Manic symptoms in youth: dimensions, latent classes, and associations with parental psychopathology

A systematic review and network meta-analysis on comparative efficacy, acceptability, and safety of treatments in acute bipolar mania in youths

BACKGROUND

The evidence of treatment options' efficacy on acute bipolar manic episodes is relatively less in youths than adults. We aimed to compare and rank the drug's efficacy, acceptability, tolerability, and safety for acute mania in children and adolescents.

METHOD

We systematically reviewed the double-blinded, randomized controlled trials (RCTs) comparing drugs or placebo for acute manic episodes of bipolar disorder in children and adolescents using PRISMA guidelines. We searched PubMed/MEDLINE, EMBASE, Web of Science, EBSCO, Scopus, the Cochrane Central Register of Controlled Trials, and https://clinicaltrials.gov from inception until November 20, 2022. Response to treatment was the primary outcome, and random-effects network meta-analyses were conducted (PROSPERO 2022: CRD42022367455).

RESULTS

Of 10,134 citations, we included 15 RCTs, including 2372 patients (47 % female), 15 psychotropic drugs, and the placebo. Risperidone 0.5-2.5 mg/day, aripiprazole 30 mg/day olanzapine, quetiapine 400 mg/day, quetiapine 600 mg/day, asenapine 5 mg/day, asenapine 10 mg, ziprasidone, and aripiprazole 10 mg were found to be effective (in comparison with placebo) in children and adolescents, respectively (τ2 = 0.0072, I2 = 10.2 %). The tolerability of aripiprazole 30 mg/day was lower than risperidone 0.5-2.5 mg/day and olanzapine. Oxcarbazepine had the highest discontinuation due to the adverse effects risk ratio.

LIMITATIONS

Efficacy ranking of the treatments could be performed by evaluating relatively few RCT results, and only monotherapies were considered.

CONCLUSIONS

Efficacy, acceptability, tolerability, and safety are changing with the doses of antipsychotics for children and adolescents with acute bipolar manic episodes. Drug selection and optimum dosage should be carefully adjusted in children and adolescents.

The diagnosis of bipolar disorder in children and adolescents: Past, present and future

AIMS

This article examines the ongoing debate concerning the diagnosis of bipolar disorder in children and adolescents. This contentious issue has generated robust discussion over the past two decades without consensus, and as such the true prevalence of so-called paediatric bipolar disorder (PBD) remains unknown. In this article we offer a solution to break this deadlock.

METHODS

Recent meta-analyses and additional literature concerning the definition and prevalence of PBD was critically reviewed with a view to understanding the perspectives of those developing the taxonomy of PBD, and those engaged in research and clinical practice.

RESULTS

A key finding is the lack of iteration and meaningful communication between the various groups interested in PBD that stems from deep-seated problems within our classificatory systems. This undermines our research efforts and complicates clinical practice. These problems make the already difficult diagnosis of bipolar disorder in adults even more challenging to transpose to younger populations, and additional complexities arise when parsing clinical phenomenology from normative developmental changes in youth. Therefore, in those manifesting bipolar symptoms post-puberty, we argue for the use of adolescent bipolar disorder to describe bipolar symptoms whereas in pre-pubertal children, we propose a reconceptualisation that allows symptomatic treatment to be advanced whilst requiring critical review of these symptoms over time.

CONCLUSION

Significant changes in our current taxonomy are necessary and to be clinically meaningful, these revisions to our diagnoses need to be developmentally-informed.

'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.

A Latent Class Analysis of Manic and Psychotic Symptoms

Bipolar spectrum disorders encompass heterogeneous clinical manifestations and comorbidities. A latent class analysis (LCA) was performed in 1846 subjects who experienced an episode of abnormally elevated or irritable mood to identify homogeneous groups of subjects, based on the distribution of 11 manic and 7 psychotic symptoms. LCA identified five classes: 1) two classes with irritability and with low and high level of psychosis (respectively "irritable," 29.1% of the sample, and "irritable-psychotic," 16.2%); 2) a class with expansive mood and hyperactivity ("expansive-hyperactive," 12.7%); and 3) two classes with manic symptoms and high and low level of psychosis ("manic-psychotic," 15.0%, and "manic," 27.2%). "Irritable" displayed lower rates of depressive episode, panic, and substance use disorders. Manic-psychotic displayed higher rates of depressive episode, panic, generalized anxiety, and substance use disorders. Use of mental health treatment more frequent in manic-psychotic and manic classes. Five classes of bipolar spectrum disorders were characterized by different sociodemographic and clinical patterns.

Suicidal Behavior in Adolescents: A Latent Class Analysis

The main goal of the present study was to identify and validate latent classes of suicidal behavior in a representative sample of adolescents. The sample comprised a total of 1506 students, including 667 males (44.3%), selected through a sample stratified by clusters. The mean age was 16.15 years (SD = 1.36). The instruments used evaluated suicidal behavior, positive and negative affect, emotional and behavioral problems, prosocial behavior, and subjective well-being. Using the Paykel Suicide Scale, the latent class analysis identified four homogeneous subgroups: “low risk”, “suicidal act”, “suicidal ideation”, and “high risk for suicide”. These subgroups presented a differential pattern in terms of their social-emotional adjustment. The subgroups with the highest theoretical risk showed lower scores on subjective well-being and positive affect as well as higher scores on emotional and behavioral problems and negative affect compared to the non-risk subgroups. This study contributes to an understanding of the typologies of suicidal behavior among adolescents and the relationship with psychopathological adjustment. Ultimately, these findings may promote the development or improvement of early detection and prevention strategies in the suicidal behavior field in order to reduce the socio-economic burdens associated with suicide in young populations.

Network analysis of mood symptoms in adolescents with or at high risk for bipolar disorder

OBJECTIVES

Network analyses of psychopathology examine the relationships between individual symptoms in an attempt to establish the causal interactions between symptoms that may give rise to episodes of psychiatric disorders. We conducted a network analysis of mood symptoms in adolescents with or at risk for bipolar spectrum disorders.

METHODS

The sample consisted of 272 treatment-seeking adolescents with or at high risk for bipolar disorder who had at least subsyndromal depressive or (hypo)manic symptoms. Based on symptom scores assessed via semi-structured interviews, we constructed the network of depressive and manic symptoms and identified the most central symptoms and symptom communities within the network. We used bootstrapping analyses to determine the reliability of network parameters.

RESULTS

Symptoms within the depressive and manic mood poles were more related to each other than to symptoms of the opposing mood pole. Four communities were identified, including a depressive symptom community and three manic symptom communities. Fatigue and depressed mood were the strongest individual symptoms within the overall network (ie the most highly correlated with other symptoms), followed by motor hyperactivity. Mood lability and irritability were found to be "bridge" symptoms that connected the two mood poles.

CONCLUSIONS

Symptoms of activity/energy (ie fatigue and hyperactivity) and depressed mood are the most prominent mood symptoms among youth with bipolar spectrum disorders. Mood lability and irritability represent potential warning signs of emergent episodes of either polarity. Targeting these central and bridge symptoms would lead to more efficient assessments and therapeutic interventions for bipolar disorder.

Debate: Dimensions of mania in youth: possibly bipolar, probably risk indicators, certainly impairing

We comment on the utility of latent manic dimensions to elucidate the prevalence of youth Bipolar Disorder in epidemiological samples, irrespective of sample's cultural background or clinician's predetermined prototypical definitions of a bipolar case.

Debate: Looking forward: choose data over opinions to best serve youth with bipolar spectrum disorders - commentary on Parry et al. (2018)

Over the past two decades, research on pediatric bipolar disorder has grown geometrically. The diagnosis of pediatric bipolar disorder was met with enthusiasm, which in healthy doses catalyzed change, and skepticism, which in good measure pushes for rigor. Skepticism led to productive questions about the phenomenology of pediatric bipolar disorder and how best to diagnose and treat it. With regard to prevalence, key questions included whether it was increasing over time, and whether it was limited to the United States. In 2011, we published a meta-analysis addressing the prevalence questions; results indicated that bipolar disorder manifested at statistically indistinguishable rates in youth community samples across the world. In their recent paper, Parry et al. examine the studies included in the 2011 meta-analysis using a qualitative approach. Their opinion piece represents a step backwards; every study has shortcomings, but in focusing on a dozen individual studies, Parry et al. fail to take into account the preponderance of evidence - literally thousands of articles across countries, cohorts and methodologies - that support the existence of bipolar disorder in both prepubescent youth and adolescents. This commentary addresses misperceptions regarding the diagnosis of bipolar disorder in youth, particularly with regard to cross-informant agreement, to present converging data from international sources regarding the onset of bipolar disorder in childhood, and to correct the false claim that pediatric bipolar disorder is controversial. As clinicians and researchers, we have an obligation to do what we can to improve the lives of youth affected by mental illness. Denying the existence of a serious mood disorder will not serve the best interests of young people and will perpetuate the long delays many experience before getting an accurate diagnosis, appropriate treatment, and a fair chance at a good quality of life.

Debate: Pediatric bipolar disorder - divided by a common language?

The paediatric bipolar disorder (pBD) debate is seen as a prototypical transatlantic controversy. But this is a Eurocentric view that ignores just how big a country the United States is - it contains multitudes, to paraphrase Walt Whitman writing in the aftermath of the Civil War. Indeed, such are the multitudes that a child can receive a diagnosis of bipolar in one State, but not in a neighbouring one. It was the force of this intra-American division that swept over the Atlantic. As this has been the case for many other goods imported from the United States, the European high-brow response was that pBD was just a New World fad. This response was evidently wrong. Of course, there are young children who have full-blown manic and depressive episodes and who need treatment. And the bitter truth was (and continues to be in parts of the United Kingdom) that often such children are dismissed as having 'character pathology' and their families accused of all sorts of inadequacies. Clearly, here was an important problem hidden under layers of Old-World crustiness.

Debate: Bipolar disorder: extremely rare before puberty and antipsychotics cause serious harms - a commentary on Van Meter et al. (2019)

'Paediatric bipolar disorder' (PBD) remains controversial; because it is based on the hypothesis that bipolar disorder (BD) often begins in childhood with atypical forms of mania. A meta-analysis of 12 epidemiological surveys found a high prevalence of PBD among children and adolescents worldwide (1.8%), however, our study of the measurement issues (Child and Adolescent Mental Health, 23, 2018, 14) found that PBD rates were lower than claimed. Our findings are consistent with the developmental trajectory of BD, as described by most longitudinal studies of high-risk offspring. BD is extremely rare in childhood with nearly all index manic/hypomanic episodes being in midadolescence or later. Treatment for BD should not commence until the first well-defined manic/hypomanic episode, because children and younger adolescents are extremely sensitive to the side effects of second-generation antipsychotics including weight gain, metabolic syndrome, extrapyramidal side effects and the risk of cerebral atrophy, as observed in studies of juvenile animals.

Suicidal ideation and behavior in institutions of higher learning: A latent class analysis

Suicide is the second leading cause of death among undergraduate students, with an annual rate of 7.5 per 100,000. Suicidal behavior (SB) is complex and heterogeneous, which might be explained by there being multiple etiologies of SB. Data-driven identification of distinct at-risk subgroups among undergraduates would bolster this argument. We conducted a latent class analysis (LCA) on survey data from a large convenience sample of undergraduates to identify subgroups, and validated the resulting latent class model on a sample of graduate students. Data were collected through the Interactive Screening Program deployed by the American Foundation for Suicide Prevention. LCA identified 6 subgroups from the undergraduate sample (N = 5654). In the group with the most students reporting current suicidal thoughts (N = 623, 66% suicidal), 22.5% reported a prior suicide attempt, and 97.6% endorsed moderately severe or worse depressive symptoms. Notably, LCA identified a second at-risk group (N = 662, 27% suicidal), in which only 1.5% of respondents noted moderately severe or worse depressive symptoms. When graduate students (N = 1138) were classified using the model, a similar frequency distribution of groups was found. Finding multiple replicable groups at-risk for suicidal behavior, each with a distinct prevalence of risk factors, including a group of students who would not be classified as high risk with depression-based screening, is consistent with previous studies that identified multiple potential etiologies of SB.

The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research

OBJECTIVES

Over the past two decades, there has been tremendous growth in research regarding bipolar disorder (BD) among children and adolescents (ie, pediatric BD [PBD]). The primary purpose of this article is to distill the extant literature, dispel myths or exaggerated assertions in the field, and disseminate clinically relevant findings.

METHODS

An international group of experts completed a selective review of the literature, emphasizing areas of consensus, identifying limitations and gaps in the literature, and highlighting future directions to mitigate these gaps.

RESULTS

Substantial, and increasingly international, research has accumulated regarding the phenomenology, differential diagnosis, course, treatment, and neurobiology of PBD. Prior division around the role of irritability and of screening tools in diagnosis has largely abated. Gold-standard pharmacologic trials inform treatment of manic/mixed episodes, whereas fewer data address bipolar depression and maintenance/continuation treatment. Adjunctive psychosocial treatment provides a forum for psychoeducation and targets primarily depressive symptoms. Numerous neurocognitive and neuroimaging studies, and increasing peripheral biomarker studies, largely converge with prior findings from adults with BD.

CONCLUSIONS

As data have accumulated and controversy has dissipated, the field has moved past existential questions about PBD toward defining and pursuing pressing clinical and scientific priorities that remain. The overall body of evidence supports the position that perceptions about marked international (US vs elsewhere) and developmental (pediatric vs adult) differences have been overstated, although additional research on these topics is warranted. Traction toward improved outcomes will be supported by continued emphasis on pathophysiology and novel therapeutics.

A developmental approach to dimensional expression of psychopathology in child and adolescent offspring of parents with bipolar disorder

The aim of this is to describe psychopathology, functioning and symptom dimensions accounting for subthreshold manifestations and developmental status in child and adolescent offspring of parents with bipolar disorder ("high-risk offspring"). The study population comprised 90 high-risk offspring (HR-offspring) and 107 offspring of community control parents (CC-offspring). Direct clinical observations and parental and offspring reports based on selected standardized clinical scales were used to assess offspring threshold and subthreshold diagnoses, symptoms and functioning. All outcomes were compared between the whole HR-offspring and CC-offspring samples and then by developmental status. After controlling for potential confounders, HR-offspring showed significantly poorer adjustment for childhood (r = 0.18, p = 0.014) and adolescence (r = 0.21, p = 0.048) than CC-offspring, as well as more emotional problems (r = 0.24, p = 0.001) and higher depression scores (r = 0.16, p = 0.021). As for differences in lifetime categorical diagnoses (threshold and subthreshold) between HR-offspring and CC-offspring, the prevalence of disruptive disorders was higher in pre-pubertal HR-offspring (OR 12.78 [1.45-112.42]), while prevalence of mood disorders was higher in post-pubertal HR-offspring (OR 3.39 [1.14-10.06]). Post-pubertal HR-offspring presented more prodromal (r = 0.40, p = 0.001), negative (r = 0.38, p = 0.002), manic (r = 0.22, p = 0.035) and depressive (r = 0.23, p = 0.015) symptoms than pre-pubertal HR-offspring, as well as more peer relationship problems (r = 0.31, p = 0.004), poorer childhood adjustment (r = 0.22, p = 0.044) and worse current psychosocial functioning (r = 0.27, p = 0.04). Externalizing psychopathology is more prevalent in pre-pubertal HR-offspring, while depressive and prodromal symptoms leading to functional impairment are more prominent in post-pubertal HR-offspring. Developmental approaches and dimensional measures may be useful for identifying children at high risk of developing bipolar disorder and help guide specific preventive strategies.

The predictive value of childhood subthreshold manic symptoms for adolescent and adult psychiatric outcomes

BACKGROUND

Childhood subthreshold manic symptoms may represent a state of developmental vulnerability to Bipolar Disorder (BD) and may also be associated with other adverse psychiatric outcomes. To test this hypothesis we examined the structure and predictive value of childhood subthreshold manic symptoms for common psychiatric disorders presenting by early adulthood.

METHODS

Subthreshold manic symptoms at age 11 years and lifetime clinical outcomes by age 19 years were ascertained in the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective Dutch community cohort. We used latent class analysis to identify subthreshold manic symptom profiles at baseline. The association between class membership and subsequent clinical diagnoses of BD (comprising BD-I, BD-II, mania and hypomania), depressive, anxiety and substance abuse disorders was determined using Cox proportional-hazard ratio (HR) models.

RESULTS

At age 11 years, we identified a normative (n=916; 47%), a mildly symptomatic (n=843; 43%) and a highly symptomatic class (n=198; 10%). Referenced to the normative class, the sex- and age-adjusted risk of new-onset BD by the age of 19 years was significantly increased in the mildly (HR=2.01, 95%CI 1.13-3.59) and highly symptomatic classes (HR=5.02, 95%CI 2.48-10.16). These estimates remained significant after further adjustments for cognitive and family function, parental socioeconomic status, parental psychiatric morbidity, and comorbid disorders at baseline (p-value for linear trend across classes<0.01). Class membership did not show significant associations with incident depressive, anxiety and substance abuse disorders in the fully adjusted regression models.

LIMITATIONS

The period of risk for adult-onset BD extends beyond the observational period of the study.

CONCLUSIONS

Elevated childhood subthreshold manic symptoms are associated with increased risk of BD by early adulthood and are therefore a potentially useful phenotype for the early identification of at-risk individuals.

Distinct relationships between social aptitude and dimensions of manic-like symptoms in youth

Difficulties with interpersonal relationships have been reported in children and adolescents with manic symptoms, even if they do not fulfil criteria for a manic episode. The role of social aptitude (SA) in youths with manic symptoms has never been examined in the general population. Moreover, no study has examined whether SA is differentially associated with dimensions of manic symptoms. We hypothesised that youth with predominantly undercontrol manic symptoms (characterised by irritability) would show lower levels of SA; conversely, youth with predominantly exuberant symptoms would show better than average social skills. Our sample comprised 5325 participants from the 2004 British Child and Adolescent Mental Health Survey (B-CAMHS04), mean age 10.3 years, SD = 3.3, 48 % girls. Manic symptoms were assessed with the Development and Wellbeing Assessment by interviewing parents and young people. Children and adolescents with manic symptoms had a lower SA score, compared to the general population by parent report, but not by self-report. SA score was higher in youths with predominantly exuberant manic symptoms compared to the general population; whereas the youths with predominantly undercontrol manic symptoms had lower SA scores by parent and self-report. Our results provide further evidence for the distinction between exuberant and undercontrol manic symptoms and highlight the need to focus on SA in future research.