What goes up must come down: the burden of bipolar depression in youth

Comparing self-reported quality of life in youth with bipolar versus other disorders

OBJECTIVES

This study benchmarks quality of life (QoL) of youth with bipolar disorder (BD) against healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders. The relative impacts of depressive, (hypo)manic, mixed, and externalizing symptoms on QoL are tested for youth with BD.

METHOD

In total, 657 youth completed the Schedule for Affective Disorders and Schizophrenia for Children (KSADS), the KSADS depression and mania scales, the Parent General Behavior Inventory (PGBI), and the Child Behavior Checklist (CBCL). Youth-reported QoL was determined by the Revised Children Quality of Life Questionnaire (KINDL) and was compared to healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders.

RESULTS

Youth with BD reported poorer QoL overall and on most subscales compared to healthy youth, youth with chronic medical conditions, youth with behavior disorders, and youth with other non-behavior/non-mood disorders. QoL in youth with BD did not differ significantly from QoL in youth with unipolar depression. Parent-report and interview-rated depressive symptoms were associated with decreases in Total QoL and all QoL subscales except Family. Externalizing symptoms were associated with decreases in Family QoL and increases in Friend QoL, and (hypo)manic symptoms were associated with increases in Emotional Well-Being QoL.

CONCLUSIONS

Depressive symptoms may drive the decline in QoL causing youth with BD to rate their QoL worse than healthy youth, youth with chronic medical conditions, and youth with behavior disorders, but not worse than youth with unipolar depression.

Cognitive, Family, and Quality-of-Life Characteristics of Youth with Depression Associated with Bipolar Disorder

Background: Depression associated with bipolar disorder (BD) is more common compared to mania. Cognitive, family, and quality-of-life (QOL) factors associated with pediatric bipolar depression are understudied. The goal of this study was to evaluate cognitive, family environmental, and QOL characteristics of youth with bipolar depression. Methods: Thirty-two youth (12-18 years of age) with BD type I currently depressed were recruited from inpatient and outpatient setting. Subjects were assessed using the Behavior Rating Inventory of Executive Function (BRIEF), the Family Environment Scale (FES), and the Child Health Questionnaire-Parental-Form 50 (CHQ-PF50). Results were compared with population norms and the relationship between these domains was calculated. Results: Youth with depression associated with BD did not show significant impairment in executive functions. They displayed impaired family environment in the domains of cohesion, independence, achievement orientation, and organization. Youth also displayed impairments in the psychosocial health domains compared with the population normative data. The CHQ-Psychosocial health significantly negatively correlated with the BRIEF-Global Executive Control score (r = -0.76, p < 0.0001). Conclusion: Depression in youth with BD is associated with impairments in family functioning and QOL. Impairments in psychosocial QOL are associated with cognitive functioning. Further intervention studies examining executive functioning and family environment as treatment targets are needed. ClinicalTrials.gov identifier:NCT00232414.

Fourteen-year trends in the prescribing patterns of pediatric bipolar patients discharged from two public mental hospitals in Taiwan

INTRODUCTION

The management of pediatric bipolar disorder (PBD) requires pharmacotherapy to control acute symptoms, reduce relapse, prevent suicide, and improve psychosocial functioning. The purpose of this study was to investigate prescribing patterns among PBD patients discharged from two public mental hospitals in Taiwan, from 2006 to 2019.

METHODS

PBD patients discharged from the two study hospitals, from 1 January 2006 to 31 December 2019 (n = 420), were included in the analysis. Prescribed drugs at discharge, including mood stabilizers (i.e., lithium, valproate, carbamazepine, and lamotrigine), antipsychotics (i.e., second- and first-generation antipsychotics, SGAs and FGAs), and antidepressants, were explored. Complex polypharmacy was defined as the use of 3 or more agents among the prescribed drugs. Time trends of each prescribing pattern were analyzed using the Cochran-Armitage Trend test.

RESULTS

The most commonly prescribed psychotropic agents were SGAs (76.0%), followed by valproate (65.7%) and FGAs (24.8%). The prescription rates of SGAs, antidepressants, antidepressant plus antipsychotic, and antidepressant without mood stabilizer significantly increased over time, whereas the prescription rates of mood stabilizers, lithium, and FGAs significantly decreased.

DISCUSSIONS

Prescribing patterns changed greatly for PBD patients over time. However, much more evidence supporting the effectiveness of psychotropic agents in PBD patients is required.

Systematic Review and Network Meta-analysis: Efficacy and Safety of Second-Generation Antipsychotics in Youths With Bipolar Depression

OBJECTIVE

To assess the relative efficacy and safety of second-generation antipsychotics for treating major depressive episodes in youths with bipolar disorder.

METHOD

A systematic literature review using PRISMA guidelines and network meta-analysis (NMA) of randomized controlled trials (RCTs) of second-generation antipsychotics for bipolar depression in youths 10 to 18 years of age was conducted. Efficacy measures included Children's Depression Rating Scale, Revised (CDRS-R) and Clinical Global Impressions-Bipolar Disorder-Severity Depression (CGI-BP-S-depression) and Overall (CGI-BP-S-overall) scores. Available safety outcomes included discontinuations (all-cause, lack of efficacy, adverse events), metabolic parameters (weight change, cholesterol, triglycerides, glucose), changes in prolactin, and somnolence. Results from the NMA were reported as mean changes from baseline or odds ratios (OR) with 95% credible intervals (CrIs).

RESULTS

Four RCTs comparing placebo to lurasidone, quetiapine (1 each for immediate- and extended-release), and the olanzapine-fluoxetine combination (OFC) met all of the inclusion criteria. Lurasidone and OFC demonstrated similar and statistically significant improvements in CDRS-R, but quetiapine did not (lurasidone: -5.70 [-8.66, -2.76]; OFC: -5.01 [-8.63, -1.38]; quetiapine: -1.85 [-5.99, 2.27]). Lurasidone was associated with smaller changes in weight, cholesterol, and triglycerides from baseline compared to OFC and quetiapine. There were no differences in changes in glucose levels among antipsychotics. In addition, lurasidone was associated with smaller change in prolactin levels compared to OFC but not quetiapine.

CONCLUSION

Evidence from 4 studies in this NMA indicated that lurasidone and OFC, but not quetiapine, were efficacious for the treatment of bipolar depression in youths. Lurasidone was associated with less weight gain and smaller impacts on cholesterol and triglycerides compared with quetiapine and OFC.

Elevated Epidermal Growth Factor (EGF) as Candidate Biomarker of Mood Disorders-Longitudinal Study in Adolescent and Young Adult Patients

Bipolar disorder (BD) is a chronic mental disorder that affects more than 1% of the population worldwide. Over 65% of patients experience early onset of the disease. Most cases of juvenile bipolar disorder begin with a depressed mood episode, and up to 50% of youth initially diagnosed with major depression go onto developing a BD. Our study aimed to find biomarkers of diagnosis conversion in young patients with mood disorders. We performed a two-year follow-up study on 79 adolescent patients diagnosed with MDD or BD, with a detailed clinical assessment at five visits. We monitored diagnosis change from MDD to BD. The control group consisted of 31 healthy youths. According to the neurodevelopmental and neuroimmunological hypotheses of mood disorders, we analyzed serum levels of brain-derived neurotrophic factor (BDNF), proBDNF, epidermal growth factor (EGF), migration inhibitory factor (MIF), stem cell factor (SCF), and correlations with clinical factors. We detected a significant disease-dependent increase in EGF level in MDD and BP patients at baseline exacerbation of depressive or hypomanic/manic episodes as well as in euthymic state compared to healthy controls. No potential biological predictors of disease conversion were found. Replication studies on a larger cohort of patients are needed.

Analysis of the psychometric properties of the five-factor self-concept questionnaire (AF-5) in Spanish students during the COVID-19 lockdown

The present research aims to analyse the psychometric properties of the AF5 questionnaire for its adaptation for use with young people during a lockdown period. Research was conducted with a sample of 534 students aged between 13 and 17 years (M = 14.49; SD = 1.805). Exploratory factor analysis was conducted using the FACTOR program and confirmatory factor analysis was conducted using the M-PLUS 7 program. Results indicate that a four-dimensional model is most appropriate for bringing together the emotional and physical dimensions. Further, 11 items were removed due to poor factor loadings. The majority of factors were directly and positively correlated (99%; p < .01). The data obtained supports conclusions that the AF-5 meets validity and reliability requirements for it to be considered a useful instrument for use with young people during the COVID-19 lockdown period.

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.

Cross-Sectional Study of Self-Concept and Gender in Relation to Physical Activity and Martial Arts in Spanish Adolescents during the COVID-19 Lockdown

The COVID-19 lockdown has negatively affected individuals’ welfare. However, there has been no research published heretofore about the levels of self-concept (SC) in adolescents, nor how having practised martial arts (MA) or any physical activity (PA) before the lockdown may have influenced the SC in that time. Hence, this study aimed to analyze some demographic, physical, and psychosocial parameters in Spanish adolescents throughout the COVID-19 quarantine through a cross-sectional investigation, establishing correlations among these factors. Methods: The present study had a descriptive, comparative, and cross-sectional design. The sample comprised of 54 (39.7%) male and 82 (60.3%) female Spanish adolescents aged 12–18 (M = 14.49; SD = 1.80). An ad-hoc questionnaire collected sociodemographic data; the self-concept Form 5 (AF5) questionnaire obtained data on SC dimensions. Results: There were some differences among the SC dimensions, with family and academic dimensions having higher values than the physical and emotional ones. Females’ academic SC was higher than that of males (p = 0.019). The practice of PA before the lockdown was positively associated with physical (p < 0.001) and social (p = 0.012) SC, yet there was no significant association between the previous practice of MA and SC (p > 0.050). Conclusions: the findings suggest that the COVID-19 lockdown negatively affected Spanish adolescents by decreasing their total SC and some dimensions of it, although PA may buffer psychological harmfulness in adolescents.

Immune response to stress induction as a predictor of cognitive-behavioral therapy outcomes in adolescent mood disorders: A pilot study

Cognitive-behavioral therapy (CBT) alleviates symptoms of depression in youth with bipolar disorder (BD) and major depressive disorder (MDD). Empirical research has linked inflammatory markers to depressive symptoms and acute psychosocial stress; however, a gap remains as to whether immune response to stress may serve as a putative mechanism of treatment. This preliminary pilot study determined the modest feasibility of assessing psychobiological response to stress as a predictor of CBT outcomes for youth with mood disorders. We evaluated whether participation in a 10-session group-CBT intervention for mood disorders altered inflammatory response to a laboratory psychosocial stress induction and if this alteration in immune stress responsivity was related to a decrease in depressive symptoms. Thirty-four youth (age M = 15.03, SD = 1.91) diagnosed with BD or MDD participated in a 10-session CBT group and pre- and post-group assessments; twenty-eight participants who completed the group had usable cytokine data. Pre- and post-group assessments included stress induction with the Trier Social Stress Test (TSST) during which inflammatory cytokines were measured at baseline (time 0) and after the TSST at 30, 60, and 90 min. Results suggest it is modestly feasible to measure immune response to stress alongside CBT treatment for adolescent mood disorders. Our findings were mixed; across seven cytokines, hierarchical linear models indicated two cytokines, IL6 and IL12, were sensitive to acute laboratory stress. We also found significant correlations between life stress, inflammation, and depression both pre- and post- CBT group. Inflammation pre-group, as measured by IL12 and IL1 β predicted depressive symptoms following treatment. Although we did not find significant within-subject reductions in inflammation, chronic stress predicted changes in IL β, signaling the central role of chronic stress. This study offers preliminary evidence that immune responsivity to stress induction could serve as a mechanism of treatment for mood disorders in youth, indicating a potential marker for more personalized model of healthcare.

Parsing cyclothymic disorder and other specified bipolar spectrum disorders in youth

OBJECTIVE

Most studies of pediatric bipolar disorder (BP) combine youth who have manic symptoms, but do not meet criteria for BP I/II, into one "not otherwise specified" (NOS) group. Consequently, little is known about how youth with cyclothymic disorder (CycD) differ from youth with BP NOS. The objective of this study was to determine whether youth with a research diagnosis of CycD (RDCyc) differ from youth with operationalized BP NOS.

METHOD

Participants from the Course and Outcome of Bipolar Youth study were evaluated to determine whether they met RDCyc criteria. Characteristics of RDCyc youth and BP NOS youth were compared at baseline, and over eight-years follow-up.

RESULTS

Of 154 youth (average age 11.96 (3.3), 42% female), 29 met RDCyc criteria. RDCyc youth were younger (p = .04) at baseline. Over follow-up, RDCyc youth were more likely to have a disruptive behavior disorder (p = .01), and were more likely to experience irritability (p = .03), mood reactivity (p = .02), and rejection sensitivity (p = .03). BP NOS youth were more likely to develop hypomania (p = .02), or depression (p = .02), and tended to have mood episodes earlier in the eight-year follow-up period.

LIMITATIONS

RDCyc diagnoses were made retrospectively and followed stringent criteria, which may highlight differences that, under typical clinical conditions and more vague criteria, would not be evident.

CONCLUSION

There were few differences between RDCyc and BP NOS youth. However, the ways in which the groups diverged could have implications; chronic subsyndromal mood symptoms may portend a severe, but ultimately non-bipolar, course. Longer follow-up is necessary to determine the trajectory and outcomes of CycD symptoms.

Quality of life in children and adolescents with bipolar I depression treated with olanzapine/fluoxetine combination

BACKGROUND

We examined the efficacy of olanzapine/fluoxetine combination (OFC) in improving health-related quality of life (QoL) in the treatment of bipolar depression in children and adolescents.

METHODS

Patients aged 10-17 years with bipolar I disorder, depressed episode, baseline children's depression rating scale-revised (CDRS-R) total score ≥40, Young Mania Rating Scale (YMRS) total score ≤15, and YMRS-item 1 ≤ 2 were randomized to OFC (6/25-12/50 mg/day olanzapine/fluoxetine; n = 170) or placebo (n = 85) for up to 8 weeks of double-blind treatment. Patients and parents completed the revised KINDL questionnaire for measuring health-related QoL in children and adolescents (KINDL-R) at baseline and endpoint. The mean change in CDRS-R total and item scores were used to compare improvement in symptomatology in patients taking OFC and placebo. Tests were 2-sided using a Type I error cutoff of 0.05, and no adjustments for multiple comparisons were made.

RESULTS

Baseline QoL as measured by the KINDL-R was substantially impaired relative to published norms for a healthy school-based sample. OFC-treated patients demonstrated an improvement over placebo at endpoint with respect to mean change from baseline in the patient-rated KINDL-R Self-esteem subscale score (p = 0.028), and in the parent KINDL-R ratings of emotional well-being (p = 0.020), Self-esteem (p = 0.030), and Family (p = 0.006). At endpoint, OFC-treated patients still had a lower QoL compared to the normative population. OFC showed significant improvement (p ≤ 0.05) versus placebo on the CDRS-R total score and on 7 of the 17 CDRS-R items.

CONCLUSIONS

Patients aged 10-17 years with an acute episode of bipolar depression and their parents reported greater improvements (parents noticed improvements in more areas than did their offspring) on some aspects of QoL when treated with OFC compared with placebo. However, after 8 weeks of treatment, KINDL-R endpoint scores remained lower than those of the, presumably healthy, control population. Clinical trial registration information A Study for Assessing Treatment of Patients Ages 10-17 with Bipolar Depression; http://www.clinicaltrials.gov; NCT00844857.

Distinguishing bipolar disorder from other psychiatric disorders in children

Pediatric onset bipolar disorder (BD) is a challenging diagnosis with potentially debilitating outcomes. This review aims to critically evaluate recently published literature relevant to the diagnosis of BD in youth, emphasizing interesting and important new findings characterizing pediatric BD and reporting updates in the diagnostic and statistical manual relevant to this disorder in youth. Challenges regarding the diagnosis of BD will be discussed, in addition to important distinctions with other childhood disorders, including other bipolar spectrum disorders; major depressive disorder; dysthymia; disruptive mood dysregulation disorder (DMDD); attention-deficit/hyperactivity disorder (ADHD) and other disruptive behavioral disorders; anxiety disorders, including post-traumatic stress disorder (PTSD); psychotic disorders; autism spectrum disorders; substance use disorders; and borderline personality disorder. The review concludes with a comment on past research limitations and future directions in the field.