Complex and rapid-cycling in bipolar children and adolescents: a preliminary study

Pediatric Bipolar Disorder: Challenges in Diagnosis and Treatment

Despite an opportunity to prevent adult psychopathology associated with bipolar disorder through early diagnosis in children, there is insufficient information and awareness among healthcare providers about the unique features and treatment of mania and its comorbid conditions in children. Converging evidence from disparate sites describe a developmentally distinct presentation of bipolar disorder in youth that is highly morbid, persistent and responds to treatment with the mood stabilizer medications used in the treatment of adult bipolar disorder, such as divalproex sodium and carbamazepine. Some are additionally approved for use in pediatric populations including, for manic or mixed states, risperidone, aripiprazole, and asenapine for those aged 10-17 years and also including lithium and olanzapine for ages 13-17 years. Quetiapine is approved as monotherapy or as adjunct to lithium or divalproex sodium for manic states in those aged 10-17 years. Delayed or missed diagnosis, inappropriate treatment, worsening course, and treatment resistance unfortunately still occur. While an array of mood-stabilizing medications is available for treatment, such as second-generation antipsychotics, lithium, and anticonvulsants, these can be only partially effective and fraught with annoying and serious side effects. This article will review current practice in the diagnosis and treatment of pediatric bipolar disorder and its comorbid conditions, highlighting areas of need for future research.

A Delphi consensus among experts on assessment and treatment of disruptive mood dysregulation disorder

Objective

The aim of this study was to explore consensus among clinicians and researchers on how to assess and treat Disruptive Mood Dysregulation Disorder (DMDD).

Methods

The Delphi method was used to organize data collected from an initial sample of 23 child psychiatrists and psychologists. Three rounds of closed/open questions were needed to achieve the objective.

Results

Fifteen experts in the field completed the whole study. Finally, 122 proposals were validated and 5 were rejected. Globally, consensus was more easily reached on items regarding assessment than on those regarding treatment. Specifically, experts agreed that intensity, frequency, and impact of DMDD symptoms needed to be measured across settings, including with parents, siblings, peers, and teachers. While a low level of consensus emerged regarding optimal pharmacological treatment, the use of psychoeducation, behavior-focused therapies (e.g., dialectical behavior therapy, chain analysis, exposure, relaxation), and systemic approaches (parent management training, family therapy, parent-child interaction therapy) met with a high degree of consensus.

Conclusion

This study presents recommendations that reached a certain degree of consensus among researchers and clinicians regarding the assessment and treatment of youths with DMDD. These findings may be useful to clinicians working with this population and to researchers since they also highlight non-consensual areas that need to be further investigated.

The Different Impact of Depressive or Manic First-episode on Pediatric Bipolar Disorder Patients: Evidence From Resting-state fMRI

Bipolar disorder may begin as depression or mania, which can affect the treatment and prognosis of bipolar disorder. However, the physiological and pathological differences of pediatric bipolar disorder (PBD) patients with different onset symptoms are not clear. The purpose of this study was to investigate the differences of clinical, cognitive function and intrinsic brain networks in PBD patients with first-episode depression and first-episode mania. A total of 63 participants, including 43 patients and 20 healthy controls, underwent resting-state fMRI scans. PBD patients were classified as first-episode depressive and first-episode manic based on their first-episode symptoms. Cognitive tests were used to measure attention and memory of all participants. Independent component analysis (ICA) was used to extract the salience network (SN), default-mode network (DMN), central executive network (ECN) and limbic network (LN) for each participant. Spearman rank correlation analysis was performed between abnormal activation and clinical and cognitive measures. The results showed that there were differences in cognitive functions such as attention and visual memory between first-episode depression and mania, as well as differences activation in anterior cingulate cortex (ACC), posterior cingulate cortex (PCC), precuneus, inferior parietal cortex and parahippocampus. And significant associations of brain activity with clinical assessments or cognition were found in different patients. In conclusion, we found differential impairments in cognitive and brain network activation in first-episode depressive and first-episode manic PBD patients, and correlations were found between these impairments. These evidences may shed light on the different developmental paths of bipolar disorder.

Regional microstructural differences in ADHD youth with and without a family history of bipolar I disorder

BACKGROUND

Having a first-degree relative with bipolar I disorder (BD) in conjunction with prodromal attention deficit/hyperactivity disorder (ADHD) may represent a unique phenotype that confers greater risk for developing BD than ADHD alone. However, underlying neuropathoetiological mechanisms remain poorly understood. This cross-sectional study compared regional microstructure in psychostimulant-free ADHD youth with ('high-risk', HR) and without ('low-risk', LR) a first-degree relative with BD, and healthy controls (HC).

METHODS

A total of 140 (high-risk, n = 44; low-risk, n = 49; and HC, n = 47) youth (mean age: 14.1 ± 2.5 years, 65 % male) were included in the analysis. Diffusion tensor images were collected and fractional anisotropy (FA) and mean diffusivity (MD) maps were calculated. Both tract-based and voxel-based analyses were performed. Correlations between clinical ratings and microstructural metrics that differed among groups were examined.

RESULTS

No significant group differences in major long-distance fiber tracts were observed. The high-risk ADHD group exhibited predominantly higher FA and lower MD in frontal, limbic, and striatal subregions compared with the low-risk ADHD group. Both low-risk and high-risk ADHD groups exhibited higher FA in unique and overlapping regions compared with HC subjects. Significant correlations between regional microstructural metrics and clinical ratings were observed in ADHD groups.

LIMITATIONS

Prospective longitudinal studies will be required to determine the relevance of these findings to BD risk progression.

CONCLUSIONS

Psychostimulant-free ADHD youth with a BD family history exhibit different microstructure alterations in frontal, limbic, and striatal regions compared with ADHD youth without a BD family history, and may therefore represent a unique phenotype relevant to BD risk progression.

Paediatric bipolar disorder and its controversy

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.

'Pediatric Bipolar Disorder' rates are still lower than claimed: a re-examination of eight epidemiological surveys used by an updated meta-analysis

Background

‘Pediatric bipolar disorder’ (PBD) is a controversial diagnosis with varying rates of clinical diagnosis. A highly cited meta-analysis (Van Meter et al. 2011) of a dozen epidemiological surveys suggested a global community prevalence of PBD of 1.8%. This was updated to 3.9% with eight additional surveys (Van Meter et al. 2019a). In terms of the Cochrane Handbook for Systematic Reviews of Interventions, the heterogenous community surveys were arguably unsuitable for statistical meta-analysis and warranted a narrative analysis. A narrative analysis (Parry et al. 2018) of the original 12 surveys concluded rates of PBD were substantially lower than 1.8% and led to a nine-article debate on the validity, arguable overdiagnosis and iatrogenic aspects of the PBD diagnosis (e.g. Carlson and Dubicka Child Adolesc Mental Health 21:86–87, 2019). This article extends the narrative analysis to include the eight newer community surveys.

Methods

A narrative analysis of the methodologies and the prevalence rates reported by the epidemiological surveys.

Results

Across all twenty surveys there was significant variation in methodologies and reported prevalence rates. Of the eight newer surveys, five (two Brazilian, one English, one Turkish, one United States) provided information of pre-adolescent prevalence rates of bipolar spectrum disorder. These pre-adolescent rates were zero or close to zero. Rates of adolescent hypomania and mania were higher, but follow-up data in two studies suggested hypomania might sometimes achieve prolonged remission or not lead to adult bipolar disorder.

Limitations

Methods in the original surveys vary and criteria used for various bipolar diagnoses were not always fully described. This limitation applies to a narrative analysis but also to a statistical meta-analysis.

Conclusion

Bipolar disorder is very rare in childhood and rare in adolescence. PBD as a diagnostic construct fails to correlate with adult bipolar disorder and the term should be abandoned. Hypomanic syndromes in adolescence may not always progress to adult bipolar disorder. Early diagnosis of bipolar disorder is important, but over-diagnosis risks adverse iatrogenic consequences.

Emotion regulation in pediatric bipolar disorder: A meta-analysis of published studies

BACKGROUND

Emotion regulation is a relatively recent topic in psychiatry, and has only recently begun to be tested across Pediatric Bipolar Disorder (PBD). To date, no meta-analysis has investigated the presence of emotion regulation deficits in PBD patients.

OBJECTIVES

The aim of this study is to understand where the literature stands on this topic, as well as how different researchers are measuring and grasping the concept of emotion regulation in pediatric bipolar disorders.

METHODS

A systematic search of trials using the terms ("Pediatric Bipolar Disorder") AND ("Emotion Regulation" OR "Affect Regulation" OR "Mood Lability" OR "Mood Instability" OR "Irritability") was conducted using PubMed, Google Scholar, ResearchGate, Web of Science and Psych Info databases. Of the initial 366 articles identified, 8 met eligibility criteria for the meta-analysis and were included in this study.

RESULTS

There is a statistically significant difference in Accuracy in Emotion Regulation tasks, with a tendency for lower accuracy in PBD patients; however, both groups did not differ statistically regarding Response Time.

CONCLUSION

Our data suggests that PBD patients do present emotion regulation deficits, particularly regarding facial emotion recognition and affective language interference tasks mediated by cognitive assignments. These results have important implications in developing novel psychotherapeutic interventions for this population.

The Phenomenology of Outbursts

Outbursts (severe temper loss) in children are a common reason for treatment referral. However, the diagnostic system has not classified them in a way that expands knowledge. Outbursts are nested in the concept of irritability, which consists of a feeling and a behavioral dimension. Both need to be identified but kept separate. This review summarizes the phenomenology of outbursts normatively and clinically. Severe temper loss needs a consistent label, an operationalized way of classification and measurement, and an assessment approach independent of diagnosis until other data are gathered to more accurately determine what condition provides the most accurate diagnostic home.

The geography of a controversial diagnosis: A bibliographic analysis of published academic perspectives on 'paediatric bipolar disorder'

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.

Motor function in an animal model with ouabain-induced bipolar disorder and comorbid anxiety behavior

In a clinical setting, anxiety disorder is highly correlated with bipolar I disorder in humans. However, the comorbidity of anxiety behavior and bipolar disorder still remains unclear in an animal model. This study utilized an ouabain-induced animal mode to examine anxiety and mania in an open field test. In the present study, 5 µl of artificial cerebrospinal fluid (aCSF) or ouabain (10^-5, 10^-4, and 10^-3 M) were administered into the left ventricle. The animals' motor functions and anxiety behaviors were measured for 15 min. The results showed that 10^-3 M ouabain significantly increased the animal's total distance traveled, average speed, and maximum speed compared to the control group. The time spent inside (i.e., how much time rats spent in the center of the square) and the inside-outside times of the central square (i.e., how many times rats ran across the center square) of the higher-concentration groups (10^-4 M and 10^-3 M) were significantly decreased. Therefore, a high concentration of ouabain may induce hyperactivity. The 10^-4 M and 10^-3 M ouabain groups exhibited more anxiety behaviors. The study is the first model to examine comorbid anxiety behaviors and bipolar disorder in an animal model. The study provides some insights for comorbid anxiety and bipolar disorder in clinics.

Treatment-Emergent Mania in a Prepubertal Boy

Bipolar disorder among children has gained acceptance as a diagnostic entity but continues to pose diagnostic and management challenges due to the developmental differences in children and inadequate evidence for pharmacological management. We present the case of a prepubertal child presenting with an apparent depressive episode who developed treatment-emergent mania when commenced on sertraline. This case highlights the need for further research into the presentations and pharmacological management of prepubertal children with bipolar affective disorder.

'Paediatric bipolar disorder' rates are lower than claimed - a reexamination of the epidemiological surveys used by a meta-analysis

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.

Bipolar Disorder in Children With ADHD: A Clinical Sample Study

OBJECTIVE

To explore the impact of early-onset bipolar disorder (pediatric bipolar disorder [PBD]) on ADHD.

METHOD

We compared ADHD symptom severity, ADHD subtype distribution, and rates of comorbid and familial psychiatric disorders between 49 ADHD children with comorbid PBD and 320 ADHD children without PBD.

RESULTS

Children with ADHD and PBD showed higher scores in the Hyperactive and Inattentive subscales of the ADHD Rating Scale, than children with ADHD alone. The frequency of combined subtype was significantly higher in ADHD children with PBD, than in those with ADHD alone. ADHD children with PBD showed a higher rate of familial psychiatric disorders than ADHD children without PBD. The rate of conduct disorder was significantly greater in children with PBD and ADHD compared with children with ADHD alone.

CONCLUSION

ADHD along with PBD presents with several characteristics that distinguish it from ADHD alone, suggesting that these may be distinct disorders.

Sustained Attention and Visual Processing Speed in Children and Adolescents with Bipolar Disorder and other Psychiatric Disorders

To investigate the cognitive functioning of children and adolescents with bipolar illness, 112 child and adolescent psychiatric inpatients and day-hospital patients at a state psychiatric hospital were administered the Wechsler Intelligence Scale for Children–III (WISC–III) as part of an admission psychological assessment. There were 22 patients with Bipolar Disorder and 90 with other psychiatric disorders; all were between 8 and 17 years of age. The patients with Bipolar Disorder had a mean age of 14 yr., a mean Verbal IQ of 78, a mean Performance IQ of 76, and a mean Full Scale IQ of 75. When their WISC–III scores were compared with those who had Schizophrenia Spectrum disorders (Schizophrenia and Schizoaffective Disorder), Psychosis Not Otherwise Specified, Attention Deficit Hyperactivity Disorder, and Conduct Disorder and Oppositional Defiant Disorder, there were no significant between-group mean differences for Verbal IQ, but patients with Bipolar Disorder had a significantly lower mean Performance IQ than those with ADHD and those with Conduct Disorder and Oppositional Defiant Disorder. Contrary to the expectation that the patients with Bipolar Disorder might have better sustained attention (higher Digit Span scores) than those with Schizophrenia Spectrum disorders and worse visual processing speed (lower Coding scores) than the other diagnostic groups, the bipolar patients' Digit Span and Coding scores did not differ significantly from those of the other groups. The patients with Psychosis, Not Otherwise Specified had significantly lower mean Performance IQ, Full Scale IQ, and Coding than the ADHD and the Conduct Disorder and Oppositional Disorder groups.

Complexity and Comorbidity in a Case of Early-Onset Bipolar Disorder

A reproducible characteristic of early-onset bipolar disorder (BPD) is its atypicality when compared to the adult form. Research and practice consistently confirms early-onset BPD to be chronic rather than acute and continuous rather than episodic, with mixed manic states rather than biphasic and multifarious patterns of comorbidity. Research into successful psychotropic treatments for early-onset BPD is on-going and diverse. Similarly, psychosocial interventions are in the prototype phase. This school-based case study follows an 18-month course of treatment for a 16-year-old female with early-onset BPD comorbid with attentiondeficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder, and situationally predisposed panic attacks. The first 6 months of treatment involved no medications. During this time, intensive psychosocial and cognitive-behavioral interventions including affect-regulation training, behavior modification, self-monitoring, contingency management, educational accommodations, emergency classroom protocols, and intensive psychotherapy were successfully implemented. In the second phase of treatment, after numerous unsuccessful psychotropic trials, the client's mood was stabilized with gabapentin (Neurontin), with methylphenidate (Ritalin) being added to treat her ADHD with astounding results.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding 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 these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Is premenstrual dysphoric disorder really a disorder?

Premenstrual dysphoric disorder (PMDD) was recently moved to a full category in the DSM-5 (the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders). It also appears set for inclusion as a separate disorder in the ICD-11 (the upcoming edition of the World Health Organization's International Statistical Classification of Diseases and Related Health Problems). This paper argues that PMDD should not be listed in the DSM or the ICD at all, adding to the call to recognise PMDD as a socially constructed disorder. I first present the argument that PMDD pathologises understandable anger/distress and that to do so is potentially dangerous. I then present evidence that PMDD is a culture-bound phenomenon, not a universal one. I also argue that even if (1) medication produces a desired effect, (2) there are biological correlates with premenstrual anger/distress, (3) such anger/distress seems to occur monthly, and (4) women are more likely than men to be diagnosed with affective disorders, none of these factors substantiates that premenstrual anger/distress is caused by a mental disorder. I argue that to assume they do is to ignore the now accepted role that one's environment and psychology play in illness development, as well as arguments concerning the social construction of mental illness. In doing so, I do not claim that there are no women who experience premenstrual distress or that their distress is not a lived experience. My point is that such distress can be recognised and considered significant without being pathologised and that it is unethical to describe premenstrual anger/distress as a mental disorder. Further, if the credibility of women's suffering is subject to doubt without a clinical diagnosis, then the way to address this problem is to change societal attitudes towards women's suffering, not to label women as mentally ill. The paper concludes with some broader implications for women and society of the change in status of PMDD in the DSM-5 as well as a sketch of critical policy suggestions to address these implications.

Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment

BACKGROUND

Research on pediatric bipolar disorder (PBD) is providing a plethora of empirical findings regarding its comorbidity. We addressed this question through a systematic review concerning the prevalence, clinical impact, etiology and treatment of main comorbid disorders involved.

METHOD

A comprehensive database search was performed from 1990 to August 2014. Overall, 167 studies fulfilled the inclusion criteria.

RESULTS

Bipolar youth tend to suffer from comorbid disorders, with highest weighted mean prevalence rate arising from anxiety disorders (54%), followed by attention deficit hyperactivity disorder (ADHD) (48%), disruptive behavior disorders (31%), and substance use disorders (SUD) (31%). Furthermore, evidence indicates that ADHD and anxiety disorders negatively affect the symptomatology, neurocognitive profile, clinical course and the global functioning of PBD. Likewise, several theories have been posited to explain comorbidity rates in PBD, specifically common risk factors, one disorder being a risk factor for the other and nosological artefacts. Lastly, randomized controlled trials highlight a stronger therapeutic response to stimulants and atomoxetine (vs. placebo) as adjunctive interventions for comorbid ADHD symptoms. In addition, research focused on the treatment of other comorbid disorders postulates some benefits from mood stabilizers and/or SGA.

LIMITATIONS

Epidemiologic follow-up studies are needed to avoid the risk of nosological artefacts. Likewise, more research is needed on pervasive developmental disorders and anxiety disorders, especially regarding their etiology and treatment.

CONCLUSIONS

Psychiatric comorbidity is highly prevalent and is associated with a deleterious clinical effect on pediatric bipolarity. Different etiological pathways may explain the presence of these comorbid disorders among bipolar youth. Standardized treatments are providing ongoing data regarding their effectiveness for these comorbidities among bipolar youth.

Diagnostic stability in pediatric bipolar disorder

BACKGROUND

The diagnostic stability of pediatric bipolar disorder has not been investigated previously. The aim was to investigate the diagnostic stability of the ICD-10 diagnosis of pediatric mania/bipolar disorder.

METHODS

All patients below 19 years of age who got a diagnosis of mania/bipolar disorder at least once in a period from 1994 to 2012 at psychiatric inpatient or outpatient contact in Denmark were identified in a nationwide register.

RESULTS

Totally, 354 children and adolescents got a diagnosis of mania/bipolar disorder at least once; a minority, 144 patients (40.7%) got the diagnosis at the first contact whereas the remaining patients (210; 59.3%) got the diagnosis at later contacts before age 19. For the latter patients, the median time elapsed from first treatment contact with the psychiatric service system to the first diagnosis with a manic episode/bipolar disorder was nearly 1 year and for 25% of those patients it took more than 2½ years before the diagnosis was made. The most prevalent other diagnoses than bipolar disorder at first contact were depressive disorder (21.4%), acute and transient psychotic disorders or other non-organic psychosis (19.2%), reaction to stress or adjustment disorder (14.8%) and behavioral and emotional disorders with onset during childhood or adolescents (10.9%). Prevalence rates of schizophrenia, personality disorders, anxiety disorder or hyperkinetic disorders (ADHD) were low.

LIMITATIONS

Data concern patients who get contact to hospital psychiatry only.

CONCLUSIONS

Clinicians should be more observant on manic symptoms in children and adolescents who at first glance present with transient psychosis, reaction to stress/adjustment disorder or with behavioral and emotional disorders with onset during childhood or adolescents (F90-98) and follow these patients more closely over time identifying putable hypomanic and manic symptoms as early as possible.

Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: a randomized clinical trial

OBJECTIVE

Previous studies have found that family-based psychosocial treatments are effective adjuncts to pharmacotherapy among adults and adolescents with bipolar disorder (BD). The objective of this study was to compare the efficacy of adjunctive child- and family-focused cognitive-behavioral therapy (CFF-CBT) to psychotherapy as usual (control) for mood symptom severity and global functioning in children with BD.

METHOD

Sixty-nine youth, aged 7 to 13 years (mean = 9.19, SD = 1.61) with DSM-IV-TR bipolar I, II, or not otherwise specified (NOS) disorder were randomly assigned to CFF-CBT or control groups. Both treatments consisted of 12 weekly sessions followed by 6 monthly booster sessions delivered over a total of 9 months. Independent evaluators assessed participants at baseline, week 4, week 8, week 12 (posttreatment), and week 39 (6-month follow-up).

RESULTS

Participants in CFF-CBT attended more sessions, were less likely to drop out, and reported greater satisfaction with treatment than controls. CFF-CBT demonstrated efficacy compared to the control treatment in reducing parent-reported mania at posttreatment and depression symptoms at posttreatment and follow-up. Global functioning did not differ at posttreatment but was higher among CFF-CBT participants at follow-up.

CONCLUSION

CFF-CBT may be efficacious in reducing acute mood symptoms and improving long-term psychosocial functioning among children with BD.

Rapid cycling mood disorder: A review

Objectives: Rapid cycling mood disorder is an important clinical phenomenon. The concept of rapid cycling has evolved since it was first described in 1974. The purpose of this review is to summarise current diagnostic criteria, postulated risk factors and suggested management strategies.

Method: A Medline and Psych-Lit computerised literature search was supplemented by tracing back through the references from existing review work.

Results: Over 80 papers were identified which discussed diagnosis and management of rapid cycling.

Conclusions: DSM-IV provides a useful but narrow definition of rapid cycling. Standard treatment of affective disorder may exacerbate rapid cycling. If a rapid cycling course develops, discontinuation of antidepressants and use of mood stabilisers is recommended.

The bipolar-borderline personality disorders connection in major depressive patients

OBJECTIVE

The study focuses on the controversial relationship between borderline personality disorder (BPD) and bipolar disorder (BD), defined according to different criteria set, in a world-wide sample of patients with a current major depressive episode (MDE).

METHOD

A total of 5635 patients with an MDE were enrolled in a multinational study, designed to assess varying definition of hypo/mania and familial and clinical variables associated with bipolarity. Patients with (BPD+) and without (BPD-)comorbid BPD were compared on sociodemographic, familial and clinical characteristics.

RESULTS

Five hundred and thirty-two patients (9.3%) met criteria for BPD. A diagnosis of BD was more frequent in BPD+ than in BPD- using either DSM-IVTR-modified criteria or the bipolar specifier. BPD+ were younger than BPD- depressives with regard to age and age at onset. They also showed more hypomania/mania in first-degree relatives in comparison to BPD- as well as more psychiatric comorbidity, psychotic symptoms, mixed states, atypical features, seasonality of mood episodes, suicide attempts, prior mood episodes and antidepressants-induced hypo/manic switches.

CONCLUSION

In our sample, selected on the basis of the presence of a mood disorder, the BD-BPD connection is confirmed by the high prevalence of bipolarity in depressive patients with BPD and by the significant association with familial and clinical features classically considered as external validators of bipolarity.

Is comorbid borderline personality disorder in patients with major depressive episode and bipolarity a developmental subtype? Findings from the international BRIDGE study

BACKGROUND

The nature of the relationship between bipolar disorder (BD) and borderline personality disorder (BPD) is controversial. The aim of this study was to characterize the clinical profile of patients with BD and comorbid BPD in a world-wide sample selected during a major depressive episode (MDE).

METHODS

From a general sample of 5635 in and out-patients with an MDE, who were enrolled in the multicenter, multinational, transcultural BRIDGE study, we identified 2658 subjects who met bipolarity specifier criteria. Bipolar specifier patients with (BPD+) and without (BPD-) comorbid BPD were compared on diagnostic, socio-demographic, familial and clinical characteristics.

RESULTS

386 patients (14.5%) met criteria for BPD. A diagnosis of BD according to DSM-IV criteria was significantly more frequent in the BPD- than in BPD+, while similar rates in the two groups occurred using DSM-IV-Modified criteria. A subset of the BD criteria with an atypical connotation, such as irritability, mood instability and reactivity to drugs were significantly associated withthe presence of BPD. BPD+ patients were significantly younger than BPD- bipolar patients for age, age at onset of first psychiatric symptoms and age at first diagnosis of depression. They also reported significantly more comorbid Alcohol and Substance abuse, Anxiety disorders, Eating Disorder and Attention Deficit Hyperactivity Disorder. In comparison with BPD-, BPD+ patients showed significantly more psychotic symptoms, history of suicide attempts, mixed states, mood reactivity, atypical features, seasonality of mood episodes, antidepressants induced mood lability and irritability, and resistance to antidepressant treatments.

LIMITATIONS

Centers were selected for their strong mood disorder clinical programs, recall bias is possible with a cross-sectional design, and participating psychiatrists received limited training.

CONCLUSIONS

We confirm in a large sample of BD patients with MDE the high prevalence of patients who meet DSM-IV criteria for BPD. Further prospective researches should clarify whether the mood reactivity and instability captured by BPD DSM-IV criteria are distinguishable from the subjective mood of an instable, dysphoric, irritable manic/hypomanic/mixed state or simply represent a phenotypic variant of BD, related to developmental factors.

Comorbidity Between ADHD and Symptoms of Bipolar Disorder in a Community Sample of Children and Adolescents

The prevalence and frequency of comorbidity of possible bipolar disorder was examined with attention-deficit hyperactivity disorder (ADHD) in a nonreferred population of twins. Children and adolescents aged 7 to 18 years with a history of manic symptoms were identified from a population-based twin sample obtained from state birth records (n = 1610). The sample was enriched for ADHD; however, there was also a random control sample (n = 466), which allowed a look at the population prevalence of the disorder. Juveniles with threshold or below threshold manic episodes were further assessed for comorbidity with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) and population-defined ADHD subtypes (from latent class analysis) using Fisher's exact test. Nine juveniles who exhibited DSM-IV manic (n = 1), hypomanic (n = 2) or below threshold episodes (n = 6) were identified. The population prevalence of broadly defined mania in the random sample was 0.2%. The possible manic episodes showed significant comorbidity with population-defined severe combined and talkative ADHD subtypes. It can be concluded that there is a significant association of bipolar symptoms with two population-defined subtypes of ADHD. Episodes of possible bipolar disorders as defined by DSM-IV are uncommon in this nonreferred sample. Children and adolescents with ADHD appear to be only modestly at increased risk for bipolar disorders.

Pediatric bipolar disorder in an era of "mindless psychiatry"

OBJECTIVE

Pediatric bipolar disorder (PBD) reflects shifts in conceptualizing bipolar disorder among children and adolescents since the mid-1990s. Since then, PBD diagnoses, predominantly in the United States, have increased dramatically, and the diagnosis has attracted significant controversy. During the same period, psychiatric theory and practice has become increasingly biological. The aim of this paper is to examine the rise of PBD in terms of wider systemic influences.

METHOD

In the context of literature referring to paradigm shifts in psychiatry, we reviewed the psychiatric literature, media cases, and information made available by investigative committees and journalists.

RESULTS

Social historians and prominent psychiatrists describe a paradigm shift in psychiatry over recent decades: from an era of "brainless psychiatry," when an emphasis on psychodynamic and family factors predominated to the exclusion of biological factors, to a current era of "mindless psychiatry" that emphasizes neurobiological explanations for emotional and behavioral problems with limited regard for contextual meaning. Associated with this has been a tendency within psychiatry and society to neglect trauma and attachment insecurity as etiological factors; the "atheoretical" (but by default biomedical) premise of the Diagnostic and Statistical Manual of Mental Disorders (3rd and 4th eds.); the influence of the pharmaceutical industry in research, continuing medical education, and direct-to-consumer advertising; and inequality in the U.S. health system that favors "diagnostic upcoding." Harm from overmedicating children is now a cause of public concern.

CONCLUSION

It can be argued that PBD as a widespread diagnosis, particularly in the United States, reflects multiple factors associated with a paradigm shift within psychiatry rather than recognition of a previously overlooked common disorder.

Sleep Disturbances in Pediatric Bipolar Disorder: A Comparison between Bipolar I and Bipolar NOS

INTRODUCTION

The diagnosis of bipolar disorder (BD) in youths has been controversial, especially for the subtype BD not otherwise specified (BD-NOS). In spite of growing evidence that sleep is a core feature of BD, few studies characterize and compare sleep disturbances in youth with BD type I (BD-I) and BD-NOS. Sleep disturbances are frequently reported in clinical descriptions of children and adolescents with BD, however the reporting of the frequency and characteristics of sleep symptoms in youth with BD-NOS and BD-I during episodes remain poor. This study compares symptom of sleep disturbance as occurring in manic and depressive episodes in BD-I and BD-NOS youth using Kiddie-schedule for affective disorders and schizophrenia, present and lifetime version (K-SADS-PL) interview data. The study also addresses whether symptoms of sleep disturbance vary in different age groups.

MATERIALS AND METHODS

The sample consisted of 70 children and adolescent outpatients at an urban specialty clinic (42M/28F, 10.8 ± 3.6 years old) including 24 BD-I and 46 BD-NOS assessed using K-SADS-PL-parent interview.

RESULTS

Sleep disturbances including insomnia and decreased need for sleep were reported by 84.3% of the sample. Enuresis was diagnosed in 27% of sample. There were no significant differences in frequency of sleep symptoms between BD-I and BD-NOS. Regardless of BD subtype, current functioning was negatively correlated with decreased need for sleep but not insomnia, and regardless of BD subtype.

CONCLUSION

The majority of youth with BD presents with sleep symptoms during mood episodes. BD-NOS presents with the same proportion of sleep symptoms as BD-I in our sample.

Psychosocial functioning, familiality, and psychiatric comorbidity in bipolar youth with and without psychotic features

OBJECTIVE

Few studies have examined the correlates of psychosis in children and adolescents with bipolar disorder (BPD). We examined psychiatric comorbidity, familiality, and psychosocial functioning in multiple domains in BPD children and adolescents with and without psychotic features.

METHOD

As part of 2 ongoing family-based studies of children and adolescents with DSM-IV-defined BPD, we compared youth and their families with psychotic symptoms (BPD+P) and without psychotic symptoms (BPD-P). All youth and family members were assessed using indirect and direct structured psychiatric interviews (Kiddie Schedule for Affective Disorders-Epidemiologic Version and DSM-IV Structured Clinical Interview) in a blinded manner. One study was conducted from January 2000 through December 2004, and the other study was conducted from February 1997 through September 2006.

RESULTS

Of the 226 youth with BPD, 33% manifested psychotic symptoms, as defined by the presence of hallucinations or delusions. We found that BPD+P youth had a greater number of BPD episodes (P < .01), more psychiatric hospitalizations (P < .01), and significantly higher rates of psychiatric comorbidity compared to BPD-P youth (all P values < .05). Additionally, a higher percentage of BPD+P youth had a family history of psychosis (P = .01). There was a lower processing speed (P = .03) and lower arithmetic scaled score (P = .04) in BPD+P youth, but no other meaningful differences in cognitive variables were identified between the 2 BPD groups. Psychosis in BPD was also associated with decreased family cohesion (P = .04) and poorer overall global functioning (P < .01).

CONCLUSIONS

In children and adolescents with BPD, those who manifest psychotic features have higher rates of comorbid psychopathology, family history of psychosis, and poorer overall functioning in multiple domains than BPD children without psychosis. Future studies should examine neuroimaging correlates, medication response, and longitudinal course of children and adolescents with BPD who manifest psychosis as part of their clinical picture.

Longitudinal Assessment of Manic Symptoms (LAMS) study: background, design, and initial screening results

OBJECTIVE

To describe the design of a longitudinal study of youth with elevated symptoms of mania (ESM), as well as the prevalence and correlates of manic symptoms. Bipolar disorder in youth is serious and is surrounded by controversy about its phenomenology, course, and treatment. Yet, there are no longitudinal studies of youth selected only for ESM, the phenomenological hallmark. The study's objective is to document the rate and sociodemographic correlates of ESM in children attending outpatient psychiatric clinics.

METHOD

Parents of 3,329 children aged 6-12 years visiting 10 outpatient clinics were asked to complete the Parent General Behavior Inventory 10-Item Mania Scale (PGBI-10M). Children with PGBI-10M scores ≥ 12 (ESM positive-screen [ESM+]) and a matched sample of ESM screen-negative (ESM-) children were invited to enroll in the longitudinal study. The sample was accrued from November 14, 2005, to November 28, 2008.

RESULTS

Most of the children whose parents filled out the PGBI-10M (N = 2,622, 78.8%) participated in the study. Nonparticipants were slightly younger (mean age = 9.1 years [SD = 2.0 years] versus 9.4 years [SD = 2.0 years] for participants; t3327 = 4.42, P < .001). Nearly half of the participants (43%) were ESM+; these were more likely to be Latino (4.2% versus 2.5% for ESM-; χ(2)1 = 5.45, P = .02), younger (mean age = 9.3 years [SD = 2.0 years] versus 9.6 years [SD = 1.9 years] for ESM-; t2620 = 3.8, P < .001), and insured by Medicaid (48.4% versus 35.4% for ESM-; χ(2)1 = 45.00, P < .001). There were no sociodemographic differences between those who did versus did not agree to enroll in the longitudinal portion (yes to enrollment: n = 621, 55.2%; no to enrollment: n = 503, 44.8%). Four items best discriminated ESM+ children from ESM- children. Three of the 4 items were not the most commonly endorsed items, but all were indicative of behavioral extremes.

CONCLUSIONS

Data suggest that ESM+ is not rare in 6- to 12-year-olds. Children who are ESM+ show behavioral extremes, including rapid mood shifts, compared to ESM- children.

Psychodynamic-oriented psychological assessment predicts evolution to schizophrenia at 8-year follow-up in adolescents hospitalized for a manic/mixed episode: interest of an overall subjective rating

Little is known concerning the prognostic significance of manic/mixed episodes in adolescents. In particular, whether the use of psychodynamic-oriented projective psychological testing predicts evolution to schizophrenia at follow-up has not been established. Eighty subjects, aged 12-20years old, consecutively hospitalized for a manic or mixed episode between 1994 and 2003 were recruited. All patients were contacted in 2005-2006 for a follow-up assessment. For the subgroup of adolescents (N=40) who had psychodynamic-oriented psychological testing (Rorschach and TAT), two scores regarding psychosocial risk and schizophrenia risk were computed using the clinical global impression (CGI) assessment based on an overall subjective rating given by a panel of expert psychologists who reviewed all protocols. At follow-up (average 8years), 25 (62.5%) patients, 16 females and nine males, were assessed: 14 still had a diagnosis of bipolar disorder; eight changed to schizo-affective disorder and three to schizophrenia. Inter-rater reliability of both CGI-risk scores (psychosocial risk and schizophrenia risk) showed good clinical consensus with intraclass correlation and Kappa scores ranging from 0.53 to 0.75. Univariate analysis showed that CGI-psychosocial risk score (p=0.017), type of index episode (p=0.049) and CGI-schizophrenia risk score (p=0.09) were associated with transition to schizophrenia spectrum disorder at follow-up. Age, sex, socioeconomic status, duration of stay and the presence of psychotic features at index episode were not associated with the transition. We conclude that the CGI assessment appears to be valid to score risk of poor outcome using psychodynamic-oriented psychological testing and that these scores may predict, in part, the transition to schizophrenia in adolescents with a history of manic/mixed episode.

Differences of clinical characteristics and phenotypes between prepubertal- and adolescent-onset bipolar disorders

The aim of this study is to describe the clinical characteristics of prepubertal- and adolescent-onset bipolar disorder (BD) and to identify any clinical differences between patients with prepubertal- and adolescent-onset BD. We analyzed the clinical records of 53 inpatients with BD. These patients were divided into prepubertal-onset and adolescent-onset groups. We also divided the subjects into narrow, intermediate, and broad phenotypes according to the definitions proposed by Leibenluft and colleagues. Of the total sample, 16 patients (30.2%) were in the prepubertal-onset group and 37 (69.8%) were in the adolescent-onset group. Patients with prepubertal-onset BD were more likely to display an insidious clinical presentation, atypical features, and comorbid psychopathology. And the majority of the subjects, especially in the prepubertal-onset group, were classified under the intermediate and broad phenotypes. These results suggest that the clinical presentation of BD with prepubertal-onset is different from that of adolescent-onset BD. It is inferred that a significant number of patients with prepubertal- and adolescent-onset BD do not meet DSM-IV criteria for mania or hypomania from the results of this study.

Controversies concerning the diagnosis and treatment of bipolar disorder in children

This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the present, ending with current efforts to distinguish between a small number of children whose behaviors closely fit DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disorder with Dysphoria.Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSM's diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compromised. And because BP has a strong genetic component, the label can distract attention from the family or social context.Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much on the child's context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed consent, they must be forthcoming with families about the relevant uncertainties and complexities.

Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists

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.

Prescribing patterns for treatment of pediatric bipolar disorder in a specialty clinic

OBJECTIVE

The aim of this study was to describe prescribing practices in the treatment of pediatric bipolar disorder in a university practice setting.

METHOD

A retrospective chart review was performed on 53 youths diagnosed using Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV), criteria with bipolar spectrum disorder under the active care of child psychiatrists practicing in a pediatric psychopharmacology specialty clinic. Current medications, doses, and related adverse events were recorded. Clinicians were asked to provide a target disorder (bipolar mania/mixed state, depression, attention deficit hyperactivity disorder [ADHD], or anxiety) for each medication to the best of their ability. The Clinical Global Impressions-Severity (CGI-S) scale was used to measure severity of each disorder before treatment and the Clinical Global Impressions-Improvement (CGI-I) was used to quantify the magnitude of improvement with treatment. Meaningful improvement of the disorder was defined by CGI-I score of 1 or 2.

RESULTS

The mean number of psychotropic medications per patient was 3.0 +/- 1.6. A total of 68% of patients were treated for co-morbid disorders; 23% of patients were treated with monotherapy, primarily with second-generation antipsychotics. Mania improved in 80% of cases, mixed state improved in 57% of cases, ADHD improved in 56% of cases, anxiety improved in 61% of cases, and depression improved in 90% of cases.

CONCLUSION

The management of pediatric bipolar disorder often requires multiple medications. For the treatment of mania/mixed states, clinicians prescribed second-generation antipsychotics more frequently than mood stabilizers, especially in the context of monotherapy. Co-morbidity was a frequent problem with moderate success obtained with combined pharmacotherapy approaches. Further psychosocial strategies to augment pharmacotherapy may improve outcome while reducing the medication burden in pediatric bipolar disorder.

Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology

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.

Comorbidity in Pediatric Bipolar Disorder

The growing literature shows the pervasiveness and importance of comorbidity in youth with bipolar disorder (BPD). For instance, up to 90% of youth with BPD have been described to manifest comorbidity with attention-deficit hyperactivity disorder. Multiple anxiety, substance use, and disruptive behavior disorders are the other most commonly reported comorbidities with BPD. Moreover, important recent data highlight the importance of obsessive-compulsive and pervasive developmental illness in the context of BPD. Data suggest that not only special developmental relationships are operant in the context of comorbidity but also that the presence of comorbid disorders with BPD results in a more severe clinical condition. Moreover, the presence of comorbidity has therapeutic implications for the treatment response for both BPD and the associated comorbid disorder. Future longitudinal studies to address the relationship and the impact of comorbid disorders on course and therapeutic response over time are required in youth with BPD.

Phenomenology, socio-demographic factors and outcome upon discharge of manic and mixed episodes in hospitalized adolescents: a chart review

BACKGROUND

The existence of bipolar disorder type I (BD-I) during adolescence is now clearly established whereas there are still some controversies on BD-II and BD-NOS diagnosis, mainly in Europe (O'Dowd in Br Med J 29, 2006). Little is known on the phenomenology and potential short-term prognosis factors of bipolar episodes in this age population. In particular, very few studies examine this issue on inpatients in the European context of free access to care.

OBJECTIVE

To describe the phenomenology of acute manic and mixed episodes in hospitalized adolescents and to analyse potential predictive factors associated with clinical improvement at discharge and length of hospitalization.

METHODS

A total of 80 subjects, aged 12-20 years, consecutively hospitalized for a manic or mixed episode. Socio-demographic and clinical data were extracted by reviewing patients' charts. We used a multivariate analysis to evaluate short-term outcome predictors.

RESULTS

The sample was characterized by severe impairment, high rates of psychotic features (N = 50, 62.5%), a long duration of stay (mean 80.4 days), and an overall good improvement (86% very much or much improved). Thirty-three (41.3 %) patients had a history of depressive episodes, 13 (16.3%) had manic or brief psychotic episodes but only 3 (3.7%) had a history of attention deficit/hyperactivity disorders. More manic episodes than mixed episodes were identified in subjects with mental retardation (MR) and in subjects from migrant and/or low socio-economic families. Overall severity and female gender predicted better improvement in GAF scores. Poor insight and the existence of psychotic features predicted longer duration of stay.

CONCLUSION

These results suggest that severe manic and mixed episodes in adolescents with BD-I need prolonged inpatient care to improve and that socio-cultural factors and MR should be examined more closely in youth with BD.

Quality of life in pediatric bipolar disorder

OBJECTIVE

Bipolar disorder is a common mood disorder associated with significant disability and impairment in quality of life in adults. Little research has examined the impact of the disorder on quality of life in children and adolescents. The current study examines the quality of life in children and adolescents with bipolar disorder compared with other physical and psychiatric illnesses.

METHODS

This study included 529 youth and caregiver pairs who sought services at a community mental health center or an academic medical center. Diagnoses were based on semistructured interviews of caregivers and youths, and quality of life was determined by the parent-reported Revised Children Quality of Life Questioinnaire (KINDL) questionnaire and compared with published benchmarks for many medical illnesses.

RESULTS

Mean age of the youths was 12.0 years, 57% were boys, 72% were black, 22% were white, and 17% had received bipolar disorder diagnoses. Youths with bipolar disorder had significantly lower quality-of-life scores than youths with asthma, atopic dermatitis, obesity, arthritis, oxygen dependence, heart surgery during infancy, depression, behavior disorders, and nonmood and nonbehavior psychiatric diagnoses.

CONCLUSIONS

Youths with bipolar disorder reported lower quality of life than other youths encountered in pediatric practice. Pediatricians should attend not only to the child's mood symptoms but also to the overall impairment of the disorder.

Assessment and diagnostic issues in pediatric bipolar disorder

The purpose of this article is to provide clinicians with detailed information on pediatric bipolar disorder (PBD) in children and adolescents to aid in the accurate assessment and diagnosis of the disorder. PBD is a complex condition that presents with a wide array of features, making it a difficult disorder to diagnose and treat. The debilitating nature of PBD makes it necessary for clinicians to address the disorder as early as possible to help ensure positive outcomes. The assessment and diagnostic process is an integral step toward determining appropriate treatment interventions. This article presents an overview of the assessment and diagnostic process, including diagnostic criteria, epidemiology, comorbidities, differential diagnoses, and risk factors. The distinctive childhood features of PBD and the diagnostic controversies are also addressed.

Bipolar disorder--methodological problems and future perspectives

Since its “rebirth” in 1966, bipolar disorder (BPD) has rapidly come to occupy a central position in the research and treatment of mood disorders. Compared with major depressive disorder (MDD), BPD is a more serious condition, characterized by much more frequent recurrence, more complex comorbidity, and higher mortality. One major problem is the lack of valid definitions in adult and in child psychiatry; the current definitions are unsatisfactory, and heavily favor an overdiagnosis of MDD. Biological research is partially based on those definitions, which have a short half-life. An additional, dimensional, approach, quantifying hypomania, depression, and anxiety by self-assessment and symptom checklists is recommended, A further, related problem is the early recognition of the onset of BPD, especially in adolescence, and the identification of correlates in childhood. Early and timely diagnosis of BPD is necessary to enable prompt intervention and secondary prevention of the disorder. The paper describes the current status and future directions of developing clinical concepts of bipolarity

Multiple episodes in children and adolescents with bipolar disorder: comorbidity, hospitalization, and treatment (data from a cohort of 8,129 patients of a national managed care database)

OBJECTIVE

The purpose of this study was to delineate the prevalence, demographic characteristics, comorbidity, hospitalization, and medication use of a large cohort of patients with and without multiple episodes per year. We hypothesized that children and adolescents with multiple episodes per year would have a higher comorbidity and require more hospitalizations and pharmacological treatment than their counterparts without multiple episodes.

METHODS

Analysis was conducted on a cohort of 8,129 children and adolescents patients (< or = 18 y.o.) with bipolar disorders (BD), from the Integrated Healthcare Information Services (IHCIS) identified from June 30, 2000 to July 1, 2003. Demographics variables, type of hospitalization, and psychotropic medication used in the year of follow-up were compared between children and adolescents with multiple and those without multiple episodes per year.

RESULTS

Included were 58 patients with multiple episodes (defined as: > or = 4 or more reports of inpatient treatment for any affective disorders per year) and 8,071 without multiple episodes. Children and adolescents with multiple episodes versus those without multiple episodes were differentiated as follows: more comorbid attention deficit disorder (ADD) (80.9% versus 29.4%) (chi2 = 70.61, df = 1, p < 0.0001); higher rate of hospital admission for depression (12.1% vs. 1.8%, chi2 = 27.86, df = 1, p < 0.0001); for other psychiatric conditions (48.3% vs. 11.2, chi2 = 74.47, df = 1, p < 0.0001) and for medical conditions (22.4% vs. 3.9%, chi2 = 46.26, df = 1, p < 0.0001). Patients with multiple episodes per year were more likely than those without multiple episodes to be given mood stabilizers (91.4% vs. 60.3%, chi2 = 22.02, df = 1, p < 0.0001), antidepressants (79.3% vs. 59.2%, chi2 = 8.82, df = 1, p = .0003), and antipsychotics (89.7% vs. 45.8%, chi2 = 42.91, df = 1, p < 0.0001). The use of stimulants did not differ between the two groups (24.1% vs. 23.0%), chi2 = 0.02, df = 1, p = 0.96).

CONCLUSIONS

Our findings support previous studies demonstrating that children and adolescents with multiple episodes per year present a higher comorbidity and require more hospitalizations and pharmacological treatment than those without multiple episodes. The diagnosis and treatment of children and adolescents with BD will have to take into account the high comorbidity of ADD mainly in children and adolescents with multiple episodes. Future prospective studies will help to better characterize the impact of multiple episodes in the course of pediatric BD and facilitate appropriate treatment strategies.

Rapid switching of mood in families with familial bipolar disorder

OBJECTIVE

Rapid switching of moods in bipolar disorder has been associated with early age at onset, panic comorbidity, and suicidality. This study aims to confirm these associations and investigate other potential correlates of rapid switching of mood using families from a multisite bipolar linkage study.

METHODS

The subjects were comprised of 1,143 probands and relatives with diagnosis of bipolar disorder. All subjects were interviewed directly with a standard diagnostic instrument, and all subjects who met criteria for bipolar disorder were asked if their moods had ever switched rapidly.

RESULTS

Individuals with rapid mood switching had significantly earlier age at onset (18 versus 21 years, p < 0.00001), higher comorbid anxiety (47% versus 26%, p < 0.00001) and substance use disorders (52% versus 42%, p = 0.0006), higher rate of violent behavior (6% versus 3%, p < 0.004), suicidal behavior (46% versus 31%, p < 0.00001), and nonsuicidal self-harm (13% versus 6%, p < 0.0002). Multiple logistic regression analysis found significant net effects on rapid mood switching for early emergence of symptoms [odds ratio (OR) = 0.62; 95% confidence interval (CI): 0.45-0.85]; anxiety comorbidity (OR = 2.31; 95% CI: 1.34-3.98); and hypersensitivity to antidepressants (OR = 2.05; 95% CI: 1.49-2.83) as the strongest predictors.

CONCLUSIONS

This confirms earlier reports associating rapid switching with a more complex clinical course, in particular early emergence of bipolar symptomatology, antidepressant activation, and anxiety comorbidity. These results support a clinical differentiation of bipolar disorder into subtypes based on symptom stability.

Further evidence of an association between adolescent bipolar disorder with smoking and substance use disorders: a controlled study

Although previous work suggests that juvenile onset bipolar disorder increases risk for substance use disorders and cigarette smoking, the literature on the subject is limited. We evaluated the association of risk for substance use disorders and cigarette smoking with bipolar disorder in adolescents in a case-control study of adolescents with bipolar disorder (n=105, age 13.6+/-2.5 years [mean]; 70% male) and without bipolar disorder ("controls"; n=98, age 13.7+/-2.1 years; 60% male). Rates of substance use and other disorders were assessed with structured interviews (KSADS-E for subjects younger than 18, SCID for 18-year-old subjects). Bipolar disorder was associated with a significant age-adjusted risk for any substance use disorder (hazard ratio[95% confidence interval]=8.68[3.02 25.0], chi(2)=16.06, p<0.001, df=1), alcohol abuse (7.66 [2.20 26.7], chi(2)=10.2, p=0.001, df=1), drug abuse (18.5 [2.46 139.10], chi(2)=8.03, p=0.005, df=1) and dependence (12.1 [1.54 95.50], chi(2)=5.61, p=0.02, df=1), and cigarette smoking (12.3 [2.83 53.69], chi(2)=11.2, p<0.001, df=1), independently of attention deficit/hyperactivity disorder, multiple anxiety, and conduct disorder (CD). The primary predictor of substance use disorders in bipolar youth was older age (BPD-SUD versus BPD+SUD, logistic regression: chi(2)=89.37, p<0.001). Adolescent bipolar disorder is a significant risk factor for substance use disorders and cigarette smoking, independent of psychiatric comorbidity. Clinicians should carefully screen adolescents with bipolar disorder for substance and cigarette use.

Pediatric Bipolar Disorder

In the past decade, interest in and research on pediatric bipolar disorder (BD) has increased substantially. Prevalence rates of the disorder have doubled in outpatient settings, while twice as many research articles on pediatric BD were published in the past five years as in the prior decade. This review focuses on recent developments in the study of pediatric BD. We examine current research on the diagnostic boundaries of BD in youths, in particular the issues of episodicity and irritability, and provide assessment guidelines. We review data elucidating the pathophysiology of pediatric BD, with a focus on how these results may inform diagnosis. Finally, we discuss treatment approaches for pediatric BD, particularly psychotherapeutic interventions. Throughout the review, we pay particular attention to youths with severe chronic irritability, hyperarousal, and hyperreactivity, who reflect the population in whom the diagnosis of BD is most debated.