Understanding Early Age of Onset: a Review of the Last 5 Years

Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately1

Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.

Does the apple fall far from the tree? Commentary on Hafeman et al., early indicators of bipolar risk in preschool offspring of parents with bipolar disorder

Comorbid externalizing and internalizing disorders are common in offspring of a parent with bipolar I or II disorder. In some cases, the symptoms are harbingers of future bipolar spectrum disorder. Even when they are not, they are likely to be impairing to the child. Clinicians need to be better informed about how the history leading up to mania/hypomania unfolds, and what comorbid disorders are impairing in and of themselves. More information is needed about the parents' psychopathology, course of illness and response to treatment. Until we have data on how to prevent bipolar disorder, the best course of action is to treat the child's current impairing symptoms and render the parent as asymptomatic as possible.

Predicting bipolar disorder I/II in individuals at clinical high-risk: Results from a systematic review

INTRODUCTION

No systematic review has estimated the consistency and the magnitude of the risk of developing bipolar disorder I-II (BD-I/II) in individuals at clinical high risk for bipolar disorder (CHR-BD).

METHODS

PubMed and Web of Science databases were searched until April 2022 in this pre-registered (PROSPERO CRD42022346515) PRISMA-compliant systematic review to identify longitudinal studies in individuals meeting pre-defined CHR-BD criteria. The risk of bias was assessed using the Newcastle-Ottawa Scale, and results were systematically synthesized around CHR-BD criteria across follow-up periods and different subgroups.

RESULTS

Altogether, 13 studies were included reporting on nine prospective independent cohorts (n = 678 individuals at CHR-BD). The mean age of participants was 15.7 years (range 10.1-22.6 years), and 54.2 % were females. The most common CHR-BD subgroup was subthreshold mania (55.5 %), followed by BD-Not Otherwise Specified (BD-NOS: 33.3 %). Development of BD I/II ranged from 7.1 % to 23.4 % after 2 years. Development of BD-I ranged from 3.4 % at 4 years to 23 % at 8 years. Development of BD-II ranged from 10 % at 2 years to 63.8 % at 4 years. The risk of developing BD-I appeared highest in those meeting BD-NOS criteria (23 % at eight years). Predictors of development of BD were identified but remained mostly unreplicated. The quality of the included studies was moderate (NOS = 5.2 ± 1.1).

CONCLUSIONS

Emerging data from research studies point towards the promising utility of CHR-BD criteria. These studies may pave the way to the next generation of research, implementing detection, prognostication, and preventive interventions in individuals at CHR-BD identified and followed in clinical practice.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Environmental factors in offspring of parents with mood disorders and their role in parent-child transmission: findings from a 14-year prospective high-risk study

Background

The factors involved in the transmission of mood disorders are only partially elucidated. Aside from genes, the family environment might play a crucial role in parent–child transmission. Our goals were to (1) assess the associations of parental bipolar disorder (BPD) and Major Depressive Disorder (MDD) with individual or shared family environmental factors, including traumatic events in offspring, parental separation, family cohesion and parental attitudes; and 2) test whether these factors were mediators of the association between exposure to parental mood disorders and the onset of these disorders in offspring.

Methods

The sample stems from an ongoing family high-risk study of mood disorders conducted in the French-speaking part of Switzerland. Given the strong impact of the age of onset of parental disorders on their transmission to children, parental disorders were dichotomized according to the onset (cut-off 21 years). Probands with early-onset (n = 30) and later-onset BPD (n = 51), early-onset (n = 21) and later-onset MDD (n = 47) and controls (n = 65), along with their spouses (n = 193) and offspring (n = 388; < 18 years on study inclusion), were assessed over a mean follow-up duration of 14 years (s.d: 4.6). The environmental measures were based on reports by offspring collected before the onset of their first mood episode.

Results

Offspring of probands with later-onset BPD and offspring of probands with both early-onset and later-onset MDD reported traumatic events more frequently than comparison offspring, whereas exposure to parental separation was more frequent in all groups of high-risk offspring. Moreover, several familial environment scores including parenting attitudes differed between offspring of probands with BPD and comparison offspring. However, none of these factors were mediators of the parent–child transmission of BPD. Among the environmental factors, traumatic events were shown to be modest mediators of the transmission of early-onset MDD.

Conclusions

Our data do not support the implication of the assessed environmental factors in the parent–child transmission of BPD. In contrast to BPD, traumatic events partially mediate the parent–child transmission of early-onset MDD, which has important implications for intervention and prevention. Early therapeutic efforts in offspring exposed to these events are likely to reduce their deleterious impact on the risk of subsequent MDD.

The Dutch Bipolar Offspring Study: Cognitive Development and Psychopathology

Various aspects of the relationship between cognitive impairment and bipolar disorder are not clear yet. This study examines cognitive and educational functioning prospectively in offspring at familial risk for bipolar disorder, in order to improve our understanding of the association between cognitive functioning and psychopathology. Bipolar offspring (N = 92) from the prospective Dutch bipolar offspring study were evaluated at adolescence and adulthood for IQ estimate, educational achievement and development of any psychiatric disorder. The main outcome was IQ estimate after 12 years of follow-up (offspring mean age 28 years). Generalized estimating equation (GEE) analyses showed that any lifetime DSM-IV axis I diagnosis was related to a lower cognitive outcome at adulthood as compared to unaffected bipolar offspring. No specific association was found for type of diagnosis. Early onset psychopathology (diagnosis at or before age 15 years) was significantly related to lower IQ estimate at adulthood, indicating a sensitive period for neurocognitive development.

Obstetric complications and subsequent risk of mood disorders for offspring in adulthood: a comprehensive overview

Background: A number of studies reported obstetric complications (OCs) to be a risk factor for the development of psychiatric conditions in the adulthood, including mood disorders.Aim: The aim of this study was to review the literature about the link between OCs during the perinatal period (items of Lewis-Murray scale) and the future risk of developing a mood disorder in adulthood, such as the major depressive disorder (MDD) or the bipolar disorder (BD).Methods: A research in the main database sources has been conducted to obtain an overview of the association mentioned above.Results: Few studies have investigated the role of OCs in the development of mood disorders in adulthood. The most robust evidence is that low birth weight (LBW) and preterm birth may be risk factors for the development of MDD in the future, even if some of the available data come from studies with small sample sizes or a retrospective design.Conclusion: OCs may confer a risk of developing mood disorders in adulthood. Future research should confirm these preliminary findings and clarify if other obstetric or neonatal complications (e.g. cyanosis or newborn epileptic seizures) may have a role in the future onset of mood disorders.

Demographic and Clinical Characteristics, Including Subsyndromal Symptoms Across Bipolar-Spectrum Disorders in Adolescents

Objectives: Bipolar disorder (BD) is a debilitating illness that often starts at an early age. Prevention of first and subsequent mood episodes, which are usually preceded by a period characterized by subthreshold symptoms is important. We compared demographic and clinical characteristics including severity and duration of subsyndromal symptoms across adolescents with three different bipolar-spectrum disorders. Methods: Syndromal and subsyndromal psychopathology were assessed in adolescent inpatients (age = 12-18 years) with a clinical mood disorder diagnosis. Assessments included the validated Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P). We compared phenomenology across patients with a research consensus conference-confirmed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnoses of BD-I, BD-not otherwise specified (NOS), or mood disorder (MD) NOS. Results: Seventy-six adolescents (age = 15.6 ± 1.4 years, females = 59.2%) were included (BD-I = 24; BD-NOS = 29; MD-NOS = 23) in this study. Median baseline global assessment of functioning scale score was 21 (interquartile range = 17-40; between-group p = 0.31). Comorbidity was frequent, and similar across groups, including disruptive behavior disorders (55.5%, p = 0.27), anxiety disorders (40.8%, p = 0.98), and personality disorder traits (25.0%, p = 0.21). Mania symptoms (most frequent: irritability = 93.4%, p = 0.82) and depressive symptoms (most frequent: depressed mood = 81.6%, p = 0.14) were common in all three BD-spectrum groups. Manic and depressive symptoms were more severe in both BD-I and BD-NOS versus MD-NOS (p < 0.0001). Median duration of subthreshold manic symptoms was shorter in MD-NOS versus BD-NOS (11.7 vs. 20.4 weeks, p = 0.002) and substantial in both groups. The most used psychotropics upon discharge were antipsychotics (65.8%; BD-I = 79.2%; BD-NOS = 62.1%; MD-NOS = 56.5%, p = 0.227), followed by mood stabilizers (43.4%; BD-I = 66.7%; BD-NOS = 31.0%; MD-NOS = 34.8%, p = 0.02) and antidepressants (19.7%; BD-I = 20.8%; BD-NOS = 10.3%; MD-NOS = 30.4%). Conclusions: Youth with BD-I, BD-NOS, and MD-NOS experience considerable symptomatology and are functionally impaired, with few differences observed in psychiatric comorbidity and clinical severity. Moreover, youth with BD-NOS and MD-NOS undergo a period with subthreshold manic symptoms, enabling identification and, possibly, preventive intervention of those at risk for developing BD or other affective episodes requiring hospitalization.

Tracking and Predicting Depressive Symptoms of Adolescents Using Smartphone-Based Self-Reports, Parental Evaluations, and Passive Phone Sensor Data: Development and Usability Study

BACKGROUND

Depression carries significant financial, medical, and emotional burden on modern society. Various proof-of-concept studies have highlighted how apps can link dynamic mental health status changes to fluctuations in smartphone usage in adult patients with major depressive disorder (MDD). However, the use of such apps to monitor adolescents remains a challenge.

OBJECTIVE

This study aimed to investigate whether smartphone apps are useful in evaluating and monitoring depression symptoms in a clinically depressed adolescent population compared with the following gold-standard clinical psychometric instruments: Patient Health Questionnaire (PHQ-9), Hamilton Rating Scale for Depression (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A).

METHODS

We recruited 13 families with adolescent patients diagnosed with MDD with or without comorbid anxiety disorder. Over an 8-week period, daily self-reported moods and smartphone sensor data were collected by using the Smartphone- and OnLine usage-based eValuation for Depression (SOLVD) app. The evaluations from teens' parents were also collected. Baseline depression and anxiety symptoms were measured biweekly using PHQ-9, HAM-D, and HAM-A.

RESULTS

We observed a significant correlation between the self-evaluated mood averaged over a 2-week period and the biweekly psychometric scores from PHQ-9, HAM-D, and HAM-A (0.45≤|r|≤0.63; P=.009, P=.01, and P=.003, respectively). The daily steps taken, SMS frequency, and average call duration were also highly correlated with clinical scores (0.44≤|r|≤0.72; all P<.05). By combining self-evaluations and smartphone sensor data of the teens, we could predict the PHQ-9 score with an accuracy of 88% (23.77/27). When adding the evaluations from the teens' parents, the prediction accuracy was further increased to 90% (24.35/27).

CONCLUSIONS

Smartphone apps such as SOLVD represent a useful way to monitor depressive symptoms in clinically depressed adolescents, and these apps correlate well with current gold-standard psychometric instruments. This is a first study of its kind that was conducted on the adolescent population, and it included inputs from both teens and their parents as observers. The results are preliminary because of the small sample size, and we plan to expand the study to a larger population.

Findings From a Trial of the Smartphone and OnLine Usage-based eValuation for Depression (SOLVD) Application: What Do Apps Really Tell Us About Patients with Depression? Concordance Between App-Generated Data and Standard Psychiatric Questionnaires for Depression and Anxiety

OBJECTIVE

Depression imposes a notable societal burden, with limited treatment success despite multiple available psychotherapy and medications choices. Potential reasons may include the heterogeneity of depression diagnoses and the presence of comorbid anxiety symptoms. Despite technological advances and the introduction of many mobile phone applications (apps) claiming to relieve depression, major gaps in knowledge still exist regarding what apps truly measure and how they correlate with psychometric questionnaires. The goal of this study was to evaluate whether mobile daily mood self-ratings may be useful in monitoring and classifying depression symptoms in a clinically depressed population compared with standard psychometric instruments including the Patient Health Questionaire-9 (PHQ-9), the Hamilton Rating Scale for Depression (HAM-D), and the Hamilton Anxiety Rating Scale (HAM-A).

METHOD

For this study, 22 patients with major depressive disorder with or without comorbid anxiety disorder were recruited. The diagnosis of depression was confirmed through the Mini International Neuropsychiatric Interview (MINI). Over an 8-week period, daily moods were self-reported through the Smartphone and OnLine Usage-based eValuation for Depression (SOLVD) application, a custom-designed application that was downloaded onto patients' mobile devices. Depression and anxiety symptoms were also measured biweekly using the HAM-D, HAM-A, and PHQ-9.

RESULTS

Significant correlations were observed among self-evaluated mood, daily steps taken, SMS (text) frequency, average call duration, and biweekly psychometric scores (|r|>0.5, P<0.05). The correlation coefficients were higher in individuals with more severe depressive symptoms.

CONCLUSIONS

Although this study, given its limited sample size, was exploratory in nature, it helps fill a significant gap in our knowledge of the concordance between ratings obtained on the Ham-D, Ham-A, and the PHQ-9 psychometric instruments and data obtained via a smartphone app. These questionnaires represent gold-standard, commonly used psychiatric research/clinical instruments, and, thus, this information can serve as a foundation for digital phenotyping for depression and pave the way for interventional studies using smartphone applications.

Does Anhedonia Presage Increased Risk of Posttraumatic Stress Disorder? : Adolescent Anhedonia and Posttraumatic Disorders

Anhedonia, the reduced ability to experience pleasure, is a dimensional entity linked to multiple neuropsychiatric disorders, where it is associated with diminished treatment response, reduced global function, and increased suicidality. It has been suggested that anhedonia and the related disruption in reward processing may be critical precursors to development of psychiatric symptoms later in life. Here, we examine cross-species evidence supporting the hypothesis that early life experiences modulate development of reward processing, which if disrupted, result in anhedonia. Importantly, we find that anhedonia may confer risk for later neuropsychiatric disorders, especially posttraumatic stress disorder (PTSD). Whereas childhood trauma has long been associated with increased anhedonia and increased subsequent risk for trauma-related disorders in adulthood, here we focus on an additional novel, emerging direct contributor to anhedonia in rodents and humans: fragmented, chaotic environmental signals ("FRAG") during critical periods of development. In rodents, recent data suggest that adolescent anhedonia may derive from aberrant pleasure/reward circuit maturation. In humans, recent longitudinal studies support that FRAG is associated with increased anhedonia in adolescence. Both human and rodent FRAG exposure also leads to aberrant hippocampal function. Prospective studies are underway to examine if anhedonia is also a marker of PTSD risk. These preliminary cross-species studies provide a critical construct for future examination of the etiology of trauma-related symptoms in adults and for and development of prophylactic and therapeutic interventions. In addition, longitudinal studies of reward circuit development with and without FRAG will be critical to test the mechanistic hypothesis that early life FRAG modifies reward circuitry with subsequent consequences for adolescent-emergent anhedonia and contributes to risk and resilience to trauma and stress in adulthood.

Investigating polygenic burden in age at disease onset in bipolar disorder: Findings from an international multicentric study

OBJECTIVES

Bipolar disorder (BD) with early disease onset is associated with an unfavorable clinical outcome and constitutes a clinically and biologically homogenous subgroup within the heterogeneous BD spectrum. Previous studies have found an accumulation of early age at onset (AAO) in BD families and have therefore hypothesized that there is a larger genetic contribution to the early-onset cases than to late onset BD. To investigate the genetic background of this subphenotype, we evaluated whether an increased polygenic burden of BD- and schizophrenia (SCZ)-associated risk variants is associated with an earlier AAO in BD patients.

METHODS

A total of 1995 BD type 1 patients from the Consortium of Lithium Genetics (ConLiGen), PsyCourse and Bonn-Mannheim samples were genotyped and their BD and SCZ polygenic risk scores (PRSs) were calculated using the summary statistics of the Psychiatric Genomics Consortium as a training data set. AAO was either separated into onset groups of clinical interest (childhood and adolescence [≤18 years] vs adulthood [>18 years]) or considered as a continuous measure. The associations between BD- and SCZ-PRSs and AAO were evaluated with regression models.

RESULTS

BD- and SCZ-PRSs were not significantly associated with age at disease onset. Results remained the same when analyses were stratified by site of recruitment.

CONCLUSIONS

The current study is the largest conducted so far to investigate the association between the cumulative BD and SCZ polygenic risk and AAO in BD patients. The reported negative results suggest that such a polygenic influence, if there is any, is not large, and highlight the importance of conducting further, larger scale studies to obtain more information on the genetic architecture of this clinically relevant phenotype.

Association of suicidal risk with ratings of affective temperaments

BACKGROUND

Ratings of particular temperament-types with the TEMPS-A autoquestionnaire have been associated with suicidal risk, and combinations of such ratings may enhance the association. However, the predictive value of scores for individual temperaments and combinations remains to be quantified.

METHOD

We evaluated associations of TEMPS-A ratings for anxious (anx), cyclothymic (cyc), dysthymic (dys), hyperthymic (hyp) and irritable (irr) temperaments, with a history of suicidal acts or reported suicidal ideation in 882 patients with bipolar (BD; n = 509), major depressive (MDD; n = 268) or anxiety (ANX; n = 105) disorders.

RESULTS

With BD, scores for cyc and irr were highest and anx lowest; with MDD, dys scored highest, hyp lowest; anx was highest with ANX and MDD. Women (n = 497) had higher anx and cyc scores than men; scores for irr and hyp decreased with age. Scores for dys, anx, and cyc, were higher, and hyp lower, with greater HDRS₂₁ depression ratings. Among 347 suicidal subjects (112 with attempts), cyc, dys, and irr scores were higher, hyp lower. Pooled score [cyc+ dys+ irr - hyp] best distinguished subjects with suicide attempts versus nonsuicidal subjects, including in Receiver-Operating Characteristic (ROC) analysis (AUC for acts = 70.1% [64.9- 75.3]). Multivariable modeling associated suicidal acts with TEMPS-A [cyc+ dys+ irr - hyp] composite-score, depression severity, BD or MDD diagnosis, and older at illness-onset.

CONCLUSIONS

Subjects with suicidal acts or ideation were best distinguished by composite TEMPS-A score [cyc+ dys+ irr - hyp]. These factors should help to identify those at suicidal risk.

Commentary: Bipolar disorder in youth - what is it and where is it? - a commentary on Parry et al. (2018)

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.