Biological risk factors in pediatric bipolar disorder

The Manic Idea Creator? A Review and Meta-Analysis of the Relationship between Bipolar Disorder and Creative Cognitive Potential

Even though a relationship between psychopathology and creativity has been postulated since the time of ancient Greece, systematic meta-analyses on this topic are still scarce. Thus, the meta-analysis described here can be considered the first to date that specifically focuses on the relationship between creative potential, as measured by divergent thinking, and bipolar disorder, as opposed to psychopathology in general. An extensive literature search of 4670 screened hits identified 13 suitable studies, including a total of 42 effect sizes and 1857 participants. The random-effects model showed an overall significant, positive, yet diminutively small effect (d = 0.11, 95% CI: [0.002, 0.209], p = 0.045) between divergent thinking and bipolar disorder. A handful of moderators were examined, which revealed a significant moderating effect for bipolar status, as either euthymic (d = 0.14, p = 0.043), subclinical (d = 0.17, p = 0.001), manic (d = 0.25, p = 0.097), or depressed (d = -0.51, p < 0.001). However, moderator analyses should be treated with caution because of the observed confounding of moderators. Finally, none of the employed methods for publication-bias detection revealed any evidence for publication bias. We discuss further results, especially regarding the differences between subclinical and clinical samples.

Pediatric Bipolar Disorder: A Practical Guide for Clinicians

Pediatric bipolar disorder (PBD) is a controversial clinical entity and it still needs to be satisfactorily defined. Having a polymorphous presentation and associated with numerous symptoms of comorbid psychiatric illnesses often diagnosed during childhood and adolescence, including attention deficit hyperactivity disorder, its symptoms do not completely parallel those of bipolar disorder in adults. The clinician must be able to reach a diagnosis of PBD in the presence of fluctuating and atypical symptoms, especially in children, who tend to experience mixed episodes and very rapid cycles. Historically a key symptom for diagnosing PBD is episodic irritability. Proper diagnosis is critical due to the gravity of its prognosis. Clinicians may find supporting evidence for a diagnosis through careful study of the medical and developmental history of the young patient in addition to psychometric data. Treatment prioritizes psychotherapeutic intervention and assigns important roles to family involvement and a healthy lifestyle.

Early-onset bipolar disorder, stress, and coping responses of mothers: A comparative study

BACKGROUND

Providing care and nurturance to a child with bipolar disorder (BPAD) is a challenging task for parents, especially mothers. In Indian contexts, mothers are the primary caregivers of ailing children and they have to keep intrafamily situation stable, which makes their role more stressful.

OBJECTIVES

The objective of the study was to assess maternal stress and coping in mothers of adolescents with BPAD.

MATERIALS AND METHODS

This study was a comparative one and carried out on sixty mothers of adolescents; of which thirty were adolescents with BPAD, and the remaining thirty were the mothers of normal adolescents. The participants were selected purposively as per the mothers' age and education level, and the socioeconomic status of the families they belong to. Sociodemographic and clinical data sheet, Parenting Stress Index/Short Form (PSI/SF), and Brief COPE were applied on the mothers for data collection.

RESULTS

Mothers' of the BPAD adolescents reported higher scores in the both PSI/SF and Brief COPE.

CONCLUSION

Mothers of the adolescents with BPAD tend to perceive high level of stress and they also use maladaptive coping more in dealing with stressful situations.

Concordance between maternal recall of birth complications and data from obstetrical records

BACKGROUND

Prenatal complications are associated with poor outcomes in the offspring. Access to medical records is limited in the United States and investigators often rely on maternal report of prenatal complications.

STUDY DESIGN AND AIMS

We tested concordance between maternal recall and birth records in a community-based sample of mothers participating in a longitudinal study in order to determine the accuracy of maternal recall of perinatal complications.

SUBJECTS

Participants were 151 biological mothers, who were interviewed about gestational age at birth, birthweight, and the most commonly occurring birth complications: nuchal cord and meconium aspiration when the female child was on average 6years old, and for whom birth records were obtained.

OUTCOME MEASURES

Concordance between reports was assessed using one-way random intra-class coefficients for continuous measures and kappa coefficients for dichotomous outcomes. Associations between maternal demographic and psychological factors and discrepancies also were tested.

RESULTS

Concordance was excellent for continuously measured birthweight (ICC=0.85, p<0.001) and good for gestational age (ICC=0.68, p<0.001). Agreement was good for low birthweight (<2500g) (kappa=0.67, p<0.001), fair for preterm delivery (<37weeks gestation) (kappa=0.44, p<0.001), and poor for nuchal cord or meconium aspiration. Most discrepancies were characterized by presence according to birth record and absence according to maternal recall. Receipt of public assistance was associated with a decrease in discrepancy in report of nuchal cord.

CONCLUSIONS

Concordance between maternal retrospective report and medical birth records varies across different types of perinatal events. There was little evidence that demographic or psychological factors increased the risk of discrepancies. Maternal recall based on continuous measures of perinatal factors may yield more valid data than dichotomous outcomes.

Interaction between BDNF rs6265 Met allele and low family cohesion is associated with smaller left hippocampal volume in pediatric bipolar disorder

BACKGROUND

Genetic and environmental factors are implicated in the onset and evolution of pediatric bipolar disorder, and may be associated to structural brain abnormalities. The aim of our study was to assess the impact of the interaction between the Brain-Derived Neurotrophic Factor (BDNF) rs6265 polymorphism and family functioning on hippocampal volumes of children and adolescents with bipolar disorder, and typically-developing controls.

METHODS

We evaluated the family functioning cohesion subscale using the Family Environment Scale-Revised, genotyped the BDNF rs6265 polymorphism, and performed structural brain imaging in 29 children and adolescents with bipolar disorder, and 22 healthy controls.

RESULTS

We did not find significant differences between patients with BD or controls in left or right hippocampus volume (p=0.44, and p=0.71, respectively). However, we detected a significant interaction between low scores on the cohesion subscale and the presence of the Met allele at BNDF on left hippocampal volume of patients with bipolar disorder (F=3.4, p=0.043). None of the factors independently (BDNF Val66Met, cohesion scores) was significantly associated with hippocampal volume differences.

LIMITATIONS

small sample size, cross-sectional study.

CONCLUSIONS

These results may lead to a better understanding of the impact of the interaction between genes and environment factors on brain structures associated to bipolar disorder and its manifestations.

Neurodevelopmental origins of bipolar disorder: iPSC models

Bipolar disorder (BP) is a chronic neuropsychiatric condition characterized by pathological fluctuations in mood from mania to depression. Adoption, twin and family studies have consistently identified a significant hereditary component to BP, yet there is no clear genetic event or consistent neuropathology. BP has been suggested to have a developmental origin, although this hypothesis has been difficult to test since there are no viable neurons or glial cells to analyze, and research has relied largely on postmortem brain, behavioral and imaging studies, or has examined proxy tissues including saliva, olfactory epithelium and blood cells. Neurodevelopmental factors, particularly pathways related to nervous system development, cell migration, extracellular matrix, H3K4 methylation, and calcium signaling have been identified in large gene expression and GWAS studies as altered in BP. Recent advances in stem cell biology, particularly the ability to reprogram adult somatic tissues to a pluripotent state, now make it possible to interrogate these pathways in viable cell models. A number of induced pluripotent stem cell (iPSC) lines from BP patient and healthy control (C) individuals have been derived in several laboratories, and their ability to form cortical neurons examined. Early studies suggest differences in activity, calcium signaling, blocks to neuronal differentiation, and changes in neuronal, and possibly glial, lineage specification. Initial observations suggest that differentiation of BP patient-derived neurons to dorsal telencephalic derivatives may be impaired, possibly due to alterations in WNT, Hedgehog or Nodal pathway signaling. These investigations strongly support a developmental contribution to BP and identify novel pathways, mechanisms and opportunities for improved treatments.

Instruments that prospectively predict bipolar disorder - A systematic review

BACKGROUND

Identification of earlier stages of Bipolar Disorder (BD), even prior to the first manic episode, may help develop interventions to prevent or delay the onset of BD. However, reliable and valid instruments are necessary to ascertain such earlier stages of BD. The aim of the current review was to identify instruments that had predictive validity and utility for BD for use in early intervention (EI) settings for the prevention of BD.

METHODS

We undertook a systematic examination of studies that examined participants without BD I or II at baseline and prospectively explored the predictive abilities of instruments for BD onset over a period of 6 months or more. The instruments and the studies were rated with respect to their relative validity and utility predicting onset of BD for prevention or early intervention. Odds ratios and area under the curve (AUC) values were derived when not reported.

RESULTS

Six studies were included, identifying five instruments that examined sub-threshold symptoms, family history, temperament and behavioral regulation. Though none of the identified instruments had been examined in high-quality replicated studies for predicting BD, two instruments, namely the Child Behavioral Checklist - Pediatric BD phenotype (CBCL-PBD) and the General Behavioral Inventory - Revised (GBI-R), had greater levels of validity and utility.

LIMITATION

Non-inclusion of studies and instruments that incidentally identified BD on follow-up limited the breadth of the review.

CONCLUSION

Instruments that test domains such as subthreshold symptoms, behavioral regulation, family history, and temperament hold promise in predicting BD onset.

Finnish Prenatal Study of Bipolar Disorders (FIPS-B): overview, design and description of the sample

BACKGROUND

Bipolar disorders (BPD) are chronic mental illnesses, the development of which involves genetic factors and environmental influences.

AIMS

The aim of this paper is to provide an overall description of the Finnish Prenatal Study of Bipolar Disorders (FIPS-B), including the study design, national registers and linkage of the registers.

METHODS

FIPS-B is a population-based prenatal epidemiological study of BPD with a nested case-control study design using several national registers. The registers used are: the Finnish Medical Birth Register (FMBR), the Finnish Hospital Discharge Register (FHDR), the Population Central Register and the Finnish Maternity Cohort (FMC), which are linked using the unique personal identity code (PIC). FIPS-B includes all children born from January 1, 1983 to December 31, 1998 and diagnosed with BPD in Finland by December 31, 2008.

RESULTS

The total number of cases included in the FIPS-B is 1887. The age at first diagnosis ranged from 4 to 25 years. Half (50.4%) of the cases utilized only outpatient services, 12.7% only inpatient services and the rest (36.9%) utilized both services. Offspring of mothers with the lowest educational level had an increased odds of BPD (OR = 1.46, 95% CI 1.13-1.88). The cumulative incidence of BPD in the population aged 25 years or younger was 11.6/10,000 in 2008.

CONCLUSIONS

FIPS-B has all the strengths of a register-based prenatal epidemiological study, along with the availability of maternal biomarkers, enabling it to examine several prenatal, perinatal and familial risk factors for BPD.

Family history of a mood disorder indicates a more severe bipolar disorder

BACKGROUND

In the clinical setting, patients with bipolar disorder (BD) are often asked about potential family history (FH) of mood disorders. The aim of the present study was to examine differences between BD patients with FH of a mood disorder, and those without, on clinical, personality and social functioning characteristics, as well as on the symptomatic course of the disorder.

METHODS

Data was collected from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). For this report, we included 2600 patients, 1963 of those reported having a first-degree family member with a mood disorder, and 637 reported of no such FH. We investigated the impact of FH on socio-demographic, clinical, personality and quality of life variables, as well as on symptomatology during the first year of treatment.

RESULTS

Patients reporting FH of a mood disorder had an earlier age at onset of depression/mania, more phases, rapid cycling and more suicide attempts. Across different assessments, patients with FH showed consistently elevated depressive symptoms, such as lower concentration and energy, higher suicidal ideation, as well as increased racing thoughts and distractibility within the manic spectrum of symptoms. Further, the FH group had lower quality of life, higher neuroticism and higher personality disorder scores compared to patients without FH.

LIMITATIONS

Information on FH was obtained through the proband.

CONCLUSIONS

Overall, BD patients reporting FH of a mood disorder showed a worse clinical profile upon presentation for treatment and a more symptomatic course of the disorder.

Dimensional psychopathology in preschool offspring of parents with bipolar disorder

BACKGROUND

The purpose of this study is to compare the dimensional psychopathology, as ascertained by parental report, in preschool offspring of parents with bipolar disorder (BP) and offspring of community control parents.

METHODS

122 preschool offspring (mean age 3.3 years) of 84 parents with BP, with 102 offspring of 65 control parents (36 healthy, 29 with non-BP psychopathology), were evaluated using the Child Behavior Checklist (CBCL), the CBCL-Dysregulation Profile (CBCL-DP), the Early Childhood Inventory (ECI-4), and the Emotionality Activity Sociability (EAS) survey. Teachers' Report Forms (TRF) were available for 51 preschoolers.

RESULTS

After adjusting for confounders, offspring of parents with BP showed higher scores in the CBCL total, externalizing, somatic, sleep, aggressive, and CBCL-DP subscales; the ECI-4 sleep problem scale; and the EAS total and emotionality scale. The proportion of offspring with CBCL T-scores ≥ 2 SD above the norm was significantly higher on most CBCL subscales and the CBCL-DP in offspring of parents with BP compared to offspring of controls even after excluding offspring with attention deficit hyperactivity disorder and/or oppositional defiant disorder. Compared to offspring of parents with BP-I, offspring of parents with BP-II showed significantly higher scores in total and most CBCL subscales, the ECI-4 anxiety and sleep scales and the EAS emotionality scale. For both groups of parents, there were significant correlations between CBCL and TRF scores (r = .32-.38, p-values ≤.02).

CONCLUSIONS

Independent of categorical axis-I psychopathology and other demographic or clinical factors in both biological parents, preschool offspring of parents with BP have significantly greater aggression, mood dysregulation, sleep disturbances, and somatic complaints compared to offspring of control parents. Interventions to target these symptoms are warranted.

Influence of family history of major depression, bipolar disorder, and suicide on clinical features in patients with major depression and bipolar disorder

The extent to which a family history of mood disorders and suicide could impact on clinical features of patients suffering from major depression (MD) and bipolar disorder (BD) has received relatively little attention so far. The aim of the present work is, therefore, to assess the clinical implications of the presence of at least one first- and/or second-degree relative with a history of MD, BD and suicide in a large sample of patients with MD or BD. One thousand one hundred and fifty-seven subjects with MD and 686 subjects with BD were recruited within the context of two large projects. The impact of a family history of MD, BD, and suicide-considered both separately and together-on clinical and socio-demographic variables was investigated. A family history of MD, BD, and suicide was more common in BD patients than in MD patients. A positive family history of mood disorders and/or suicide as well as a positive family history of MD and BD separately considered, but not a positive history of suicide alone, were significantly associated with a comorbidity with several anxiety disorders and inversely associated with age of onset. The clinical implications as well as the limitations of our findings are discussed.

Are obstetrical, perinatal, and infantile difficulties associated with pediatric bipolar disorder?

OBJECTIVES

Despite increasing acknowledgement of bipolar disorder (BD) in childhood, there is a paucity of literature that has investigated obstetrical, perinatal, and infantile difficulties and their potential link with BD. To this end, we examined difficulties during delivery, immediate post-birth, and infancy and the association with BD in childhood.

METHODS

From two similarly designed, ongoing, longitudinal, case-control family studies of pediatric BD (N = 327 families), we analyzed 338 children and adolescents [mean (± standard deviation) age: 12.00 ± 3.37 years]. We stratified them into three groups: healthy controls (N = 98), BD probands (N = 120), and their non-affected siblings (N = 120). All families were comprehensively assessed with a structured psychiatric diagnostic interview for psychopathology and substance use. Mothers were directly questioned regarding the pregnancy, delivery, and infancy difficulties that occurred with each child using a module from the Diagnostic Interview for Children and Adolescents-Parent Version (DICA-P).

RESULTS

Mothers of BD subjects were more likely to report difficulties during infancy than mothers of controls [odds ratio (95% confidence interval) = 6.6 (3.0, 14.6)]. Specifically, children with BD were more likely to have been reported as a stiffened infant [7.2 (1.1, 47.1)] and more likely to have experienced 'other' infantile difficulties [including acting colicky; 4.9 (1.3, 18.8)] compared to controls. We found no significant differences between groups in regards to obstetrical or perinatal difficulties (all p values > 0.05).

CONCLUSIONS

While our results add to previous literature on obstetrical and perinatal difficulties and BD, they also highlight characteristics in infancy that may be prognostic indicators for pediatric BD.

Psychosocial treatments for childhood and adolescent bipolar disorder

Adjunctive psychosocial interventions are increasingly recognized as an important aspect of comprehensive treatment for bipolar disorder (BPD) in childhood and adolescence. Research in this area is relatively new, but psychosocial interventions being developed and tested include: multi-family psychoeducation groups for school-aged children with either BPD or depressive disorders; family-focused treatment, dialectical behavior therapy, and interpersonal and social rhythm therapy for adolescents with BPD; and child and family-focused cognitive-behavioral therapy for school-aged children with BPD. Preliminary evidence, where available, indicates that these interventions are feasible, well-received by families, and associated with positive outcomes. The continued study of adjunctive psychosocial interventions will help identify critical treatment ingredients that target specific areas of functioning and enhance overall treatment effectiveness for children and adolescents with BPD and their families.

AACAP 2006 Research Forum--Advancing research in early-onset bipolar disorder: barriers and suggestions

OBJECTIVE

The 2006 Research Forum addressed the goal of formulating a research agenda for early-onset bipolar disorder (EOBP) and improving outcome by understanding the risk and protective factors that contribute to its severity and chronicity.

METHOD

Five work groups outlined barriers and research gaps in EOBP genetics, neuroimaging, prodromes, psychosocial factors, and pharmacotherapy.

RESULTS

There was agreement that the lack of consensus on the definition and diagnosis of EOBP is the primary barrier to advancing research in BP in children and adolescents. Related issues included: the difficulties in managing co-morbidity both statistically and clinically; acquiring adequate sample sizes to study the genetics, biology, and treatment; understanding the EOBP's developmental aspects; and identifying environmental mediators and moderators of risk and protection. Similarly, both psychosocial and medication treatment strategies for children with BP are hamstrung by diagnostic issues. To advance the research in EOBP, both training and funding mechanisms need to be developed with these issues in mind.

CONCLUSIONS

EOBP constitutes a significant public health concern. Barriers are significant but identifiable and thus are not insurmountable. To advance the understanding of EOBP, the field must be committed to resolving diagnostic and assessment issues. Once achieved, with adequate personnel and funding resources, research into the field of EOBP will doubtless be advanced at a rapid pace.

Bipolar and major depressive disorder: neuroimaging the developmental-degenerative divide

Both major depressive disorder and bipolar disorder are the subject of a voluminous imaging and genetics literature. Here, we attempt a comprehensive review of MRI and metabolic PET studies conducted to date on these two disorders, and interpret our findings from the perspective of developmental and degenerative models of illness. Elevated activity and volume loss of the hippocampus, orbital and ventral prefrontal cortex are recurrent themes in the literature. In contrast, dorsal aspects of the PFC tend to display hypometabolism. Ventriculomegaly and white matter hyperintensities are intimately associated with depression in elderly populations and likely have a vascular origin. Important confounding influences are medication, phenotypic and genetic heterogeneity, and technological limitations. We suggest that environmental stress and genetic risk variants interact with each other in a complex manner to alter neural circuitry and precipitate illness. Imaging genetic approaches hold out promise for advancing our understanding of affective illness.

The phenomenology of recurrent brief depression with and without hypomanic features

BACKGROUND

The nosologic status of recurrent brief depression (RBD) is debated. We studied the phenomenology of RBD in a clinical sample of outpatients.

METHODS

Forty patients (mean age 33; 73% females) and 21 age- and gender-matched mentally healthy controls were examined (clinical interview, M.I.N.I. neuropsychiatric interview, MADRS, Stanley Foundation Network Entry Questionnaire). Exclusion criteria were bipolar I or II disorders, a history of psychosis, concurrent major depressive episode, organic brain or personality disorders (clusters A and B).

RESULTS

The mean age of onset of RBD was 20 years with a mean of 14 episodes/year with brief (mean 3 days) severe depressive episodes. Nineteen (47%) reported additional short episodes of brief hypomania (>1 day duration; RBD-H) of which nine (23%) never had experienced a major depression. Twenty-one (53%) patients reported RBD only (RBD-O) with or without (n=12) past history of major depression or dysthymia. During the last depressive episode, 76% of the RBD-O and 90% of the RBD-H patients had a melancholic depression. Seventy-one % of the RBD-O and 79% of the RBD-H reported at least two out of three atypical symptoms. Nineteen (48%) of the patients reported anger attacks and panic disorder, the latter being more prevalent in the RBD-H subgroup (68% versus 29%, p=0.012).

LIMITATIONS

Cross-sectional study of self-referrals or patients referred by primary care physicians or psychiatrists.

CONCLUSIONS

The study supports the validity of RBD as a disorder separate from bipolar II, cyclothymia and recurrent major depression. A brief episode of hypomanic symptoms is a severity marker of RBD.

[Pharmacotherapy in bipolar disorders during childhood and adolescence]

OBJECTIVE

Bipolar disorders during childhood and adolescence are rare, but serious and highly recurrent disorders, often associated with negative outcome. Pharmacotherapy, including Lithium, other mood stabilizers and typical antipsychotic agents, is the first-line treatment in bipolar disorders and often necessary for many months or years.

METHOD

A computerized medline-search (Pubmed) was made for prospective studies and reviews of bipolar disorder in this age-group published during the last 10 years, which were then reviewed for their relevance.

RESULTS

Despite the widespread use of substances whose efficacy for adults is well-established, there is a substantial lack of empirical data regarding the efficacy and safety in the treatment of bipolar disorder in children and adolescents. Placebo-controlled studies are very rare, and the interpretation of the existing data is complicated by the diagnostic controversy about bipolar disorder in children. Side-effects are more common in children and adolescents than in adults.

CONCLUSIONS

Combination therapy may be favoured in cases of severe and psychotic bipolar disorder. Needed are more placebo-controlled studies and long-term studies on the efficacy and safety of mood stabilizers and atypical antipsychotic agents in the treatment of children and adolescents with bipolar disorder.

Parent-child interactions in pediatric bipolar disorder

Parent-child relationships may have a significant effect on illness characteristics of children with pediatric bipolar disorder (PBD), and these relationships may, in turn, be affected by the child's illness. We characterized maternal reports of parent-child relationships using the five-factor Parent-Child Relationship Questionnaire (PCRQ) in 60 families (30 PBD youth and 30 matched controls). Data on child proband and parental psychopathology were also obtained. Compared to controls, parent-child relationships in the PBD group were characterized by significantly less warmth, affection, and intimacy, and more quarreling and forceful punishment. Among PBD participants, elevated symptoms of mania, comorbid ADHD, an earlier age of illness onset, living in a single parent home, and the presence of a parental mood disorder were associated with greater parent-child relationship difficulties. These findings have implications for the development of interventions that focus on the quality of parent-child relationships, in addition to symptom management, in the treatment of PBD.

Comparing the psychometric properties of multiple teacher report instruments as predictors of bipolar disorder in children and adolescents

The psychometric properties of four teacher report measures and their utility for accurate diagnosis of pediatric bipolar spectrum disorders (BPSDs) were examined. Participants were 191 youth (65% male; 62% African-American; 23% diagnosed with a BPSD), age 5-18 (M=10.16, SD=3.27) years, 70% recruited from a community mental health center and 30% recruited from a mood disorders clinic. Teachers "who knew the child best" were asked to complete the Achenbach Teacher Report Form (TRF) as well as teacher versions of the General Behavior Inventory (T-GBI), the Child Mania Rating Scale (CMRS-T), and the Young Mania Rating Scale (T-YMRS). Teacher response rates and missing data varied significantly depending on the age of the child. Exploratory factor analysis identified stable and interpretable factors; however, receiver operating characteristic (ROC) and logistic regression analyses showed that teacher report measures were not able to discriminate BPSD cases from non-BPSD cases, or from attention deficit hyperactivity disorder (ADHD) cases. Teacher report appears to be insufficiently specific or sensitive to BPSD for clinical diagnostic use, although teacher scales might have research utility.

Frontiers between attention deficit hyperactivity disorder and bipolar disorder

The co-occurrence of attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received much recent attention in the literature. The authors review the literature examining associations between ADHD and bipolar disorder in children, and data concerning severe irritability in youth with ADHD. This article focuses on (1) population-based studies examining ADHD and bipolar disorder or ADHD and co-occurring irritability, (2) the co-occurrence and prospective relationships of ADHD and bipolar disorder in clinical samples, (3) phenomenology and assessment of bipolar disorder and ADHD, (4) treatment of comorbid ADHD and bipolar disorder, (5) family and genetic studies of ADHD and bipolar disorder, and (6) pathophysiologic comparisons between children with ADHD and irritability and bipolar disorder. We draw on the research to make clinical recommendations and highlight important directions for future research.