Early-onset bipolar spectrum disorders: diagnostic issues

Co-occurrence of bipolar disorder and personality disorders in the United States: Prevalence, suicidality, and the impact of substance abuse

BACKGROUND

This study investigates prevalence rates of specific personality disorders (PDs) in individuals with bipolar disorder (BD) and their impact on substance abuse and suicidality, addressing existing gaps in the literature.

METHODS

Using Nationwide Inpatient Sample data (2016-2020), adult hospitalizations for BD with coexisting PDs were analyzed. Study variables were defined using ICD-10-CM codes. Prevalence of PD were reported as cases per 100,000 BD admissions. Regression models assessed the association between substance abuse and suicidality.

RESULTS

About 993,000 admissions for BD were analyzed. The cohort was predominantly Caucasian (70.5 %) with higher female representation (54.5 %). The mean age was 41 years. 89.4 % of individuals had a Charlson Comorbidity Index score ≤ 1. The most common diagnostic subtype was manic episode of BD with or without psychotic features (32.3 %). Coexisting PDs were observed in 12.2 % of the population, with borderline PD (8.2 %) and antisocial PD (2.6 %) being most prevalent. Substance abuse was common (44.8 %), with cannabis (23.8 %), alcohol (19.4 %), cocaine (10.5 %), and opioids (9.6 %) being most reported. Substance abuse was higher in individuals with BD and PD (50 %) compared to BD alone (44.1 %). 596 suicide attempts were recorded (60 per 100,000 BD admissions). Substance abuse and coexisting PD in bipolar individuals elevated the likelihood of attempts (P < 0.001).

LIMITATIONS

Use of administrative data (retrospective, inpatient); treatment not studied.

CONCLUSION

The study reveals a notable prevalence of PDs in individuals with BD, with increased likelihood of substance abuse and suicide attempts in those with coexisting BD and PD compared to BD alone.

Altered neurochemistry in the anterior white matter of bipolar children and adolescents: a multivoxel 1H MRS study

Abnormalities within frontal lobe gray and white matter of bipolar disorder (BD) patients have been consistently reported in adult and pediatric studies, yet little is known about the neurochemistry of the anterior white matter (AWM) in pediatric BD and how medication status may affect it. The present cross-sectional 3T ¹H MRS study is the first to use a multivoxel approach to study the AWM of BD youth. Absolute metabolite levels from four bilateral AWM voxels were collected from 49 subjects between the ages of 8 and 18 (25 healthy controls (HC); 24 BD) and quantified. Our study found BD subjects to have lower levels of N-acetylaspartate (NAA) and glycerophosphocholine plus phosphocholine (GPC + PC), metabolites that are markers of neuronal viability and phospholipid metabolism and have also been implicated in adult BD. Further analysis indicated that the observed patterns were mostly driven by BD subjects who were medicated at the time of scanning and had an ADHD diagnosis. Although limited by possible confounding effects of mood state, medication, and other mood comorbidities, these findings serve as evidence of altered neurochemistry in BD youth that is sensitive to medication status and ADHD comorbidity.

Mixed States in Early-Onset Bipolar Disorder

Pediatric bipolar disorder (PBD) is a severe and chronic illness. The occurrence of mixed symptoms might add further risk of recurrence of treatment resistance and suicidality. Early recognition and treatment of mixed symptoms might prevent illness progression and development of suicide attempts. This article provides an update on the epidemiology, clinical profile, and treatment of youth with PBD with mixed states. Mixed states in PBD are characterized by higher rates of suicide and more chronic symptoms, and are associated with younger age of onset and greater comorbidity. A careful assessment for mixed states using standardized criteria is essential.

Patterns and predictors of family environment among adolescents at high and low risk for familial bipolar disorder

Children's perceptions are important to understanding family environment in the bipolar disorder (BD) high-risk context. Our objectives were to empirically derive patterns of offspring-perceived family environment, and to test the association of family environment with maternal or paternal BD accounting for offspring BD and demographic characteristics. Participants aged 12-21 years (266 offspring of a parent with BD, 175 offspring of a parent with no psychiatric history) were recruited in the US and Australia. We modeled family environment using latent profile analysis based on offspring reports on the Conflict Behavior Questionnaire, Family Adaptability and Cohesion Evaluation Scales, and Home Environment Interview for Children. Parent diagnoses were based on the Diagnostic Interview for Genetic Studies and offspring diagnoses were based on the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. Latent class regression was used to test associations of diagnosis and family environment. Two-thirds of all offspring perceived well-functioning family environment, characterized by nurturance, flexibility, and low conflict. Two 'conflict classes' perceived family environments low in flexibility and cohesion, with substantial separation based on high conflict with the father (High Paternal Conflict), or very high conflict and rigidity and low warmth with the mother (High Maternal Conflict). Maternal BD was associated with offspring perceiving High Maternal Conflict (OR 2.8, p = 0.025). Clinical care and psychosocial supports for mothers with BD should address family functioning, with attention to offspring perceptions of their wellbeing. More research is needed on the effect of paternal BD on offspring and family dynamics.

Validation of a Brief Structured Interview: The Children's Interview for Psychiatric Syndromes (ChIPS)

Evidence-based assessment is important in the treatment of childhood psychopathology. While researchers and clinicians frequently use structured diagnostic interviews to ensure reliability, the most commonly used instrument, the Schedule for Affective Disorders and Schizophrenia for School Aged Children (K-SADS) is too long for most clinical applications. The Children's Interview for Psychiatric Syndromes (ChIPS/P-ChIPS) is a highly-structured brief diagnostic interview. The present study compared K-SADS and ChIPS/P-ChIPS diagnoses in an outpatient clinical sample of 50 parent-child pairs aged 7-14. Agreement between most diagnoses was moderate to high between the instruments and with consensus clinical diagnoses. ChIPS was significantly briefer to administer than the K-SADS. Interviewer experience level and participant demographics did not appear to affect agreement. Results provide further evidence for the validity of the ChIPS and support its use in clinical and research settings.

Bipolar I and II versus unipolar depression: clinical differences and impulsivity/aggression traits

OBJECTIVE

To investigate distinguishing features between bipolar I, II and unipolar depression, and impulsivity/aggression traits in particular.

METHODS

Six hundred and eighty-five (n=685) patients in a major depressive episode with lifetime Unipolar (UP) depression (n=455), Bipolar I (BP-I) disorder (n=151), and Bipolar II (BP-II) (n=79) disorder were compared in terms of their socio-demographic and clinical characteristics.

RESULTS

Compared to unipolar patients, BP-I and BP-II depressed patients were significantly younger at onset of their first depressive episode, and were more likely to experience their first depressive episode before/at age of 15. They also had more previous affective episodes, more first- and second-degree relatives with history of mania, more current psychotic and subsyndromal manic symptoms, and received psychopharmacological and psychotherapy treatment at an earlier age. Furthermore, BP-I and BP-II depressed patients had higher lifetime impulsivity, aggression, and hostility scores. With regard to bipolar subtypes, BP-I patients had more trait-impulsivity and lifetime aggression than BP-II patients whereas the latter had more hostility than BP-I patients. As for co-morbid disorders, Cluster A and B Personality Disorders, alcohol and substance abuse/dependence and anxiety disorders were more prevalent in BP-I and BP-II than in unipolar patients. Whereas the three groups did not differ on other socio-demographic variables, BP-I patients were significantly more often unemployed that UP patients.

CONCLUSION

Our findings comport with major previous findings on differences between bipolar and unipolar depression. As for trait characteristics, bipolar I and II depressed patients had more life-time impulsivity and aggression/hostility than unipolar patients. In addition, bipolar I and II patients also differed on these trait characteristics.

Unfiltered Administration of the YMRS and CDRS-R in a Clinical Sample of Children

The objective of this study is to evaluate discriminative validity of the Young Mania Rating Scale (YMRS) and Children's Depression Rating Scale-Revised (CDRS-R) in a clinical sample of children when administered in an unfiltered manner (i.e., regardless of whether symptoms occur in a mood episode). The Kiddie Schedule for Affective Disorders and Schizophrenia is the gold standard for assessing psychiatric disorders in children and was used to make diagnoses in this study. Using a sample of 707 treatment-seeking youth (ages 6-12 years, Mage = 9.7 years, 67.6% male), receiver operating curve analyses were performed and diagnostic likelihood ratios (DLRs) were calculated to evaluate the ability to change the odds and differentiate bipolar disorder from other disorders (using the YMRS) and depression from other disorders (using the CDRS-R). Using unfiltered administration, the YMRS achieved good discriminative validity when classifying bipolar disorder compared to other disorders (Area Under the Curve [AUC] = .86) and increased odds of a bipolar diagnosis given a score in the highest quintile (DLR = 6.12). Using unfiltered administration, the CDRS-R achieved moderate to good discriminative validity in classifying depressive disorders (DD) compared to other disorders (AUCBD in comparison = .78; AUCBD not in comparison = .84) and slightly increased odds of DD given a score in the highest quintile (DLRBD in comparison = 3.12; DLRBD not in comparison = 5.08). The YMRS and CDRS-R have moderate to good discriminative validity when administered in an unfiltered way in a sample of treatment seeking youth.

Future directions for research on youth with bipolar spectrum disorders

The past 25 years has witnessed significant advances in our knowledge of Bipolar Spectrum Disorders (BPSD) in youth. Cross-sectional and longitudinal studies are clarifying the unique features of its pediatric presentation, including continuities and discontinuities across the spectrum of severity. Advances have been made, both in the pharmacological and psychological management of BPSD in youth. Current investigations may ultimately shed light on new treatment strategies. Future research is anticipated to be influenced by NIMH's Research Domain Criteria (RDoC). With this article, we summarize what is currently known about the basic phenomenology of pediatric BPSD, its clinical course, assessment and treatment, beginning with a summary of the major studies that have shed light on the topic. Next, we present a tally and content review of current research as an indicator of trends for the future. Then, we describe what we believe are important future directions for research. Finally, we conclude with implications for contemporary clinicians and researchers.

Conversion from bipolar disorder not otherwise specified (BP-NOS) to bipolar I or II in youth with family history as a predictor of conversion

BACKGROUND

Bipolar disorder-not otherwise specified (BD-NOS) is an imprecise, heterogeneous diagnosis that is unstable in youth. This study reports rates of conversion from BD-NOS to BD-I or II in children aged 8-12, and investigates the impact of family history of bipolar disorder and depression on conversion.

METHODS

As part of the Multi-Family Psychoeducational Psychotherapy (MF-PEP) study, 27 children (6-12 years of age) diagnosed with BD-NOS at baseline were reassessed every 6 months over an 18-month period. Family history of bipolar disorder and depression was assessed at baseline.

RESULTS

One-third of the sample converted from BD-NOS to BD-I or II over 18-months. Having a first-degree relative with symptoms of bipolar disorder and having a loaded pedigree for diagnosis of depression each were associated with conversion from BD-NOS to BD-I or II (odds ratio range: 1.09-3.14; relative risk range: 1.06-2.34).

LIMITATIONS

This study had very low power (range: 10-45) given the small sample size, precluding statistical significance of non-parametric Fisher's Exact test findings.

CONCLUSIONS

This study replicates the previous finding of a high rate of conversion from BD-NOS to BD-I or II among youth, and suggests conversion is related to symptoms of bipolar disorder or depression diagnoses in the family history. Additional research is warranted in a larger sample with a longer follow-up period.

Prevalence of bipolar disorder diagnoses and psychotropic drug therapy among privately insured children and adolescents

STUDY OBJECTIVES

To estimate the treated prevalence of bipolar disorder in a privately insured population, describe the characteristics of children and adolescents receiving these diagnoses, and describe patterns of their psychotropic drug therapy.

DESIGN

Retrospective, repeated cross-sectional study.

DATA SOURCE

MarketScan Commercial Claims and Encounters inpatient, outpatient, and pharmacy claims databases.

PATIENTS

A total of 22,360 children and adolescents (aged 0-17 yrs) with one inpatient or two or more outpatient claims for any bipolar spectrum disorder between January 1, 2005, and December 31, 2007.

MEASUREMENTS AND MAIN RESULTS

Annual cross-sections were used to estimate the treated prevalence of bipolar disorder diagnoses, patient characteristics, and psychotropic drugs used 30 days after a child's latest recorded bipolar disorder diagnosis within each year. The annual treated prevalence of any bipolar spectrum disorder in this privately insured population was 0.24% in 2005 and 0.26% in 2006 and 2007. Approximately 25% of diagnoses were for children younger than 13 years. Approximately 30% of children had coexisting attention-deficit-hyperactivity disorder during the year. In each year, 35% of patients used no psychotropic drug therapy in the 30-day period after their most recent diagnosis. Twenty-five percent used one psychotropic drug, and 40% used two or more drugs. The most common drug regimens were antipsychotic or mood stabilizer (lithium or anticonvulsant) monotherapy and the combination of mood stabilizers and antipsychotics.

CONCLUSION

Drug therapy patterns suggest that children and adolescents with bipolar diagnoses receive complex treatment regimens, often involving multiple classes of psychotropic drugs. Research on treatment combinations, particularly antipsychotic and mood stabilizer combinations, should be prioritized to better understand the safety and effectiveness of commonly prescribed treatments.

Treatment of Pediatric Bipolar Disorder: A Review

AIM: To review the diagnosis and the pharmacologic and psychosocial interventions for pediatric bipolar disorder (PBD). METHODS: A comprehensive literature review of studies discussing the diagnosis and treatment of PBD was conducted. RESULTS: A context for understanding controversies and difficulties in the diagnosis of PBD is provided. An evidence-based assessment protocol for PBD is reviewed. The evidence for the following three categories of pharmacologic interventions are reviewed: Lithium, antiepileptics, and second generation antipsychotics. Algorithms for medication decisions are briefly reviewed. Existing psychosocial treatments and the evidence for those treatments are also reviewed. CONCLUSION: Despite recent developments in understanding the phenomenology of PBD and in identifying pharmacologic and psychosocial interventions, critical gaps remain.