Psychosocial functioning among bipolar youth

Quantifying the interrelationships between physical, social, and cognitive-emotional components of mental fitness using digital technology

Mental fitness is a construct that goes beyond a simple focus on subjective emotional wellbeing to encompass more broadly our ability to think, feel, and act to achieve what we want in our daily lives. The measurement and monitoring of multiple (often interacting) domains is crucial to gain a holistic and complete insight into an individual's mental fitness. We aimed to demonstrate the capability of a new mobile app to characterise the mental fitness of a general population of Australians and to quantify the interrelationships among different domains of mental fitness. Cross-sectional data were collected from 4901 adults from the general population of Australians engaged in work or education who used a mobile app (Innowell) between September 2021 and November 2022. Individuals completed a baseline questionnaire comprised of 26 questions across seven domains of mental fitness (i.e., physical activity, sleep and circadian rhythms, nutrition, substance use, daily activities, social connection, psychological distress). Network analysis was applied at both a domain-level (e.g., 7 nodes representing each cluster of items) and an individual item-level (i.e., 26 nodes representing all questionnaire items). Only 612 people (12%) were functioning well across all domains. One quarter (n = 1204, 25%) had only one problem domain and most (n = 3085, 63%) had multiple problem domains. The two most problematic domains were physical activity (n = 2631, 54%) and social connection (n = 2151, 44%), followed closely by daily activity (n = 1914, 39%). At the domain-level, the strongest association emerged between psychological distress and daily activity (r = 0.301). Psychological distress was the most central node in the network (as measured by strength and expected influence), followed closely by daily activity, sleep and circadian rhythms and then social connection. The item-level network revealed that the nodes with the highest centrality in the network were: hopelessness, depression, functional impairment, effortfulness, subjective energy, worthlessness, and social connectedness. Social connection, sleep and circadian rhythms, and daily activities may be critical targets for intervention due to their widespread associations in the overall network. While psychological distress was not among the most common problems, its centrality may indicate its importance for indicated prevention and early intervention. We showcase the capability of a new mobile app to monitor mental fitness and identify the interrelationships among multiple domains, which may help people develop more personalised insights and approaches.

Dialectical Behavior Therapy for Adolescents With Bipolar Disorder: A Randomized Clinical Trial

Importance

Early-onset bipolar disorder conveys substantial risk for suicide. No psychosocial intervention for this population expressly targets suicidal behavior.

Objective

To determine whether dialectical behavior therapy (DBT) for adolescents with bipolar spectrum disorder is more effective than standard of care (SOC) psychotherapy in decreasing suicide attempts over 1 year.

Design, Settings, and Participants

Adolescents aged 12 to 18 years diagnosed with bipolar spectrum disorder were recruited from a specialty outpatient psychiatric clinic between November 2014 and September 2019. Independent evaluators conducted quarterly assessments over 1 year with participants and parents. Data were analyzed from March 2021 to November 2022.

Interventions

Participants were randomly assigned to 1 year of DBT (36 sessions; n = 47) or SOC psychotherapy (schedule clinically determined; n = 53). All youth received medication management via a flexible algorithm.

Main Outcomes and Measures

Primary outcomes included suicide attempts over 1 year and mood symptoms and states (depression and hypomania/mania). Secondary analyses included moderation of DBT effects by history of suicide attempt and mediation through emotion dysregulation.

Results

Of 100 included participants, 85 (85%) were female, and the mean (SD) age was 16.1 (1.6) years. Participants were followed up over a mean (SD) of 47 (14) weeks. Both treatment groups demonstrated significant and similar improvement in mood symptoms and episodes over 1 year (standardized depression rating scale slope, -0.17; 95% CI, -0.31 to -0.03; standardized mania rating scale slope, -0.24; 95% CI, -0.34 to -0.14). DBT and SOC participants reported similar suicide attempt rates at intake as measured on the Adolescent Longitudinal Follow-Up Evaluation (ALIFE; mean [SD] attempts, 2.0 [4.5] vs 1.8 [3.9], respectively; P = .80). DBT participants reported slightly more suicide attempts at intake as measured on the Columbia-Suicide Severity Rating Scale Pediatric Version (C-SSRS; mean [SD] attempts, 1.4 [3.6] vs 0.6 [0.9]; P = .02). DBT participants reported significantly fewer suicide attempts over follow-up compared with SOC participants via the ALIFE (mean [SD] attempts per follow-up period, 0.2 [0.4] vs 1.1 [4.3], controlling for baseline attempts: P = .03) and the C-SSRS (mean [SD] attempts per follow-up period, 0.04 [0.2] vs 0.10 [0.3], controlling for baseline attempts; P = .03). DBT was significantly more effective than SOC psychotherapy at decreasing suicide attempts over 1 year (ALIFE: incidence rate ratio [IRR], 0.32; 95% CI, 0.11-0.96; C-SSRS: IRR, 0.13; 95% CI, 0.02-0.78). Decreased rate of suicide attempts in DBT was moderated by presence of lifetime history of suicide attempt and time (IRR, 0.23; 95% CI, 0.13-0.44) and mediated by improvement in emotion dysregulation (IRR, 0.61; 95% CI, 0.42-0.89), particularly for those with high baseline emotion dysregulation (standardized β, -0.59; 95% CI, -0.92 to -0.26).

Conclusions and Relevance

In this randomized clinical trial, DBT demonstrated efficacy in decreasing suicide attempts among the high-risk population of adolescents with bipolar spectrum disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT02003690.

Early indicators of bipolar risk in preschool offspring of parents with bipolar disorder

BACKGROUND

Offspring of parents with bipolar disorder (BD-I/II) are at increased risk to develop the disorder. Previous work indicates that bipolar spectrum disorder (BPSD) is often preceded by mood/anxiety symptoms. In school-age offspring of parents with BD, we previously built a risk calculator to predict BPSD onset, which generates person-level risk scores. Here, we test whether preschool symptoms predict school-age BPSD risk.

METHODS

We assessed 113 offspring of parents with BD 1-3 times during preschool years (2-5 years old) and then approximately every 2 years for a mean of 10.6 years. We used penalized (lasso) regression with linear mixed models to assess relationships between preschool mood, anxiety, and behavioral symptoms (parent-reported) and school-age predictors of BPSD onset (i.e., risk score, subthreshold manic symptoms, and mood lability), adjusting for demographics and parental symptomatology. Finally, we conducted survival analyses to assess associations between preschool symptoms and school-age onset of BPSD and mood disorder.

RESULTS

Of 113 preschool offspring, 33 developed new-onset mood disorder, including 19 with new-onset BPSD. Preschool irritability, sleep problems, and parental factors were lasso-selected predictors of school-age risk scores. After accounting for demographic and parental factors, preschool symptoms were no longer significant. Lasso regressions to predict mood lability and subthreshold manic symptoms yielded similar predictors (irritability, sleep problems, and parental affective lability), but preschool symptoms remained predictive even after adjusting for parental factors (ps < .005). Exploratory analyses indicated that preschool irritability univariately predicted new-onset BPSD (p = .02) and mood disorder (p = .02).

CONCLUSIONS

These results provide initial prospective evidence that, as early as preschool, youth who will develop elevated risk scores, mood lability, and subthreshold manic symptoms are already showing symptomatology; these preschool symptoms also predict new-onset BPSD. While replication of findings in larger samples is warranted, results point to the need for earlier assessment of risk and development of early interventions.

Adolescent and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorders: An Open Trial and Individual Trajectories Study in Routine Psychiatric Care

Psychosocial treatments improve outcome in Pediatric bipolar disorder (PBD), but few are developed specifically for adolescents and none has been evaluated in Europe. This study evaluates family-focused cognitive-behavioral therapy for adolescents (ages 13-18) with PBD in routine psychiatric care in Sweden, adapted for teenagers in a European setting from the Child and Family-Focused Cognitive Behavioral Therapy for PBD (ages 8-12) developed in the US. In a repeated-measure open trial, psychosocial functioning, depression, skills and knowledge about PBD, and family climate were assessed at pre-treatment, post-treatment, and after 6 months. Assessments were made by adolescents (n = 45), parents (n = 61) and clinicians. Both group statistics and individual trajectories are reported. Psychosocial function, as rated by parents and clinicians, improved at post-treatment, and parents reported less mania and improved family climate at post-treatment. Both parents and adolescents reported improved skills and knowledge. Most results after treatment showed medium effect sizes. Significant improvements were seen in most individual trajectories, however no change and even deterioration was observed in some. The present trial shows that AFF-CBT is well accepted and associated with improved psychosocial function in adolescents and improved skills and knowledge about PBD in adolescents and their parents. Regarding mood symptoms and family climate the results showed more individual variability, indicating that adjustments in delivery of the treatment according to the unique patient could be of importance. AFF-CBT seems to be a valuable addition to pharmacological treatments in PBD.

Psychosocial functioning of adolescents with ADHD in the family, school and peer group: A scoping review protocol

Objective

The objective of this scoping review is to investigate what is known about the psychosocial functioning of adolescents with ADHD. All basic life environments (family, school and peer group) will be considered.

Introduction

Adolescence is especially critical for people with ADHD–natural maturation may be accompanied by changing symptoms of ADHD. A number of childhood difficulties transform during adolescence and contribute to problems in various areas that comprise psychosocial functioning. The available studies focus on selected domains of psychosocial functioning of adolescents with ADHD, however, to the authors’ best knowledge, there is no comprehensive description of this issue. The lack of such a description is the main rationale for conducting this scoping review.

Inclusion criteria

Pointing to the PCC elements (population, concept, context), the scoping review will include primary studies on the concept of psychosocial functioning (including functioning in the family, school and peer group). In the included studies, the term "psychosocial functioning" (or related) had to be used explicitly. The population will be adolescents (10 to 19 years old) with a formal diagnosis of ADHD (DSM classification) or Hyperkinetic Syndrome (ICD-9) or Hyperkinetic Disorders (ICD-10). There will be no restrictions on the research context.

Methods

The methodology of scoping reviews will be applied in accordance with the guidelines of the Joanna Briggs Institute (JBI). The following databases: Academic Search Ultimate, ERIC, MEDLINE, ProQuest Central, PsycInfo, Scopus, and databases under the Web of Science will be searched for primary studies in peer-reviewed journals, written in English and published since 1987. The analyses will be based mainly on frequency counts of the components of psychosocial functioning and population characteristics. The results will be presented in tabular form and supplemented with a descriptive summary. The protocol has been registered on the Open Science Framework: https://doi.org/10.17605/OSF.IO/MS82H [registration DOI].

Peroxisome Proliferator-Activated Receptor Gamma (PPARγ) Levels in Adolescent with Bipolar Disorder and Their Relationship with Metabolic Parameters

Peroxisome proliferator-activated receptor gamma (PPARγ) is one of the immune and metabolic regulatory agents. This study examined the serum PPARγ levels and metabolic syndrome (MetS) parameters in pediatric bipolar disorder (PBD) adolescents and compared them with healthy subjects. Serum PPARγ levels, fasting blood glucose (FBG), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and fasting insulin levels of 39 PBD-type I (age range: 14-18) and 36 age- and sex-matched healthy control subjects were compared. The anthropometric measurements were also analyzed, including body weight, height, body mass index (BMI), waist circumference (WC), and blood pressure measurements. The PPARγ levels were significantly lower, and the MetS prevalence was significantly higher in the PBD group than in the control group. The mean BMI, WC, serum TG, and FBG values of the PBD group were statistically higher than the healthy control group. There was no significant relationship between the PPARγ levels and metabolic parameters except fasting glucose. Lower PPARγ activity and higher MetS prevalence in PBD indicate dysregulation of immune and metabolic regulatory parameters. These results may shed light on developing new PBD medications.

Relationship between cognitive flexibility and subsequent course of mood symptoms and suicidal ideation in young adults with childhood-onset bipolar disorder

Neurocognitive deficits, such as cognitive flexibility impairments, are common in bipolar disorder (BD) and predict poor academic, occupational, and functional outcomes. However, the association between neurocognition and illness trajectory is not well understood, especially across developmental transitions. This study examined cognitive flexibility and subsequent mood symptom and suicidal ideation (SI) course in young adults with childhood-onset BD-I (with distinct mood episodes) vs. BD-not otherwise specified (BD-NOS) vs. typically-developing controls (TDCs). Sample included 93 young adults (ages 18-30) with prospectively verified childhood-onset DSM-IV BD-I (n = 34) or BD-NOS (n = 15) and TDCs (n = 44). Participants completed cross-sectional neuropsychological tasks and clinical measures. Then participants with BD completed longitudinal assessments of mood symptoms and SI at 6-month intervals (M = 39.18 ± 16.57 months of follow-up data). Analyses included ANOVAs, independent-samples t tests, chi-square analyses, and multiple linear regressions. Participants with BD-I had significant deficits in cognitive flexibility and executive functioning vs. BD-NOS and TDCs, and impaired spatial working memory vs. TDCs only. Two significant BD subtype-by-cognitive flexibility interactions revealed that cognitive flexibility deficits were associated with subsequent percentage of time depressed and with SI in BD-I but not BD-NOS, regardless of other neurocognitive factors (full-scale IQ, executive functioning, spatial working memory) and clinical factors (current and prior mood and SI symptoms, age of BD onset, global functioning, psychiatric medications, comorbidity). Thus, cognitive flexibility may be an important etiological brain/behavior mechanism, prognostic indicator, and intervention target for childhood-onset BD-I, as this deficit appears to endure into young adulthood and is associated with worse prognosis for subsequent depression and SI.

Facial emotion recognition and mood symptom course in young adults with childhood-onset bipolar disorder

Facial emotion recognition deficits are common in bipolar disorder (BD) and associated with impairment. However, the relationship between facial emotion recognition and mood course is not well understood. This study examined facial emotion recognition and subsequent mood symptoms in young adults with childhood-onset BD versus typically developing controls (TDCs). The sample included 116 young adults (ages 18-30, 58% male, 78% White) with prospectively verified childhood-onset BD (n = 52) and TDCs (n = 64). At baseline, participants completed a facial emotion recognition task (Diagnostic Analysis of Non-Verbal Accuracy-2) and clinical measures. Then, participants with BD completed mood symptom assessments every 6 months (M = 8.7 ± 5.2 months) over two years. Analyses included independent-samples t tests and mixed-effects regression models. Participants with BD made significantly more recognition errors for child expressions than TDCs. There were no significant between-group differences for recognition errors for adult expressions, or errors for specific child or adult emotional expressions. Participants had moderate baseline mood symptoms. Significant time-by-facial emotion recognition interactions revealed more recognition errors for child emotional expressions predicted lower baseline mania and stable/consistent trajectory; fewer recognition errors for child expressions predicted higher baseline mania and decreasing trajectory. In addition, more recognition errors for adult sad expressions predicted stable/consistent depression trajectory and decreasing mania; fewer recognition errors for adult sad expressions predicted decreasing depression trajectory and stable/consistent mania. Effects remained when controlling for baseline demographics and clinical variables. Facial emotion recognition may be an important brain/behavior mechanism, prognostic indicator, and intervention target for childhood-onset BD, which endures into young adulthood and is associated with mood trajectory.

A Randomized, Double-Blind, Controlled Trial of Lithium Versus Quetiapine for the Treatment of Acute Mania in Youth with Early Course Bipolar Disorder

Objective: To compare the efficacy and tolerability of lithium versus quetiapine for the treatment of manic or mixed episodes in youths with early course bipolar I disorder. Methods: Six-week, randomized, double-blind clinical trial of lithium versus quetiapine for the treatment of adolescents with acute manic/mixed episode. Target dose of quetiapine dose was adjusted to a target dose of 400-600 mg and target serum level for lithium was 1.0-1.2 mEq/L. Primary outcome measure was baseline-to-endpoint change in the Young Mania Rating Scale (YMRS). Secondary outcomes were treatment response (50% or more decrease from baseline in YMRS score) and remission (YMRS score ≤12, Children's Depression Rating Scale-Revised [CDRS-R] total score ≤28 and Clinical Global Impression Bipolar Severity Scale [CGI-BP-S] overall score of ≤3, respectively). Results: A total of 109 patients were randomized (quetiapine = 58 and lithium = 51). Participants in the quetiapine treatment group showed a significantly greater reduction in YMRS score than those in the lithium group (-11.0 vs. -13.2; p < 0.001; effect size 0.39). Response rate was 72% in the quetiapine group and 49% in the lithium group (p = 0.012); no differences in remission rates between groups were observed. Most frequent side effects for lithium were headaches (60.8%), nausea (39.2%), somnolence (27.5%), and tremor (27.5%); for quetiapine somnolence (63.8%), headaches (55.2%), tremor (36.2%), and dizziness (36.2%) were evidenced. Participants receiving quetiapine experienced more somnolence (p < 0.001), dizziness (p < 0.05), and weight gain (p < 0.05). Conclusions: Treatment with both lithium and quetiapine led to clinical improvement. Most study participants in this study experienced a clinical response; however, less than half of the participants in this study achieved symptomatic remission. The head-to-head comparison of both treatment groups showed quetiapine was associated with a statistically significant greater rate of response and overall symptom reduction compared with lithium. Trial registration: clinicaltrials.gov NCT00893581.

Impaired theory of mind and emotion recognition in pediatric bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Social cognition is impaired in patients with severe mental disorders. We aimed to investigate impairments in social cognition in youth with pediatric bipolar disorder (PBD) through a systematic review of the literature and the meta-analysis.

METHOD

Following the PRISMA guidelines, we searched in PubMed, Scopus, and Cochrane CENTRAL for studies reporting on the theory of mind (ToM) and emotion recognition (ER) abilities of patients with PBD compared to healthy controls (HC). We conducted a random-effects model meta-analysis for the contrast between PBD and HC. Subgroup and meta-regression analyses were conducted for demographic and clinical variables as appropriate.

RESULTS

A total of thirteen studies involving 429 patients with PBD and 394 HC were included. Patients with PBD had significantly poorer social cognitive abilities (Hedges' g for ER, g = -0.74, CI = -0.91, -0.57; and for ToM, g = -0.98, CI = -1.41 to -0.55). Subgroup analysis also revealed significant impairment in ER for patients in a euthymic state (g = -0.75). Age, gender, sample size, the severity of mood symptoms, estimated IQ, the frequencies of bipolar-I disorder, attention-deficit hyperactivity disorder, medications, study quality and euthymia did not moderate the difference in meta-regression. Heterogeneity was low in all analyses and there was no evidence for publication bias.

CONCLUSION

The results of this meta-analysis supported the notion that PBD is associated with a deficit in social cognitive abilities at a medium to a large level. Impairments in social cognition could be an illness-related trait of PBD. Meta-regression results did not find a moderator of the deficits in social cognition.

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.

Interpretation bias training for bipolar disorder: A randomized controlled trial

BACKGROUND

Bipolar disorder (BD) is associated with emotion interpretation biases that can exacerbate depressed mood. Interpretation bias training (IBT) may help; according to the "virtuous cycle" hypothesis, interpreting others' emotions as positive can lead to interactions that improve mood. Our goals were to determine whether IBT can shift emotion interpretation biases and demonstrate clinical benefits (lower depressed mood, improved social function) in people with BD.

METHOD

Young adults with BD were recruited for three sessions of computer-based IBT. Active IBT targets negative emotion bias by training judgments of ambiguous face emotions towards happy judgments. Participants were randomized to active or sham IBT. Participants reported on mood and functioning at baseline, intervention end (week two), and week 10.

RESULTS

Fifty participants (average age 22, 72% female) enrolled, 38 completed the week 10 follow-up. IBT shifted emotion interpretations (Hedges g = 1.63). There was a group-by-time effect (B = -13.88, p < .0001) on self-reported depression; the IBT group had a larger decrease in depressed mood. The IBT group also had a larger increase in perceived familial support (B = 3.88, p < .0001). Baseline learning rate (i.e., how quickly emotion judgments were updated) was associated with reduced clinician- (B = -54.70, p < 0.001) and self-reported depression (B = -58.20, p = 0.009).

CONCLUSION

Our results converge with prior work demonstrating that IBT may reduce depressed mood. Additionally, our results provide support for role of operant conditioning in the treatment of depression. People with BD spend more time depressed than manic; IBT, an easily disseminated intervention, could augment traditional forms of treatment without significant expense or side effects.

Lurasidone in Children and Adolescents with Bipolar Depression Presenting with Mixed (Subsyndromal Hypomanic) Features: Post Hoc Analysis of a Randomized Placebo-Controlled Trial

Objectives: To evaluate the efficacy and safety of lurasidone in the treatment of children and adolescents with bipolar depression presenting with mixed (subsyndromal hypomanic) features. Methods: Patients, 10-17 years of age, with a Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), diagnosis of bipolar I depression were randomized to 6 weeks of double-blind treatment with once-daily flexible doses of lurasidone 20-80 mg or placebo. The presence of mixed (subsyndromal hypomanic) features in this pediatric bipolar depression trial was defined as a Young Mania Rating Scale score of 5 or greater at study baseline. Key efficacy measures included change from baseline to week 6 in the Children's Depression Rating Scale-Revised (CDRS-R) score (primary endpoint) and Clinical Global Impressions-Bipolar Severity (CGI-BP-S) score, using a mixed model for repeated measures analysis. Results: At baseline, subsyndromal hypomanic features were present in 54.2% of patients. Treatment with lurasidone (vs. placebo) was associated with significantly greater reductions in CDRS-R scores at week 6, independent of the presence (-21.5 vs. -15.9, p < 0.01; effect size d = 0.43) or absence (-20.5 vs. -14.9, p < 0.01; d = 0.44) of subsyndromal hypomanic features. Likewise, lurasidone (vs. placebo) was associated with significantly greater reductions in CGI-BP-S scores at week 6, independent of the presence (-1.6 vs. -1.1, p < 0.001, d = 0.51) or absence (-1.3 vs. -1.0, p = 0.05; d = 0.31) of these subsyndromal hypomanic features. Rates of protocol-defined treatment-emergent hypomania or mania were similar for lurasidone and placebo in patients with (lurasidone 8.2% vs. placebo 9.0%) or without subsyndromal hypomanic features (lurasidone 1.3% vs. placebo 3.7%). Conclusions: In this post hoc analysis of a randomized placebo-controlled trial, lurasidone was found to be efficacious in the treatment of child and adolescent patients with bipolar depression who presented with mixed (subsyndromal hypomanic) features. No differences in safety profile, including the risk of treatment-emergent mania, were observed in patients with or without subsyndromal hypomanic features in this study.

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review

AIM

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment.

METHOD

This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school.

RESULTS

In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature.

CONCLUSION

Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

Childhood ADHD and Early-Onset Bipolar Disorder Comorbidity: A Case Report

INTRODUCTION

Recent research has highlighted an increased rate of co-morbidity between the neurodevelopmental-behavioral disorder of attention deficit hyperactivity disorder (ADHD) and a variety of psychiatric disorders, such as mood disorders or bipolar disorder (BD). The etiology and clinical course of BD are considered to be determined by both genetic and environmental factors, either aggravating or improving.

AIM

This follow-up study of an adolescent aimed to clarify the co-morbidity between ADHD and BD. We also discuss the controversies surrounding the two diagnoses in younger populations and describe several aspects of concern regarding diagnosis, differential diagnosis, therapeutic planning/intervention, and prognosis.

METHODS

Reporting of a two-year follow-up study of a bipolar 15-year-old female patient with a previous diagnosis of ADHD during childhood.

RESULTS

Despite the occurrence of major risk factors, such as early onset and positive family history, the patient's condition rapidly remitted with medication, without relapse and/or rehospitalization during the following two years, due to the stability of her cooperation, and support of a stable and caring familial environment. Early diagnosis of BD and differential diagnoses of ADHD are considered crucial protective factors leading to an appropriate planning of treatment. In addition, parental involvement and empathic attitude towards the patient supported the latter to cooperate and comply with the treatment, enhancing positive outcomes and stability.

CONCLUSIONS

Research is required into the reliability and validity of diagnostic protocols and criteria for BD in children and adolescents, and also into the development of individualized therapeutic planning.

Functional Impairment and Clinical Correlates in Adolescents with Bipolar Disorder Compared to Healthy Controls. A Case-control Study

BACKGROUND

Evidence shows that most adolescents with bipolar disorder (BD) achieve syndromic recovery after being referred to specialized treatment. However, functional recovery is reached in less than 50% of those cases.

METHOD

Descriptive cross-sectional case-control study, based on a clinical sample of 44 BD patients aged 12-19, matched by age and sex with 44 healthy controls (HC). Psychopathology was ascertained using the KSADS-PL, in addition to the clinical scales. Information about previous academic performance was included, as well as functional outcome based on the Children's Global Assessment Functioning Scale (CGAS). Previous exposure to stressful experiences was assessed using the Schedule for Stressful Life Events (SLES). All analyses were performed using either conditional or stepwise logistic regression models.

RESULTS

Once they have become stabilized, and even after controlling for socio-demographic differences, BD patients were associated with lower levels of functionality [OR 0.65 (0.46, 0.93), p=0.02], and worse performance at school [OR 0.03 (0.01, 0.67), p=0.03] compared with HC. Persistent sub-syndromal psychosis showed the strongest negative correlation with functionality (rho=-0.65, -0.57 for BD and HC respectively; p<0.001). Although BD was associated with more stressful life events, this association did not remain significant in the multivariate models.

LIMITATIONS

The small sample size limits our ability to detect differences between groups, and between BD subtypes.

CONCLUSIONS

Even when early detection and intervention is provided, BD has a significant impact on functioning and academic performance. It is important to address persistent sub-threshold symptoms and to emphasize the social and rehabilitative components of treatment.

Social and role functioning in youth at risk of serious mental illness

AIM

Functional impairment is common in serious mental illness (SMI). This study assessed social and role functioning in a sample of youth at risk of SMI who met different stages of risk based on a transdiagnostic clinical staging model described by McGorry and colleagues.

METHOD

The sample consisted of 243 male and female youths aged 12-26 and included: non-help-seeking youth with risk factors (stage 0; n = 41); youth with mild symptoms (stage 1a; n = 52); youth with attenuated psychiatric syndromes (stage 1b; n = 108); and healthy controls (HCs; n = 42). Social and role functioning were assessed with the Global Functioning: Social and Role scales.

RESULTS

Participants in stage 1b (attenuated syndromes) had significantly poorer social and role functioning than stage 0 participants and HCs (P < .001) and poorer social functioning than stage 1a (P < .05). Stage 1a participants had significantly poorer social functioning than HCs (P < .01) and significantly poorer role functioning than stage 0 participants (P < .01). Participants in stages 1a and 1b did not significantly differ from each other in role functioning only.

CONCLUSIONS

This study demonstrates that mild to moderate functional impairments are present in young people experiencing subthreshold psychiatric symptoms and distress in the absence of a diagnosable mental illness. Results partially validate the model in that social although not role functioning declines across the stages.

Course of longitudinal psychosocial functioning in bipolar youth transitioning to adults

OBJECTIVES

Few studies have examined domain-specific psychosocial functioning in Bipolar Disorder (BD) youths. This prospective study examines (1) Interpersonal Relationships with Family; (2) Interpersonal Relationships with Friends; (3) School/Work; (4) Recreation; (5) Life Satisfaction, in BD youths.

METHOD

A Course and Outcome of Bipolar Youth subsample (n = 367; mean intake age = 12.6 years, SD = 3.3; 46.6% female) was previously grouped into 4 Classes based on their illness trajectories and percentage of time euthymic using Latent Class Growth Analysis: Class 1 Predominantly Euthymic; Class 2 Moderately Euthymic; Class 3 Ill with Improving Course; Class 4 Predominantly Ill. Psychosocial functioning within the domains were examined for greater than 10 years using the Adolescent Longitudinal Interval Follow-Up Evaluation.

RESULTS

Class 1 demonstrated better functioning across all domains; Class 4 demonstrated worse functioning across all domains. Class 2 showed worsening relationships and recreation, and improvement in work/schoolwork. Class 3 showed variable domain declines and improvements. Despite symptomatic remission, 13%-20% of Class 1 and 20-47% of Classes 1/3 still had impairments across different domains. Early age of BD onset impacted impairment across most domains, and low SES significantly predicted impairment in family relationships.

LIMITATIONS

The study does not have a healthy control group to compare functioning findings.

CONCLUSIONS

Participants with more symptomatic mood trajectories had greater impairment across domains. Moreover, even with symptomatic remission, participants still exhibited impairment. Each Class and domain had different trajectories for impairment. Results suggest the importance of examining specific (vs. global) domains for targeted treatment, even when symptomatically remitted.

Interpersonal Relationships and Suicidal Ideation in Youth with Bipolar Disorder

This study examines how relationship quality in family and peer domains are associated with suicidal ideation (SI) in youth with bipolar disorder (BP). We assessed 404 Course and Outcome of Bipolar Youth study participants for psychiatric disorders and SI at intake and for family/peer relationships the month after intake. Multivariate logistic regression examined associations between relationships and SI, controlling for significant covariates. There were 144 youth (36%) who reported SI at intake; bivariate analyses indicated they had significantly worse family/peer relationships. Multivariate analyses showed that family/peer relationships were associated with current SI, controlling for significant covariates. Results support associations between poor relationships and SI in BP youth, regardless of current mood symptom severity. Clinicians should assess relationships when completing risk assessments with BP youth.

Social Cognition, Language, and Social Behavior in 7-Year-Old Children at Familial High-Risk of Developing Schizophrenia or Bipolar Disorder: The Danish High Risk and Resilience Study VIA 7-A Population-Based Cohort Study

OBJECTIVE

To characterize social cognition, language, and social behavior as potentially shared vulnerability markers in children at familial high-risk of schizophrenia (FHR-SZ) and bipolar disorder (FHR-BP).

METHODS

The Danish High-Risk and Resilience Study VIA7 is a multisite population-based cohort of 522 7-year-old children extracted from the Danish registries. The population-based controls were matched to the FHR-SZ children on age, sex, and municipality. The FHR-BP group followed same inclusion criteria. Data were collected blinded to familial high-risk status. Outcomes were social cognition, language, and social behavior.

RESULTS

The analysis included 202 FHR-SZ children (girls: 46%), 120 FHR-BP children (girls: 46.7%), and 200 controls (girls: 46.5%). FHR-SZ children displayed significant deficits in language (receptive: d = -0.27, P = .006; pragmatic: d = -0.51, P < .001), social responsiveness (d = -0.54, P < .001), and adaptive social functioning (d = -0.47, P < .001) compared to controls after Bonferroni correction. Compared to FHR-BP children, FHR-SZ children performed significantly poorer on adaptive social functioning (d = -0.29, P = .007) after Bonferroni correction. FHR-BP and FHR-SZ children showed no significant social cognitive impairments compared to controls after Bonferroni correction.

CONCLUSION

Language, social responsiveness, and adaptive social functioning deficits seem associated with FHR-SZ but not FHR-BP in this developmental phase. The pattern of results suggests adaptive social functioning impairments may not be shared between FHR-BP and FHR-SZ in this developmental phase and thus not reflective of the shared risk factors for schizophrenia and bipolar disorder.

Functional impairment among people diagnosed with depression in primary healthcare in rural Ethiopia: a comparative cross-sectional study

Background

There have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs). The aim of this study was to identify factors associated with functional impairment among people diagnosed with depression in PHC in Ethiopia as part of implementation of a task-shared model of mental healthcare.

Methods

A comparative cross-sectional study was conducted. As part of the Programme for Improving Mental health carE (PRIME), PHC clinicians were trained to diagnose depression using an adapted version of the World Health Organization (WHO) mental health Gap Action Programme (mhGAP). A total of 2038 adult consecutive PHC attendees were screened for depressive symptoms using the 9-item Patient Health Questionnaire (PHQ-9). Those who scored five or above on the PHQ-9 (n = 131) were assessed by PHC workers. Of these, 92 were diagnosed to have depression (“PHC diagnosed cases”) and the remaining 39 people were PHQ positive but considered not to have depression (“non-diagnosed controls”). PHC diagnosed cases were also compared to a community representative sample of adult healthy controls (n = 197; “community controls”). The 12-item version of the WHO Disability Assessment Schedule (WHODAS-2.0) was used to assess functional impairment. Multivariable negative binomial regression models were fitted to examine the association of demographic, social, economic and clinical characteristics with functional impairment.

Results

No significant difference in functional impairment was found between diagnosed cases and non-diagnosed controls. PHC diagnosed cases were found to have higher depressive symptom severity and suicidality, but lower social support compared to non-diagnosed controls (P < 0.05). In the multivariable model, greater functional impairment was associated with higher depressive symptoms (RR = 1.04; 95% CI 1.02, 1.05) and lower social support (RR = 0.96; 95% CI 0.95, 0.98). Diagnosed cases were found to have higher functional impairment compared to community controls (RR = 1.91; 95% CI 1.74, 2.09).

Conclusion

In this study, PHC clinicians identified cases of depression with high symptom burden, suicidality and functional impairment. These findings support current initiatives to scale-up mental health services at the PHC level; and indicate that social support is an important target for intervention.

Sleep alterations in pediatric bipolar disorder versus attention deficit disorder

Bipolar disorder (BD) and attention deficit/hyperactivity disorder (ADHD) share numerous clinical features, which can make the differential diagnosis challenging. Studies conducted in adults suggest that patients with BD and ADHD have different sleep patterns. However, in pediatric populations, data on these potential differences are scant. The present preliminary study was conducted to identify potential differences in sleep alterations among youths diagnosed with BD or ADHD compared to healthy controls (HC). A total of 26 patients diagnosed with BD (n = 13) or ADHD (n = 13) were compared to 26 sex- and age-matched HC ([HC_BD], n = 13, and [HC_ADHD], n = 13). All participants underwent polysomnography. The mean duration of stage N2 sleep was shorter in the BD group than in controls (HC_BD). The BD group also had higher (non-significant) REM density (REMd) scores than controls while mean REMd scores were lower in the ADHD group versus controls. Compared to the ADHD group, the BD group presented a shorter N2 stage, a longer first REM sleep duration (R1), and greater REMd. According to our findings, these three variables-N2 stage, REMd, and R1-appear to differentiate patients with BD from those with ADHD and from HC.

Brain-Derived Neurotrophic Factor in Brain Disorders: Focus on Neuroinflammation

Brain-derived neurotrophic factor (BDNF) is one of the most studied neurotrophins in the healthy and diseased brain. As a result, there is a large body of evidence that associates BDNF with neuronal maintenance, neuronal survival, plasticity, and neurotransmitter regulation. Patients with psychiatric and neurodegenerative disorders often have reduced BDNF concentrations in their blood and brain. A current hypothesis suggests that these abnormal BDNF levels might be due to the chronic inflammatory state of the brain in certain disorders, as neuroinflammation is known to affect several BDNF-related signaling pathways. Activation of glia cells can induce an increase in the levels of pro- and antiinflammatory cytokines and reactive oxygen species, which can lead to the modulation of neuronal function and neurotoxicity observed in several brain pathologies. Understanding how neuroinflammation is involved in disorders of the brain, especially in the disease onset and progression, can be crucial for the development of new strategies of treatment. Despite the increasing evidence for the involvement of BDNF and neuroinflammation in brain disorders, there is scarce evidence that addresses the interaction between the neurotrophin and neuroinflammation in psychiatric and neurodegenerative diseases. This review focuses on the effect of acute and chronic inflammation on BDNF levels in the most common psychiatric and neurodegenerative disorders and aims to shed some light on the possible biological mechanisms that may influence this effect. In addition, this review will address the effect of behavior and pharmacological interventions on BDNF levels in these disorders.

Predictors of longitudinal psychosocial functioning in bipolar youth transitioning to adults

OBJECTIVES

In a sample of participants diagnosed with Bipolar Disorder (BD) in youth, we aim: (1) to examine longitudinal psychosocial functioning; (2) to determine whether psychosocial impairment remains in those who remitted from mood disorders during later periods of follow-up; (3) to examine predictors of psychosocial impairment despite symptomatic remission.

METHOD

A Course and Outcome of Bipolar Youth subsample of 367 (≥ 4 years follow-up data) were grouped into mood trajectories: Class 1 Predominantly Euthymic; Class 2 Moderately Euthymic; Class 3 Ill with Improving Course; Class 4 Predominantly Ill. Psychosocial functioning was assessed via Children's Global Assessment Scale (C-GAS) for those under age 22; Global Assessment of Functioning (GAF) scale after 22. Current school, employment, and disability status were examined. Established predictors of symptomatic impairment were analyzed.

RESULTS

The Predominantly Euthymic Class had better psychosocial functioning, and were more likely to be in school/employed. The Persistently Ill Class had worse psychosocial functioning, and were more likely to receive disability. However, 44% of Predominantly Euthymic and 93% of Ill with Improving Course participants continued to experience current psychosocial impairment. Early BD onset, low Socioeconomic Status (SES), and current comorbidity, predicted poor psychosocial functioning. Low SES, and current comorbidity, predicted no school enrollment/unemployment.

LIMITATIONS

The study does not have a healthy control group to compare functioning findings.

CONCLUSIONS

In general, youth with persistent mood symptoms had worse psychosocial functioning, moreover, those with remitted symptoms still exhibited current psychosocial functioning deficits. High risk individuals with predictors of impairment should be targeted for functioning interventions.

Probabilistic reinforcement learning abnormalities and their correlates in adolescent bipolar disorders

Theoretical models of bipolar disorders (BD) posit core deficits in reward system function. However, specifying which among the multiple reward system's neurobehavioral processes are abnormal in BD is necessary to develop appropriately targeted interventions. Research on probabilistic-reinforcement learning deficits in BD is limited, particularly during adolescence, a period of significant neurodevelopmental changes in the reward system. The present study investigated probabilistic-reinforcement learning, using a probabilistic selection task (PST), and its correlates, using self-reported reward/threat sensitivities and cognitive tasks, in 104 adolescents with and without BD. Compared with healthy peers, adolescents with BD were less likely to persist with their choices based on prior positive feedback (i.e., lower win-stay rates) in the PST's acquisition phase. Across groups, a greater win-stay rate appeared to be a more efficient learning strategy-associated with fewer acquisition trials and better testing phase performance. Win-stay rates were also related to verbal learning indices, but not self-reported reward/threat sensitivities. Finally, lower win-stay rates had significant incremental validity in predicting a BD diagnosis, after accounting for effects of current symptoms, reward sensitivities, verbal learning, and IQ. The present findings support multiple dysfunctional processes of the reward system in adolescent BD that require additional examinations. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Neutrophil-lymphocyte and platelet-lymphocyte ratios among adolescents with bipolar disorder: A preliminary study

We aimed to evaluate the neutrophil lymphocyte and platelet lymphocyte ratios among euthymic adolescents with bipolar disorder (BD) type I. Thirty-six adolescents with BD and 30 healthy controls were included in the study. The diagnosis was made by experienced physicians using the Kiddie and Young Adult Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version and the affective module of Washington University in St. Louis Kiddie and Young Adult Schedule for Affective Disorders and Schizophrenia-Present State and Lifetime. Blood samples were taken during euthymia, which was defined as Young Mania Rating Scale and Hamilton Depression Rating Scale scores below 7. There was no significant difference in neutrophil lymphocyte ratio and platelet lymphocyte ratio between the patient and control group. Considering the literature, we may speculate that in the early stages, euthymia is associated with a lower inflammatory response, and prolongation of BD causes increased inflammatory processes predominant even in euthymia. In pediatric BD, further studies that assess neutrophil lymphocyte ratio and platelet lymphocyte ratio during different mood episodes and that identify neutrophil lymphocyte ratio and platelet lymphocyte ratio changes during the course of the disease will clarify the role of inflammation in the etiology of pediatric BD.

Adaptation of Multi-Family Psychoeducational Psychotherapy (MF-PEP) for Adolescents with Mood Disorders: Preliminary Findings

Adolescent mood disorders are a major public health concern. Clinical need for services outstrips availability in many communities. Group psychotherapy is an efficient means to provide service to a larger number of clientele and can offer certain clinical advantages. Multi-Family Psychoeducational Psychotherapy (MF-PEP), an adjunctive group psychosocial treatment, has been shown to improve children's mood symptoms, increase parents' knowledge of mood disorder symptoms, improve family interactions and improve use of behavioral health services. In this study, an adaptation of MF-PEP for adolescents with mood disorders is described and preliminary data are presented. Among the 19 adolescents with mood disorders and 22 parents who completed the study, improvements in adolescents' depressive symptoms, quality of life, families' understanding of mood disorders, and overall satisfaction with treatment were reported. Results have informed ongoing pilot testing of Teen-MF-PEP.

Functional impairment among people with severe and enduring mental disorder in rural Ethiopia: a cross-sectional study

PURPOSE

Evidence regarding functional impairment in people with severe mental disorders (SMD) is sparse in low- and middle-income countries. The aim of this study was to identify factors associated with functional impairment in people with enduring SMD in a rural African setting.

METHODS

A cross-sectional study was conducted at the baseline of a health service intervention trial. A total of 324 participants were recruited from an existing community-ascertained cohort of people with SMD (n = 218), and attendees at the Butajira General Hospital psychiatric clinic (n = 106). Inclusion criteria defined people with SMD who had ongoing need for care: those who were on psychotropic medication, currently symptomatic or had a relapse in the preceding 2 years. The World Health Organization Disability Assessment schedule (WHODAS-2.0) and the Butajira Functioning Scale (BFS) were used to assess functional impairment. Multivariable negative binomial regression models were fitted to investigate the association between demographic, socio-economic and clinical characteristics, and functional impairment.

RESULTS

Increasing age, being unmarried, rural residence, poorer socio-economic status, symptom severity, continuous course of illness, medication side effects, and internalized stigma were associated with functional impairment across self-reported and caregiver responses for both the WHODAS and the BFS. Diagnosis per se was not associated consistently with functional impairment.

CONCLUSION

To optimize functioning in people with chronic SMD in this setting, services need to target residual symptoms, poverty, medication side effects, and internalized stigma. Testing the impact of community interventions to promote recovery will be useful. Advocacy for more tolerable treatment options is warranted.

Developmental evaluation of family functioning deficits in youths and young adults with childhood-onset bipolar disorder

BACKGROUND

Childhood-onset bipolar disorder (BD) is a serious condition that affects the patient and family. While research has documented familial dysfunction in individuals with BD, no studies have compared developmental differences in family functioning in youths with BD vs. adults with prospectively verified childhood-onset BD.

METHODS

The Family Assessment Device (FAD) was used to examine family functioning in participants with childhood-onset BD (n = 116) vs. healthy controls (HCs) (n = 108), ages 7-30 years, using multivariate analysis of covariance and multiple linear regression.

RESULTS

Participants with BD had significantly worse family functioning in all domains (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, general functioning) compared to HCs, regardless of age, IQ, and socioeconomic status. Post-hoc analyses suggested no influence for mood state, global functioning, comorbidity, and most medications, despite youths with BD presenting with greater severity in these areas than adults. Post-hoc tests eliminating participants taking lithium (n = 17) showed a significant diagnosis-by-age interaction: youths with BD had worse family problem solving and communication relative to HCs.

LIMITATIONS

Limitations include the cross-sectional design, clinical differences in youths vs. adults with BD, ambiguity in FAD instructions, participant-only report of family functioning, and lack of data on psychosocial treatments.

CONCLUSIONS

Familial dysfunction is common in childhood-onset BD and endures into adulthood. Early identification and treatment of both individual and family impairments is crucial. Further investigation into multi-level, family-based mechanisms underlying childhood-onset BD may clarify the role family factors play in the disorder, and offer avenues for the development of novel, family-focused therapeutic strategies.

Further evidence of high level of persistence of pediatric bipolar-I disorder from childhood onto young adulthood: a five-year follow up

Background:

Pediatric bipolar (BP)-I disorder affects a sizeable minority of children and is associated with high levels of morbidity. Relatively few studies have assessed the persistence of the disorder over time.

Objective:

The main aim of this study was to extend our findings from our 4-year follow-up study examining rates of persistence of pediatric BP-I disorder onto late adolescent years and young adulthood 5 years after our original study.

Methods:

We conducted a 1-year extension to our original prospective study of 78 youth, ages six to 17 years, with BP-I disorder at ascertainment, who were followed up into their adolescent and young adult years (14.9 ± 3.8). All subjects were comprehensively assessed with structured diagnostic interviews and psychosocial, educational, and treatment history assessments.

Results:

Of the 78 BP-I participating youth, 68 were re-accessioned one year following the 4-year follow-up study, thus effectively 5 years since the original study. Of these, 63% continued to meet full (50%) or subthreshold (13%) diagnostic criteria for BP-I and 18% continued to have full or subthreshold major depressive disorder. Only 19% of BP-I youth were euthymic at the 5-year follow up.

Discussion:

This 1-year extension study further documents the high level of persistence of pediatric BP-I from childhood onto late adolescence and young adulthood. The results provide compelling evidence of the morbidity and dysfunction associated with this disorder and its many forms.

Clinical significance:

This study adds to a small amount of literature on the persistence of pediatric BP disorder and the critical need for early identification and intervention.

Irritability is Common and is Related to Poorer Psychosocial Outcomes in Youth with Functional Abdominal Pain Disorders (FAPD)

Functional abdominal pain disorders (FAPD) are associated with increased emotional problems which, in turn, exacerbate functional impairment. However, irritability, which relates both to internalizing and externalizing problems, has not been specifically examined in these youths. Irritability may be common and adversely impact functioning in pediatric FAPD, particularly for males who are more likely to experience such symptoms. The current study examined the relationship between irritability and psychosocial and pain-related impairment in youth with FAPD. Data were gathered as part of a larger study examining a psychological treatment for youth with FAPD and were compared to previously published data on irritability in healthy controls and in youth with severe emotional dysregulation. For the current study, participants (ages 9–14) with FAPD and caregivers completed measures of child irritability, pain-related and psychosocial functioning, and parent functioning. Pearson correlations revealed significant positive associations between irritability and anxiety, depressive symptoms, pain catastrophizing, and caregiver distress. Results also indicated that parents reported significantly greater irritability in males, but males and females reported similar rates of irritability. Gender moderated the relationship between child-report of irritability and anxiety only. Future research may include tailoring of behavioral intervention approaches for pediatric FAPD to specifically target symptoms of irritability.

Sexual Risk Behavior Among Youth With Bipolar Disorder: Identifying Demographic and Clinical Risk Factors

OBJECTIVE

This study aims to document rates of sexual activity among youth with bipolar spectrum disorder (BD) and to examine demographic and clinical factors associated with first sexual activity and sexual risk behavior during follow-up.

METHOD

The sample was drawn from the Course and Outcome of Bipolar Youth (COBY) study of 413 youth 7 to 17 years at baseline who met criteria for bipolar spectrum disorder according to the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. Psychiatric symptoms during follow-up were assessed using the Adolescent Longitudinal Interview Follow-Up Evaluation (ALIFE). Sexual behavior and level of sexual risk (e.g., unprotected sex, multiple partners, and/or partners with known sexually transmitted infections) were assessed by trained evaluators using the ALIFE Psychosocial Functioning Scale. Analyses were conducted in relation to first sexual behavior during follow-up and then to subsequent sexual behaviors (mean 9.7 years, standard deviation 3.2).

RESULTS

Sexually active COBY youth (n = 292 of 413; 71%) were more likely females, using substances, and not living with both parents. Consistent with findings among healthy youth, earlier first sexual activity in the sample was significantly associated with low socioeconomic status, female sex, comorbid disruptive behavior disorder, and substance use. As with healthy youth, sexual risk behavior during follow-up was significantly associated with non-Caucasian race, low socioeconomic status, substance use, and history of sexual abuse. Of those COBY youth who were sexually active, 11% reported sexual assault or abuse, 36% reported becoming pregnant (or the significant other becoming pregnant), and 15% reported having at least 1 abortion (or the significant other having an abortion) during follow-up. Hypomanic symptoms during follow-up were temporally associated with the greatest risk for sexual risk behavior.

CONCLUSION

Demographic and clinical factors could help identify youth with bipolar spectrum disorder at significantly greatest risk for sexual activity and sexual risk behavior. Attending to sexual risk behaviors in this population is warranted.

Efficacy and Safety of Lurasidone in Children and Adolescents With Bipolar I Depression: A Double-Blind, Placebo-Controlled Study

OBJECTIVE

To evaluate the efficacy and safety of lurasidone in children and adolescents with bipolar depression.

METHOD

Patients 10 to 17 years old with a DSM-5 diagnosis of bipolar I depression were randomized to 6 weeks of double-blind treatment with flexible doses of lurasidone 20 to 80 mg/day. The primary endpoint was change from baseline to week 6 in the Children's Depression Rating Scale-Revised (CDRS-R) total score, evaluated by a mixed-model repeated-measures analysis.

RESULTS

A total of 347 patients were randomized and received at least 1 dose of lurasidone (n = 175; mean age 14.2 years; mean dose 33.6 mg/day) or placebo (n = 172; mean age 14.3 years). At week 6, treatment with lurasidone was associated with statistically significant improvement compared with placebo in CDRS-R total score (-21.0 versus -15.3; p < .0001; effect size 0.45). Lurasidone also was associated with statistically significant improvement in the Clinical Global Impression-Bipolar Severity depression score (key secondary measure) and in measures of anxiety, quality of life, and global functioning. Study completion rates were 92.0% in the lurasidone group and 89.7% in the placebo group; discontinuation rates due to adverse events were the same for the 2 groups (1.7%). The 2 most common adverse events on lurasidone were nausea and somnolence. Treatment with lurasidone was associated with few effects on weight and metabolic parameters.

CONCLUSION

In this placebo-controlled study, monotherapy with lurasidone, in the dose range of 20 to 80 mg/day, significantly decreased depressive symptoms in children and adolescents with bipolar depression. Lurasidone was well tolerated, with minimal effects on weight and metabolic parameters. Clinical trial registration information-Lurasidone Pediatric Bipolar Study; http://Clinicaltrials.gov; NCT02046369.

Similar familial underpinnings for full and subsyndromal pediatric bipolar disorder: A familial risk analysis

OBJECTIVES

To examine the validity of subthreshold pediatric bipolar I disorder (BP-I), we compared the familial risk for BP-I in the child probands who had either full BP-I, subthreshold BP-I, ADHD, or were controls that neither had ADHD nor bipolar disorder.

METHODS

BP-I probands were youth aged 6-17 years meeting criteria for BP-I, full (N=239) or subthreshold (N=43), and also included were their first-degree relatives (N=687 and N=120, respectively). Comparators were youth with ADHD (N=162), controls without ADHD or bipolar disorder (N=136), and their first-degree relatives (N=511 and N=411, respectively). We randomly selected 162 non-bipolar ADHD probands and 136 non-bipolar, non-ADHD control probands of similar age and sex distribution to the BP-I probands from our case-control ADHD family studies. Psychiatric assessments were made by trained psychometricians using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children Epidemiological Version (KSADS-E) and Structured Clinical Interview for DSM-IV (SCID) structured diagnostic interviews. We analyzed rates of bipolar disorder using multinomial logistic regression.

RESULTS

Rates of full BP-I significantly differed between the four groups (χ23 =32.72, P<.001): relatives of full BP-I probands and relatives of subthreshold BP-I probands had significantly higher rates of full BP-I than relatives of ADHD probands and relatives of control probands. Relatives of full BP-I, subthreshold BP-I, and ADHD probands also had significantly higher rates of major depressive disorder compared to relatives of control probands.

CONCLUSIONS

Our results showed that youth with subthreshold BP-I had similarly elevated risk for BP-I and major depressive disorder in first-degree relatives as youth with full BP-I. These findings support the diagnostic continuity between subsyndromal and fully syndromatic states of pediatric BP-I disorder.

Cognitive Impairment in Euthymic Pediatric Bipolar Disorder: A Systematic Review and Meta-Analysis

OBJECTIVE

To perform a systematic review and meta-analysis of studies investigating neurocognition in euthymic youths with bipolar disorder (BD) compared to healthy controls (HCs).

METHOD

A systematic literature search was conducted in the PubMed/MEDLINE, PsycINFO, and EMBASE databases from inception up until March 23, 2016, for original peer-reviewed articles that investigated neurocognition in euthymic youths with BD compared to HCs. Effect sizes (ES) for individual tests were extracted. In addition, results were grouped according to cognitive domain. This review complied with the PRISMA statement guidelines.

RESULTS

A total of 24 studies met inclusion criteria (N = 1,146; 510 with BD). Overall, euthymic youths with BD were significantly impaired in verbal learning, verbal memory, working memory, visual learning, and visual memory, with moderate to large ESs (Hedge's g 0.76-0.99); significant impairments were not observed for attention/vigilance, reasoning and problem solving, and/or processing speed. Heterogeneity was moderate to large (I² ≥ 50%) for most ES estimates. Differences in the definition of euthymia across studies explained the heterogeneity in the ES estimate for verbal learning and memory. We also found evidence for other potential sources of heterogeneity in several ES estimates including co-occurring attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders, and the use of medications. In addition, the use of different neuropsychological tests appeared to contribute to heterogeneity of some estimates (e.g., attention/vigilance domain).

CONCLUSION

Euthymic youths with BD exhibit significant cognitive dysfunction encompassing verbal learning and memory, working memory, and/or visual learning and memory domains. These data indicate that for a subset of individuals with BD, neurodevelopmental factors may contribute to cognitive dysfunction.

Parenting Stress Among Caregivers of Children With Bipolar Spectrum Disorders

Caregivers of psychiatrically impaired children experience considerable parenting stress. However, no research has evaluated parenting stress within the context of pediatric bipolar spectrum disorders (BPSD). Thus, the aim of this investigation was to identify predictors and moderators of stress among caregivers in the Longitudinal Assessment of Manic Symptoms study. Participants included 640 children and their caregivers in the Longitudinal Assessment of Manic Symptoms cohort. Children had a mean age of 9.4 ± 1.9 years (68% male, 23% BPSD); parents had a mean age of 36.5 ± 8.3 years (84% mothers). Children with BPSD had more service utilization, psychiatric diagnoses, mood and anxiety symptoms, and functional impairment but fewer disruptive behavior disorders. Caregivers of children with BPSD were more likely than caregivers of children without BPSD to have a partner, elevated depressive symptoms, antisocial tendencies, and parenting stress (Cohen's d = .49). For the whole sample, higher child IQ, mania, anxiety, disruptive behavior, and caregiver depression predicted increased parenting stress; maternal conduct disorder predicted lower stress. Child anxiety and disruptive behavior were associated with elevated caregiver stress only for non-BPSD children. Caregivers of children with BPSD experience significant burden and thus require specialized, family-focused interventions. As stress was also elevated, to a lesser degree, among depressed caregivers of children with higher IQ, mania, anxiety, and disruptive behavior, these families may need additional supports as well. Although parents with conduct/antisocial problems evidenced lower stress, these difficulties should be monitored. Thus, parenting stress should be evaluated and addressed in the treatment of childhood mental health problems, especially BPSD.

Neurocognition and psychosocial functioning in adolescents with bipolar disorder

BACKGROUND

Adults with bipolar disorder demonstrate significantly poorer psychosocial functioning and neurocognition compared to controls. In adult bipolar disorder neurocognition predicts a substantial portion of variance in functioning. Adolescents with bipolar disorder have reducedpsychosocial functioning, but less is known about neurocognitive impairments, and no studies have examined the relationship between neurocognition and functioning in an adolescent sample.

METHODS

38 adolescents with bipolar disorder and 49 healthy controls under 20 years of age completed assessments of psychosocial functioning, neurocognitive ability, and psychiatric symptoms.

RESULTS

Adolescents with bipolar disorder had significantly poorer psychosocial functioning in domains of daily activities, social functioning, and satisfaction with functioning, ps<.006, compared to healthy controls. They also had poorer general neurocognitive functioning than controls, p=.004, with the greatest impairment on a test of sustained attention. Neurocognition was not a significant predictor of psychosocial functioning in this sample, but depressive symptoms significantly predicted functioning in all domains, p<.033.

LIMITATIONS

Limited sample size did not allow for complex statistical analyses. Differences in demographic characteristics of the clinical and control groups may limit generalization of these results.

CONCLUSIONS

This adolescent sample with bipolar disorder experiences significantly poorer neurocognitive and psychosocial functioning compared to controls; however, psychosocial functioning appears to be more strongly related to mood symptoms than to neurocognition. Future work is needed to delineate the time course of neurocognitive functioning and its relation to psychosocial functioning across the course of illness. Adolescence may provide an ideal time for cognitive enhancement and intensive psychosocial intervention.

Longitudinal Course of Bipolar Disorder in Youth With High-Functioning Autism Spectrum Disorder

OBJECTIVE

To provide the first longitudinal characterization of mood and psychosocial functioning in youth with comorbid bipolar (BD) and autism spectrum (ASD) disorders.

METHOD

The Course and Outcome of Bipolar Youth study followed 368 youth (aged 7-17 years) with DSM-IV bipolar I (BP-I), BP-II, or Not Otherwise Specified (NOS) for, on average, 9 years using the Longitudinal Interval Follow-up Evaluation. This subgroup analysis compared youth with and without ASD on clinical presentation, percentage of time with mood symptomatology, and psychosocial functioning.

RESULTS

Thirty youth (∼8%) met DSM-IV criteria for Asperger's disorder or pervasive developmental disorder-NOS (referred to here as ASD). Lifetime worst episode severity was similar in both groups, but youth with both BD and ASD (BD+ASD) had elevated rates of comorbid attention-deficit/hyperactivity and obsessive-compulsive disorders, were younger at intake, and had an earlier onset of mood symptoms. Over time, in both groups, the proportion of predominantly euthymic youth increased, and episode recurrence decreased. Compared to youth with BD, the clinical presentation of youth with BD+ASD more frequently involved distractibility, racing thoughts, depressed mood, social withdrawal, and low reactivity of negative mood states. ASD-related symptomatic differences were generally strongest early and decreased over time. Youth with BD+ASD had significantly greater impairment in friendships throughout follow-up.

CONCLUSION

Youth with BD+ASD exhibit typical BD mood symptoms but with earlier onset, mixed symptom presentation, and additive functional impairments. Significant amelioration of clinical symptoms occurred over time, suggesting that early recognition and treatment of mood disorders in youth with ASD may improve clinical outcomes.

Medication Adherence Among Adolescents with Bipolar Disorder

OBJECTIVE

To examine medication adherence and associated factors among adolescents with bipolar disorder (BP) using both objective and subjective methods.

METHOD

Participants were 21 adolescents with a primary BP diagnosis recruited from a pediatric specialty clinic. All participants were prescribed at least one psychotropic medication. Self- and parent-reported adherence were assessed monthly over 6 months. Objective data on medication adherence were gathered through an electronic weekly pillbox. Demographic and clinical factors were assessed through self, parent, and physician ratings at baseline, 3, and 6 months.

RESULTS

Objective data indicate 41.5% of doses (58.6% of days) were not taken as prescribed over a mean of 3 months of follow-up. Subjective reports (patient, parent, and physician) significantly overestimated adherence as compared with objective data. Factors from multiple domains were associated with poorer adherence, including more daily doses, higher weight, dose timing (poorer on mornings/afternoons and weekends), less temporal proximity to medication management appointment, greater self-reported cognitive difficulties with adhering to treatment; the most potent predictor of missed doses was greater overall illness severity.

CONCLUSIONS

Findings provide further evidence of poor medication adherence among youth with BP, and highlight the limits of subjective report of adherence. Providers should give careful attention to adherence when making decisions regarding treatment response and changes to medication regimen when working with youth with BP.

Effects of ankyrin 3 gene risk variants on brain structures in patients with bipolar disorder and healthy subjects

AIM

The intronic single-nucleotide polymorphism rs10994336 of the ankyrin 3 gene (ANK3 ) is one of the genome-wide supported risk variants for bipolar disorder (BD), and the T-allele of rs10761482 is also reported to have relevance to BD. We investigated the effect of ANK3 rs10761482 genetic variation on brain structure.

METHODS

Subjects were 43 BD patients and 229 healthy volunteers. We evaluated the effects of ANK3 rs10761482 genetic variation on diagnosis, and of the genotype-by-diagnosis interaction on the brain structure and the degree of age-related brain atrophy on magnetic resonance imaging data evaluated by voxel-based morphometry.

RESULTS

BD patients showed significantly lower fractional anisotropy value in the bilateral parietal regions, left fronto-occipital fasciculus, and corpus callosum, compared to healthy subjects. Further, we found considerable decreases of fractional anisotropy in the forceps minor in non-T-allele BD patients compared with the T-carrier patient group. We also found significant lessening of age-related brain atrophy in the T-allele carrier groups compared with the non-T-allele carrier groups in the area around the cerebrospinal space, cingulate cortices, and cerebellum.

CONCLUSION

Our results suggest the influence of the ANK3 on age-related brain atrophy. The ankyrin 3 genotype may be associated with pathogenesis of age-related neurodegeneration, and, in part, of BD.

Functioning Among Youth with Comorbid Mood Disorder and Chronic Physical Illness in Public Sector Care

OBJECTIVE

The current study examines parent/caregiver and youth report of psychosocial and health-related functioning among youth served in public systems of care, with mood disorder only, comorbid mood disorder and chronic physical illness, and chronic physical illness only.

METHOD

Participants were 539 youths (ages, 11-18; 64% male) with a mood disorder and/or chronic physical illness enrolled in a study of public sector care. Presence of mood disorder was based on youth report on the Diagnostic Interview Schedule for Children-IV. Parents reported whether they had been told by a school or health professional that their child had 1 of 8 categories of chronic physical illnesses. Psychosocial functioning was assessed with the Child Behavior Checklist and Youth Self Report. Parent and child versions of the Child Health Questionnaire assessed health-related functioning. Covariates included demographic variables, substance use, mental health service utilization, disruptive behavior disorders, and anxiety disorders. Multivariate analysis of covariances assessed differences on outcome measures among the 3 groups.

RESULTS

Parents and youths reported significantly worse psychosocial and health-related functioning for youth with comorbid mood and physical illnesses. Generally, parents reported lower functioning in youth with a physical illness compared with mood disorder, and youth with mood disorders reported lower functioning than those with physical illness.

CONCLUSION

Youth with comorbid mood disorder and chronic physical illness experience high levels of impairment. Increased screening of mood disorders in pediatric health settings is warranted. Health systems, clinics, and clinicians should focus on integrating mental and physical health diagnosis and treatment.

Theory of Mind in Adolescents with Bipolar Disorder in Euthymic Phase: ‎Using the Strange Stories Test

Objective: This study evaluated the theory of mind (ToM) in adolescents diagnosed with bipolar disorder ‎‎(BD) during their euthymic period compared to a typically developing (TD) group.‎ Method: The BD group consisted of thirty 11-18 year old inpatients in euthymic phase. The TD ‎group included 30 age, gender, and IQ matched volunteer students. To assess the diagnosis and ‎comorbid disorders, we performed the semi-structured interview of the Kiddie Schedule for Affective Disorders ‎and Schizophrenia-Present and Lifetime Version (K-SADS-PL) for the BD adolescents. To ‎evaluate the severity of attention deficit hyperactivity disorder (ADHD) and mania, Conner's ‎Parent Rating Scale-Revised version (CPRS-R), and Young Mania Rating Scale (YMRS) were ‎used, respectively. Ravens Progressive Matrices was conducted to evaluate intellectual ability in ‎the both groups. Happe Strange Stories test was performed to assess ToM in the participants. Data were ‎analyzed using the independent t-test, analysis of covariance, and Pearson Correlation analysis.‎ Results: The two groups did not show any differences in comprehending the stories; however, the BD ‎group's mentalizing scores were significantly weaker than the TD group (p<0.05).‎‎ Conclusion: The ToM impairments in adolescents with BD may be explained as a trait marker which may lead ‎to continuation of social problems even during remission‏.‏.

Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder

Greater understanding of cognitive function in children and adolescents with bipolar disorder (BD) is of critical importance to improve our ability to design targeted treatments to help with real-world impairment, including academic performance. We sought to evaluate cognitive performance among children with either BD type I, II, or "not otherwise specified" (NOS) participating in multi-site Course and Outcome of Bipolar Youth study compared to typically developing controls (TDC) without psychopathology. In particular, we sought to test the hypothesis that BD-I and BD-II youths with full threshold episodes of mania or hypomania would have cognitive deficits, including in reversal learning, vs. those BD-NOS participants with sub-threshold episodes and TDCs. N = 175 participants (BD-I = 81, BD-II = 11, BD-NOS = 28, TDC = 55) completed Cambridge Neuropsychological Automated Testing Battery (CANTAB) tasks. A priori analyses of the simple reversal stage of the CANTAB intra-/extra-dimensional shift task showed that aggregated BD-I/II participants required significantly more trials to complete the task than either BD-NOS participants with sub-syndromal manic/hypomanic symptoms or than TDCs. BD participants across sub-types had impairments in sustained attention and information processing for emotionally valenced words. Our results align with prior findings showing that BD-I/II youths with distinct episodes have specific alterations in reversal learning. More broadly, our study suggests that further work is necessary to see the interaction between neurocognitive performance and longitudinal illness course. Additional work is required to identify the neural underpinnings of these differences as targets for potential novel treatments, such as cognitive remediation.

Age associations with neural processing of reward anticipation in adolescents with bipolar disorders

Reward/behavioral approach system hypersensitivity is implicated in bipolar disorders (BD) and in normative development during adolescence. Pediatric onset of BD is associated with a more severe illness course. However, little is known about neural processing of rewards in adolescents with BD or developmental (i.e., age) associations with activation of these neural systems. The present study aims to address this knowledge gap. The present sample included 21 adolescents with BD and 26 healthy adolescents, ages 13 to 19. Participants completed a functional magnetic resonance imaging (fMRI) protocol using the Monetary Incentive Delay (MID) task. Behavioral performance was similar between groups. Group differences in BOLD activation during target anticipation and feedback anticipation periods of the task were examined using whole-brain analyses, as were group differences in age effects. During both target anticipation and feedback anticipation, adolescents with BD, compared to adolescents without psychopathology, exhibited decreased engagement of frontal regions involved in cognitive control (i.e., dorsolateral prefrontal cortex). Healthy adolescents exhibited age-related decreases, while adolescents with BD exhibited age-related increases, in activity of other cognitive control frontal areas (i.e., right inferior frontal gyrus), suggesting altered development in the BD group. Longitudinal research is needed to examine potentially abnormal development of cognitive control during reward pursuit in adolescent BD and whether early therapeutic interventions can prevent these potential deviations from normative development.

The Influence of Trauma, Life Events, and Social Relationships on Bipolar Depression

A growing body of research suggests that the social environment exerts a powerful influence on the course of bipolar depression. This article reviews longitudinal research to suggest that trauma, negative life events, social support deficits, and family difficulties are common and predict a more severe course of depression when present among those diagnosed with bipolar disorder. The triggers of bipolar depression overlap with those documented for unipolar depression, suggesting that many of the treatment targets for unipolar depression may be applicable for bipolar depression.

Pilot Effectiveness Evaluation of Community-Based Multi-Family Psychoeducational Psychotherapy for Childhood Mood Disorders

Several psychosocial, family-focused Evidence-Based Treatments (EBTs) for youth with disruptive behavior have proven effective in practice settings. However, limited research has examined community implementation of EBTs for pediatric depression and bipolar disorder. This pilot open trial evaluated Multi-Family Psychoeducational Psychotherapy (MF-PEP) with 41 children ages 7 to 12 (54% male, 92% Caucasian) with mood disorders and their parents in an outpatient setting. MF-PEP is an 8-session, adjunctive EBT with parallel child and parent groups. Fourteen community therapists facilitated six MF-PEP groups at three agencies over two years. Developed checklists were used to evaluate adherence. Clinical outcomes were measured via clinician assessment and self-report questionnaires at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up, and analyzed via hierarchical linear modeling. Therapist group adherence ranged from 66.71% to 78.68% (M = 72.14%, SD = 4.85). Children experienced significant improvement in depressive and manic symptoms, and parents reported a significant increase in knowledge of mood disorders. Children with bipolar disorder and families with limited treatment history benefitted most from MF-PEP. Effect sizes (Cohen's d) ranged from small to large for mood outcomes (d = 0.34 to 1.18), knowledge (d = 1.02), and treatment beliefs (d = 0.04 to 0.41). Limitations included small sample, missing data, and open design. Results suggest that MF-PEP may be impactful for families affected by pediatric mood disorders in the community, especially among youth with bipolar disorder and families novice to treatment. Randomized controlled trials are needed to provide more definitive evidence for the effectiveness of MF-PEP in practice settings.