similar across most countries. Due to the child's immaturity, the presence of comorbid disorders, and divergent interpretations of manic symptomatology it is difficult to diagnose BP in youth. Youth with subsyndromal mania and family history of BP, are at high risk to develop BP-I and BP-II. Both the full and subsyndromal syndromal BP are associated with significant psychosocial difficulties and increased risk for use of substances, suicidality, legal problems, and services utilization. CONCLUSION BP disorder exists in youth, but it is difficult to diagnose. The recurrent nature and psychosocial morbidity associated with this illness during critical developmental stages calls for comprehensive longitudinal evaluation and accurate recognition and treatment because delays in treatment are associated with poor outcome.
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Affiliation(s)
- Boris Birmaher
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Bellefield Towers Room 612, Pittsburgh, PA, 15213, USA
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Sivakumar T, Agarwal V, Sitholey P. Comorbidity of attention-deficit/hyperactivity disorder and bipolar disorder in North Indian clinic children and adolescents. Asian J Psychiatr 2013; 6:235-42. [PMID: 23642982 DOI: 10.1016/j.ajp.2012.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 10/27/2012] [Accepted: 12/29/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study examined comorbidity between attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BPD) in children attending child and adolescent psychiatry (CAP) services in a Medical University in North India. METHODS Children attending CAP services, old or new, were assessed using unstructured clinical interview, kiddie-Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime Version (K-SADS-PL), Mental State Examination (MSE) for ADHD, Child Mania Rating Scale (CMRS) Parent Version and Children's Global Assessment Scale (C-GAS). Information was collected from both children and parents. All children were clinically evaluated, and prospectively followed up. The diagnosis was made by consensus. Subjects with DSM-IV-TR diagnosis of ADHD, BPD, and ADHD+BPD were compared with each other. Research criteria for broad phenotype BPD were applied in ADHD subjects without DSM-IV-TR diagnosis of BPD. RESULTS 45 subjects had ADHD; 21, BPD and; 7 had lifetime DSM-IV-TR diagnosis of ADHD+BPD. 13.5% of ADHD subjects had comorbid BPD and 25% of BPD subjects had comorbid ADHD. ADHD-CT was the most common subtype of ADHD. Nearly two third of BPD subjects had their first mood episode before 13 years of age. ADHD+BPD subjects were more likely to be mentally retarded and have longer duration of mood episode compared to BPD subjects. Three subjects with DSM-IV-TR diagnosis of ADHD without BPD were additionally diagnosed with broad phenotype of BPD. CONCLUSIONS Variable comorbidity rates of ADHD+BPD in different studies are most likely due to differences in study setting, study sample, conceptualization of BPD and assessment methods.
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Affiliation(s)
- Thanapal Sivakumar
- Psychosocial Rehabilitation Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India.
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Youngstrom E, Zhao J, Mankoski R, Forbes RA, Marcus RM, Carson W, McQuade R, Findling RL. Clinical significance of treatment effects with aripiprazole versus placebo in a study of manic or mixed episodes associated with pediatric bipolar I disorder. J Child Adolesc Psychopharmacol 2013; 23:72-9. [PMID: 23480324 PMCID: PMC3696952 DOI: 10.1089/cap.2012.0024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Published studies in adult and pediatric bipolar disorder have used different definitions of treatment response. This analysis aimed to compare different definitions of response in a large sample of children and adolescents. METHODS Anexploratory analysis of a 4-week, multicenter, placebo-controlled study assessed patients (n=296; ages, 10-17 years) with an acute manic/mixed episode associated with BIPOLAR I disorder who were randomized to aripiprazole (10 or 30 mg/day) or placebo. The primary efficacy endpoint was mean change from baseline to week 4 in young mania rating scale (YMRS) total score. Additional assessments included: clinical global impressions-bipolar disorder (CGI-BP) Overall and mania scales, child global assessment scale (CGAS), and parent and subject general behavior inventory. Response was compared across seven operational definitions. Cohen's κ and Spearman's correlation tested relationships between various response definitions or changes in outcome measures and clinically meaningful improvement (defined as a CGI-BP overall improvement score of 1 or 2). RESULTS Response rates varied depending upon the operational definition, but were highest for 95% reliable change (statistical method used to determine individual change from previous assessment) and ≥33% reduction in YMRS total score. Response rate definitions with the highest validity in terms of predicting clinically meaningful improvement were: ≥50% reduction on YMRS (κ=0.64), a composite definition of response (YMRS <12.5, children's depression rating scale-revised (CDRS-R) ≤40, and CGAS ≥51; κ=0.59), and 95% reliable change on the CGAS or 33% reduction on YMRS (κ=0.56). Parent ratings of symptoms were generally better at detecting symptom improvement than were subject ratings (κ=∼0.4-0.5 vs. ∼0.2 when compared with CGI-BP overall improvement score). CONCLUSIONS Clinically meaningful definitions of response in acute treatment of a manic/mixed episode in pediatric subjects include a 50% change in YMRS and a composite measure of response. Parent-reported measures of symptom improvement appear reliable for assessing symptom change.
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Affiliation(s)
- Eric Youngstrom
- Department of Psychology, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
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McNicholas F, Prior C, Bates G. A case of pervasive refusal syndrome: a diagnostic conundrum. Clin Child Psychol Psychiatry 2013; 18:137-50. [PMID: 22815320 DOI: 10.1177/1359104512440079] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A case is presented of an 11-year-old girl with pervasive refusal syndrome (PRS) who ultimately recovered acutely and completely after an 18-month paediatric hospitalisation. There was an apparent absence of previously proposed important aetiological factors in PRS, such as family pathology and markedly traumatic or abusive experiences, and her recovery was sudden and complete. The authors consider the differential diagnoses of PRS paying particular attention to the possibility of a conversion disorder or catatonia, given the absence of PRS in the North American literature. Consideration of catatonia is important as it has a diagnostic test and responds rapidly to appropriate treatment, in contrast to conventional treatment for PRS and conversion disorder.
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Affiliation(s)
- Fiona McNicholas
- Department of Psychiatry, Our Lady's Hospital For Sick Children, Republic of Ireland
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Abstract
Issues complicating the differential diagnosis of bipolar disorder in young people are discussed. They include: a) the subtype of bipolar disorder being considered; b) the person's age and stage of development; c) whether one views bipolar disorder more conservatively, requiring clear episodes that mark a distinct change from premorbid levels of function, or more liberally, focusing for instance on severe irritability/explosive outbursts as the mood change; d) who is reporting manic symptoms, and whether symptoms are past and must be recalled or current and more likely to be observed; e) impact of family history. The diagnosis of mania/bipolar I disorder may not become clear for a number of years. This is an impairing disorder, but so are the conditions from which it must be distinguished. Family history may increase the odds that certain symptoms/behaviors are manifestations of bipolar disorder but it does not make the diagnosis. Until there are biomarkers that can confirm the diagnosis, and treatments unique to the condition, it is wise to make a diagnosis of bipolar disorder in children and adolescents provisionally and keep an open mind to the likelihood that revisions may be necessary.
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Affiliation(s)
- GABRIELLE A. CARLSON
- Department of Psychiatry and Behavioral Sciences,
Stony Brook University School of Medicine, Putnam Hall-South Campus, Stony
Brook, NY 11794-8790, USA
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Jenkins MM, Youngstrom EA, Youngstrom JK, Feeny NC, Findling RL. Generalizability of evidence-based assessment recommendations for pediatric bipolar disorder. Psychol Assess 2011; 24:269-81. [PMID: 22004538 DOI: 10.1037/a0025775] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bipolar disorder is frequently clinically diagnosed in youths who do not actually satisfy Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR; American Psychiatric Association, 1994) criteria, yet cases that would satisfy full DSM-IV-TR criteria are often undetected clinically. Evidence-based assessment methods that incorporate Bayesian reasoning have demonstrated improved diagnostic accuracy and consistency; however, their clinical utility is largely unexplored. The present study examines the effectiveness of promising evidence-based decision-making strategies compared with the clinical gold standard. Participants were 562 youths, ages 5 to 17 and predominantly African American, drawn from a community mental health clinic. Research diagnoses combined a semistructured interview with youths' psychiatric, developmental, and family mental health histories. Independent Bayesian estimates that relied on published risk estimates from other samples discriminated bipolar diagnoses (area under curve = .75, p < .00005). The Bayes and confidence ratings correlated at rs = .30. Agreement about an evidence-based assessment intervention threshold model (wait/assess/treat) was κ = .24, p < .05. No potential moderators of agreement between the Bayesian estimates and confidence ratings, including type of bipolar illness, were significant. Bayesian risk estimates were highly correlated with logistic regression estimates using optimal sample weights (r = .81, p < .0005). Clinical and Bayesian approaches agree in terms of overall concordance and deciding next clinical action, even when Bayesian predictions are based on published estimates from clinically and demographically different samples. Evidence-based assessment methods may be useful in settings in which gold standard assessments cannot be routinely used, and they may help decrease rates of overdiagnosis while promoting earlier identification of true cases.
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Affiliation(s)
- Melissa M Jenkins
- Department of Psychology, University of North Carolina at Chapel Hill, NC 27599-3270, USA
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Chan J, Stringaris A, Ford T. Bipolar Disorder in Children and Adolescents Recognised in the UK: A Clinic-Based Study. Child Adolesc Ment Health 2011; 16:71-78. [PMID: 32847219 DOI: 10.1111/j.1475-3588.2010.00566.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diagnoses of paediatric bipolar disorder have increased over the last two decades in the United States, where high levels of comorbidity with ADHD have also been reported. AIMS To explore how British clinicians apply these diagnoses. METHOD We compared 378 young people under the age of 18 who received a diagnosis of bipolar disorder and/or ADHD from a large NHS mental health trust between 1992 and 2007. RESULTS Children with bipolar disorder were rare in this sample (n = 35, 1.0%), particularly under the age of 13 (n = 9, 0.3%). Children with bipolar disorder presented more often with affective and psychotic symptoms than children with ADHD. Irritability was common in both disorders. Core ADHD symptoms were prevalent in both conditions but occurred in a greater proportion of children with ADHD. CONCLUSION Our findings suggest that psychiatrists in England use the traditional adult criteria of bipolar disorder rather than the broader criteria being adopted by some practitioners in the US.
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Affiliation(s)
- Judy Chan
- The Cottage, St. Marks Hospital, Maidenhead SL6 6DU, UK. E-mail:
| | - Argyris Stringaris
- Institute of Psychiatry, King's College London, Denmark Hill, London SE5 8AF, UK
| | - Tamsin Ford
- Tamsin Ford, Peninsula College of Medicine and Dentistry, St Luke's Campus, Heavitree Road, Exeter EX1 2LU, UK
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Jenkins MM, Youngstrom EA, Washburn JJ, Youngstrom JK. Evidence-Based Strategies Improve Assessment of Pediatric Bipolar Disorder by Community Practitioners. PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2011; 42:121-129. [PMID: 21625392 PMCID: PMC3100552 DOI: 10.1037/a0022506] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The misdiagnosis of pediatric bipolar disorder (PBD) has become a major public health concern. Would available evidence-based assessment (EBA) strategies help improve diagnostic accuracy, and are clinicians willing to consider these strategies in practice? The purpose of the present study was to document the extent to which using an EBA decision tool--a probability nomogram--improves the interpretation of family history and test data by clinicians and to examine the acceptability of the nomogram technique to clinicians. Over 600 clinicians across the US and Canada attending continuing education seminars were trained to use the nomogram. Participants estimated the probability that a youth in a clinical vignette had bipolar disorder, first using clinical judgment and then using the nomogram. Brief training of clinicians (less than 30 minutes) in using the nomogram for assessing PBD improved diagnostic accuracy, consistency, and agreement. The majority of clinicians endorsed using the nomogram in practice. EBA decision aids, such as the nomogram, may lead to a significant decrease in overdiagnosis and help clinicians detect true cases of PBD.
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Affiliation(s)
| | | | - Jason J. Washburn
- Alexian Brothers Behavioral Health Hospital
- Northwestern University Feinberg School of Medicine
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Meyer TD, Fuhr K, Hautzinger M, Schlarb AA. Recognizing mania in children and adolescents-age does not matter, but decreased need for sleep does. Compr Psychiatry 2011; 52:132-8. [PMID: 21295218 DOI: 10.1016/j.comppsych.2010.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 05/23/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The diagnosis of pediatric bipolar disorders is a controversial topic. If this is mainly due to a bias against a diagnosis in younger children, then just changing the information about the age of a patient should influence the likelihood of a diagnosis despite otherwise identical symptoms. Therefore, we designed a study to test if the age of a patient will influence diagnostic decisions. We further attempted to replicate an earlier result with regard to "decreased need for sleep" as a salient symptom for mania. METHODS We randomly sent 1 of 4 case vignettes describing a person with current mania to child/adolescents psychiatrists in Germany. This vignette was systematically varied with respect to age of the patient (6 vs 16 years) and the presence/absence of decreased need for sleep but always included sufficient criteria to diagnose a mania. RESULTS One hundred sixteen responded and, overall, 63.8% of the respondents diagnosed a bipolar disorder in the person described in the vignette. Although age did not affect the likelihood of a bipolar diagnosis, the presence of decreased need for sleep did increase its likelihood. Furthermore, the number of core symptoms identified by the clinicians was closely linked to the likelihood of assigning a bipolar diagnosis. CONCLUSION Certain symptoms such as the decreased need for sleep, and also elated mood and grandiosity, seem to be salient for some clinicians and influence their diagnoses. Biological age of the patient, however, does not seem to cause a systematic bias against a diagnosis of bipolar disorder in children.
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Affiliation(s)
- Thomas D Meyer
- Institute of Neuroscience, Newcastle University, NE1 7RU Newcastle upon Tyne, UK.
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37
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Abstract
Rates of bipolar disorder in any sample will depend on the sample studied, the interview used, with whom, how the information is integrated, the criteria applied, and the conceptualisation of a manic episode and its symptoms. A cross-national diagnostic study is needed to determine the implications of different approaches and definitions.
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Hassan A, Agha SS, Langley K, Thapar A. Prevalence of bipolar disorder in children and adolescents with attention-deficit hyperactivity disorder. Br J Psychiatry 2011; 198:195-8. [PMID: 21357877 PMCID: PMC3046179 DOI: 10.1192/bjp.bp.110.078741] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 11/01/2010] [Accepted: 11/03/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Some research suggests that children with attention-deficit hyperactivity disorder (ADHD) have a higher than expected risk of bipolar affective disorder. No study has examined the prevalence of bipolar disorder in a UK sample of children with ADHD. AIMS To examine the prevalence of bipolar disorder in children diagnosed with ADHD or hyperkinetic disorder. METHOD Psychopathology symptoms and diagnoses of bipolar disorder were assessed in 200 young people with ADHD (170 male, 30 female; age 6-18 years, mean 11.15, s.d. = 2.95). Rates of current bipolar disorder symptoms and diagnoses are reported. A family history of bipolar disorder in parents and siblings was also recorded. RESULTS Only one child, a 9-year-old boy, met diagnostic criteria for both ICD-10 hypomania and DSM-IV bipolar disorder not otherwise specified. CONCLUSIONS In a UK sample of children with ADHD a current diagnosis of bipolar disorder was uncommon.
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Affiliation(s)
- Amani Hassan
- Child and Adolescent Mental Health Services Network, Medical Research Council Centre for Neuropsychiatric Genetics, Department of Psychological Medicine and Neurology, Cardiff University, UK
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Zappitelli MC, Bordin IA, Hatch JP, Caetano SC, Zunta-Soares G, Olvera RL, Soares JC. Lifetime psychopathology among the offspring of Bipolar I parents. Clinics (Sao Paulo) 2011; 66:725-30. [PMID: 21789371 PMCID: PMC3109366 DOI: 10.1590/s1807-59322011000500003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 01/20/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Recent studies have demonstrated high rates of psychopathology in the offspring of parents with bipolar disorder. The aim of this study was to identify psychiatric diagnoses in a sample of children of bipolar parents. METHOD This case series comprised 35 children and adolescents aged 6 to 17 years, with a mean age of 12.5 ± 2.9 years (20 males and 15 females), who had at least one parent with bipolar disorder type I. The subjects were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version (K-SADS-PL). Family psychiatric history and demographics were also evaluated. RESULTS Of the offspring studied, 71.4% had a lifetime diagnosis of at least one psychiatric disorder (28.6% with a mood disorder, 40% with a disruptive behavior disorder and 20% with an anxiety disorder). Pure mood disorders (11.4%) occurred less frequently than mood disorders comorbid with attention deficit hyperactivity disorder (17.1%). Psychopathology was commonly reported in second-degree relatives of the offspring of parents with bipolar disorder (71.4%). CONCLUSIONS Our results support previous findings of an increased risk for developing psychopathology, predominantly mood and disruptive disorders, in the offspring of bipolar individuals. Prospective studies with larger samples are needed to confirm and expand these results.
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40
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Youngstrom EA, Arnold LE, Frazier TW. Bipolar and ADHD Comorbidity: Both Artifact and Outgrowth of Shared Mechanisms. ACTA ACUST UNITED AC 2010; 17:350-359. [PMID: 21278822 DOI: 10.1111/j.1468-2850.2010.01226.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Published rates of comorbidity between pediatric bipolar disorder (PBD) and attention-deficit/hyperactivity disorder (ADHD) have been higher than would be expected if they were independent conditions, but also dramatically different across different studies. This review examines processes that could artificially create the appearance of comorbidity or substantially bias estimates of the ADHD-BPD comorbidity rate, including: categorization of dimensional constructs, overlap among diagnostic criteria, over-splitting, developmental sequencing, and referral or surveillance biases. Evidence also suggests some mechanisms for "true" BPD-ADHD comorbidity, including shared risk factors, distinct subtypes, and weak causal relationships. Keys to differential diagnosis include focusing on episodic presentation and non-overlapping symptoms unique to mania.
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41
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Grimmer Y, Hohmann S, Banaschewski T, Holtmann M. Früh beginnende bipolare Störungen, ADHS oder Störung der Affektregulation? KINDHEIT UND ENTWICKLUNG 2010. [DOI: 10.1026/0942-5403/a000025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Die Arbeit gibt einen Überblick über die Hintergründe der Kontroverse und leitet daraus konkrete Schlussfolgerungen für die klinische Praxis ab. Bei der Diagnostik früher bipolarer Störungen ist vorrangig auf das Auftreten von abgrenzbaren Episoden mit eindeutigen Stimmungsänderungen und Veränderungen von Verhalten und Kognition zu achten. Das Mischbild aus ADHS und begleitender affektiver Dysregulation sollte nicht im Sinne einer beginnenden bipolaren Störung interpretiert werden, bedarf aber stärkerer Beachtung, insbesondere bei der Entwicklung geeigneter psycho- und pharmakotherapeutischer Ansätze. Erläutert werden zudem Gemeinsamkeiten und Unterschiede von bipolaren Störungen mit Schizophrenie, Depression, ADHS, Borderline-Persönlichkeitsstörung und Substanzmissbrauch.
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Affiliation(s)
- Yvonne Grimmer
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters am Zentralinstitut für Seelische Gesundheit Mannheim
| | - Sarah Hohmann
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters am Zentralinstitut für Seelische Gesundheit Mannheim
| | - Tobias Banaschewski
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters am Zentralinstitut für Seelische Gesundheit Mannheim
| | - Martin Holtmann
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters am Zentralinstitut für Seelische Gesundheit Mannheim
- Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik der LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum
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42
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Holtmann M, Duketis E, Poustka L, Zepf FD, Poustka F, Bölte S. Bipolar disorder in children and adolescents in Germany: national trends in the rates of inpatients, 2000-2007. Bipolar Disord 2010; 12:155-63. [PMID: 20402708 DOI: 10.1111/j.1399-5618.2010.00794.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Increasing admission and prevalence rates of bipolar disorder (BD) are a matter of controversy in international child and adolescent psychiatry. We seek to contribute to this discussion by presenting data obtained in a population of German children and adolescents. METHODS Nationwide, whole population changes in inpatient admissions of BD and other psychiatric disorders between 2000 and 2007 were analyzed in individuals aged up to 19 years using registry data from the German Federal Health Monitoring System. RESULTS Inpatient admissions for BD in individuals aged up to 19 years increased from 1.13 to 1.91 per 100,000 or 68.5% between 2000 and 2007 (odds ratio: 1.69; 95% confidence interval: 1.41-2.02), with a nonsignificant decline in children less than 15 years and the largest relative increase in adolescents aged 15-19 years. Inpatient rates for depressive disorders increased by 219.6% and for hyperkinetic disorder by 111.3%. Conduct disorders increased by 18.1%, considerably less than the 38.1% general rise for all mental disorders in children and adolescents. The only significant decline in a diagnostic category occurred for psychotic disorders (-11.8%). BD inpatient admission represented only 0.22% of all mental disorder admissions in 2000 and 0.27% in 2007. CONCLUSIONS An elevation of inpatient admissions of BD in Germany in adolescents was detected, exceeding the general trend for increased mental disorder admissions. The results may indicate a higher clinical awareness and appreciation of mood symptoms at earlier ages and, in part, a reconceptualization of previously diagnosed psychotic disorders in youth. However, a diagnosis of BD in youngsters is still extremely rare in Germany. Diagnoses were based on the judgment of the treating physician. A correction for multiple admissions in the data set is not possible.
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Affiliation(s)
- Martin Holtmann
- LWL-University Hospital for Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Ruhr University Bochum, Hamm, Germany.
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43
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Galanter CA, Pagar DL, Oberg PP, Wong C, Davies M, Jensen PS. Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists. J Child Adolesc Psychopharmacol 2009; 19:641-7. [PMID: 20035582 PMCID: PMC2830216 DOI: 10.1089/cap.2008.0151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We surveyed child and adolescent psychiatrists (CAPs) to characterize how they diagnose bipolar disorder (BPD) in children. METHODS We approached by mail and then telephone 100 CAPs randomly sampled from five regions of the main professional organization of American CAPs; 53 CAPs were reached and agreed to participate. We asked about their training and practice setting, and asked them to name 10 symptoms indicative of BPD. We conducted descriptive analyses to determine how CAPs ranked symptoms, whether reports were consistent with Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria, and whether alternative symptom models might guide their decision making. RESULTS CAPs considered lability, grandiosity, family history of BPD, aggression, and expansive or euphoric mood as the most important factors in diagnosing BPD. Only 21 (39.6%) CAPs reported sufficient symptoms to meet DSM criteria for BPD (DSM-Yes status). DSM-Yes status was associated with participants' region, less expertise (< or =10 years practicing child and adolescent psychiatry), and lower levels of self-reported confidence in their ability to diagnose BPD. CONCLUSIONS CAPs vary in the symptoms they use to diagnose BPD, with most using a mixture of DSM and non-DSM symptoms. Expertise and confidence may lessen one's reliance on DSM criteria. Further studies are needed to understand CAPs' diagnostic decisions about BD and to develop interventions to support accurate diagnostic decision making and improve patient care.
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Affiliation(s)
- Cathryn A. Galanter
- Division of Child and Adolescent Psychiatry, Columbia University, New York, New York
| | - Dana L. Pagar
- Division of Child and Adolescent Psychiatry, Columbia University, New York, New York.,Present address: Teachers College of Columbia University, New York, New York
| | - Peter P. Oberg
- Division of Child and Adolescent Psychiatry, Columbia University, New York, New York
| | - Carrie Wong
- Division of Child and Adolescent Psychiatry, Columbia University, New York, New York.,Present address: Tufts Medical Center, Boston, Massachusetts
| | - Mark Davies
- Division of Child and Adolescent Psychiatry, Columbia University, New York, New York.,Deceased
| | - Peter S. Jensen
- Division of Child and Adolescent Psychiatry, Columbia University, New York, New York.,Present address: REACH Institute, New York, New York
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44
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Goodwin GM. Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2009; 23:346-88. [PMID: 19329543 DOI: 10.1177/0269881109102919] [Citation(s) in RCA: 326] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.
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Affiliation(s)
- G M Goodwin
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
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45
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Holtmann M. [Early onset bipolar disorders]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2009; 37:159-61. [PMID: 19415600 DOI: 10.1024/1422-4917.37.3.159] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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46
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Youngstrom EA, Freeman AJ, Jenkins MM. The assessment of children and adolescents with bipolar disorder. Child Adolesc Psychiatr Clin N Am 2009; 18:353-90, viii-ix. [PMID: 19264268 PMCID: PMC2915577 DOI: 10.1016/j.chc.2008.12.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The overarching goal of this article is to examine the current best evidence for assessing bipolar disorder (BPD) in children and adolescents and provide a comprehensive, evidence-based approach to diagnosis. Evidence- based assessment strategies are organized around the "3 Ps" of clinical assessment: Predict important criteria or developmental trajectories, Prescribe a change in treatment choice, and inform Process of treating the youth and his/her family. The review characterizes BPD in youths-specifically addressing bipolar diagnoses and clinical subtypes; it then provides an actuarial approach to assessment using prevalence of disorder, risk factors, and questionnaires; discusses treatment thresholds; and identifies practical measures of process and outcomes. The clinical tools and risk factors selected for inclusion in this review represent the best empirical evidence in the literature. By the end of the article, clinicians will have a framework and set of clinically useful tools with which to effectively make evidence-based decisions regarding the diagnosis of BPD in children and adolescents.
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Affiliation(s)
- Eric A Youngstrom
- Department of Psychology, University of North Carolina, Chapel Hill, NC 27599-3270, USA.
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47
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Carlson GA, Glovinsky I. The concept of bipolar disorder in children: a history of the bipolar controversy. Child Adolesc Psychiatr Clin N Am 2009; 18:257-71, vii. [PMID: 19264263 DOI: 10.1016/j.chc.2008.11.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Before the last 150 years, the use of the term mania to mean any kind of agitated state and the term childhood to include people up to their early 20s make historical identification of manic-depression in children difficult. Not long after Kraepelin's seminal work was published, similar syndromes were identified in youth, usually adolescents. Interestingly, however, the question of whether preadolescent mania should be broadly or narrowly defined--the so-called bipolar controversy--has been an issue for at least 50 years. Although the question of whether and how a disorder characterized by discrete episodes of mania and depression with periods of relative normality between episodes relates to one characterized by more fluctuating and intense mood lability/dysregulation remains unanswered, the work of researchers in the twenty-first century will be to understand not only symptoms of bipolar disorder but also how it develops and how emotion regulation relates to both the development of bipolar disorder and to other conditions that are characterized by dysregulated emotion.
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Affiliation(s)
- Gabrielle A Carlson
- Child and Adolescent Psychiatry, Stony Brook University School of Medicine, South Campus, Stony Brook, NY 11794-8790, USA.
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Carlson GA, Findling RL, Post RM, Birmaher B, Blumberg HP, Correll C, DelBello MP, Fristad M, Frazier J, Hammen C, Hinshaw SP, Kowatch R, Leibenluft E, Meyer SE, Pavuluri MN, Wagner KD, Tohen M. AACAP 2006 Research Forum--Advancing research in early-onset bipolar disorder: barriers and suggestions. J Child Adolesc Psychopharmacol 2009; 19:3-12. [PMID: 19232018 DOI: 10.1089/cap.2008.100] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The 2006 Research Forum addressed the goal of formulating a research agenda for early-onset bipolar disorder (EOBP) and improving outcome by understanding the risk and protective factors that contribute to its severity and chronicity. METHOD Five work groups outlined barriers and research gaps in EOBP genetics, neuroimaging, prodromes, psychosocial factors, and pharmacotherapy. RESULTS There was agreement that the lack of consensus on the definition and diagnosis of EOBP is the primary barrier to advancing research in BP in children and adolescents. Related issues included: the difficulties in managing co-morbidity both statistically and clinically; acquiring adequate sample sizes to study the genetics, biology, and treatment; understanding the EOBP's developmental aspects; and identifying environmental mediators and moderators of risk and protection. Similarly, both psychosocial and medication treatment strategies for children with BP are hamstrung by diagnostic issues. To advance the research in EOBP, both training and funding mechanisms need to be developed with these issues in mind. CONCLUSIONS EOBP constitutes a significant public health concern. Barriers are significant but identifiable and thus are not insurmountable. To advance the understanding of EOBP, the field must be committed to resolving diagnostic and assessment issues. Once achieved, with adequate personnel and funding resources, research into the field of EOBP will doubtless be advanced at a rapid pace.
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Affiliation(s)
- Gabrielle A Carlson
- Department of Child and Adolescent Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York, USA
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Joseph MF, Youngstrom EA, Soares JC. Antidepressant-coincident mania in children and adolescents treated with selective serotonin reuptake inhibitors. FUTURE NEUROLOGY 2009; 4:87-102. [PMID: 19884978 PMCID: PMC2655139 DOI: 10.2217/14796708.4.1.87] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Several factors have amplified concern about the possibility that antidepressant medication may contribute to induction of pediatric mania. These include the high rate of antidepressant medication prescription, the recent surge in the rate of diagnosis of pediatric bipolar disorder in the USA, and a growing number of case reports and clinical studies showing coincidence of manic symptoms with antidepressant pharmacotherapy in both youths and adults. However, the question of how medications and manic symptoms might be related is complicated, and decisive research studies with rigorous designs for evaluating the issues have not been published. The situation makes it difficult for practitioners to make good, evidence-based decisions. The scientific literature is ambiguous, and the stakes are high. We review the extant literature, offer seven different conceptual models of how medication and mania might be related, and comment on the evidence and clinical implications of each.
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Affiliation(s)
- Megan F Joseph
- University of North Carolina – Chapel Hill, Department of Psychology, CB #3270, Davie Hall, Chapel Hill, NC 27599, USA, Tel.: +1 919 843 3956, Fax: +1 919 962 2537,
| | - Eric A Youngstrom
- University of North Carolina – Chapel Hill, Department of Psychology, CB #3270, Davie Hall, Chapel Hill, NC 27599, USA, Tel.: +1 919 962 3997, Fax: +1 919 962 2537,
| | - Jair C Soares
- University of North Carolina – Chapel Hill School of Medicine, Department of Psychiatry, CB #7160, 10612 Neurosciences Hospital, 101 Manning Drive, Chapel Hill, NC 27599, USA, Tel.: +1 919 966 8832, Fax: +1 919 843 3950,
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