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Sesso G, Masi G. Pharmacological strategies for the management of the antisocial personality disorder. Expert Rev Clin Pharmacol 2023; 16:181-194. [PMID: 36787887 DOI: 10.1080/17512433.2023.2181159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Antisocial personality disorder (AsPD) is a pervasive pattern of violation of others' rights, related to the concept of psychopathy. AsPD is stable over time from adolescence, with evidence of conduct disorder (CD) before 15 years. DSM-5 included a specifier 'with limited prosocial emotions' (LPE), which characterizes adolescents with higher developmental vulnerability to develop AsPD. Despite being relatively frequent with considerable societal impact, AsPD is a difficult-to-treat condition with high comorbidity rates and poor evidence for effective pharmacological interventions. AREAS COVERED We conducted a narrative review and searched PubMed up to September 2022. We included RCTs and naturalistic studies evaluating pharmacological interventions on AsPD in adults, including those with comorbid substance use disorder or psychopathic traits. Evidence in youths with CD, callous-unemotional (CU) traits and aggression were also reviewed, exploring the role of CU traits as moderators of response. EXPERT OPINION Psychosocial interventions are the first option, with possible improvement of CU traits, beyond behavioral and affective symptoms, particularly if implemented early during development. Limited information, based on low-quality studies, supports the pharmacological options. Second-generation antipsychotics, lithium, anti-epileptic drugs, and stimulants are first-line medications, according to different target symptoms. Developmental pathways including ADHD suggest a specific role of psychostimulants.
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Affiliation(s)
- Gianluca Sesso
- Social and Affective Neuroscience Group, Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Gabriele Masi
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
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2
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Janiri D, Moccia L, Montanari S, Zani V, Prinari C, Monti L, Chieffo D, Mazza M, Simonetti A, Kotzalidis GD, Janiri L. Use of Lithium in Pediatric Bipolar Disorders and Externalizing Childhood- related Disorders: A Systematic Review of Randomized Controlled Trials. Curr Neuropharmacol 2023; 21:1329-1342. [PMID: 36703581 PMCID: PMC10324336 DOI: 10.2174/1570159x21666230126153105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/24/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Lithium is the standard treatment for bipolar disorders (BD) in adults. There is a dearth of data on its use in the pediatric age. This review aimed to investigate the use of lithium in pediatric bipolar disorder (BD) and other externalizing childhood-related disorders. METHODS We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify randomized controlled trials evaluating the use of lithium in pediatric (BD), conduct disorder (CD), attention deficit hyperactivity disorder, oppositional defiant disorder, and disruptive mood dysregulation disorder. The primary outcome of our study was to evaluate the efficacy of lithium compared to a placebo or other pharmacological agents. The secondary outcomes were acceptability and tolerability. RESULTS Twelve studies were eligible, 8 on BD and 4 on CD. Overall, 857 patients were treated with lithium. No studies for externalizing disorder diagnoses were identified. Regarding BD patients (n = 673), efficacy results suggested that lithium was superior to placebo in manic/mixed episodes but inferior to antipsychotics. Lithium efficacy ranged from 32% to 82.4%. Results on maintenance need to be expanded. Comorbidity rates with other externalizing disorders were extremely high, up to 98.6%. Results in CD patients (n= 184) suggested the efficacy of lithium, especially for aggressive behaviors. No severe adverse events directly related to lithium were reported in BD and CD; common side effects were similar to adults. CONCLUSION This systematic review supports the use of lithium in BD and CD as an efficacious and generally well-tolerated treatment in the pediatric age. However, evidence is limited due to the paucity of available data.
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Affiliation(s)
- Delfina Janiri
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
| | - Lorenzo Moccia
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
| | - Silvia Montanari
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Valentina Zani
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Claudia Prinari
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Laura Monti
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- UOS Clinical Psychology, Clinical Government, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, 00168, Rome, Italy
| | - Daniela Chieffo
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- UOS Clinical Psychology, Clinical Government, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, 00168, Rome, Italy
| | - Marianna Mazza
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
| | - Alessio Simonetti
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
- Centro Lucio Bini, Via Crescenzio 42, Rome, 00193, Italy
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1 Baylor Plaza, Houston, 77030, TX, USA
| | - Georgios D. Kotzalidis
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
- Centro Lucio Bini, Via Crescenzio 42, Rome, 00193, Italy
- NESMOS Department, La Sapienza, Faculty of Medicine and Psychology, Sant’Andrea University Hospital, University of Rome, Via di Grottarossa, 1035-1039, Rome, 00189, Italy
| | - Luigi Janiri
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
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Sesso G, Brancati GE, Masi G. Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management. Curr Neuropharmacol 2023; 21:911-934. [PMID: 35794777 PMCID: PMC10227908 DOI: 10.2174/1570159x20666220706104117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/14/2022] [Accepted: 06/13/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment. METHODS This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders. RESULTS These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches. CONCLUSION The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.
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Affiliation(s)
- Gianluca Sesso
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiat., Calambrone (Pisa), Italy
| | | | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiat., Calambrone (Pisa), Italy
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Masi G, Berloffa S, Muratori P, Mucci M, Viglione V, Villafranca A, Inguaggiato E, Levantini V, Placini F, Pfanner C, D’Acunto G, Lenzi F, Liboni F, Milone A. A Naturalistic Study of Youth Referred to a Tertiary Care Facility for Acute Hypomanic or Manic Episode. Brain Sci 2020; 10:brainsci10100689. [PMID: 33003515 PMCID: PMC7600970 DOI: 10.3390/brainsci10100689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022] Open
Abstract
Background: Bipolar Disorders (BD) in youth are a heterogeneous condition with different phenomenology, patterns of comorbidity and outcomes. Our aim was to explore the effects of gender; age at onset (prepubertal- vs. adolescent-onset) of BD; and elements associated with attention deficit hyperactivity disorder (ADHD) and Substance Use Disorder (SUD) comorbidities, severe suicidal ideation or attempts, and poorer response to pharmacological treatments. Method: 117 youth (69 males and 57 females, age range 7 to 18 years, mean age 14.5 ± 2.6 years) consecutively referred for (hypo)manic episodes according to the Diagnostic and Statistical Manual of Mental Disorders, 54th ed (DSM 5) were included. Results: Gender differences were not evident for any of the selected features. Prepubertal-onset BD was associated with higher rates of ADHD and externalizing disorders. SUD was higher in adolescent-onset BD and was associated with externalizing comorbidities and lower response to treatments. None of the selected measures differentiated patients with or without suicidality. At a 6-month follow up, 51.3% of the patients were responders to treatments, without difference between those receiving and not receiving a psychotherapy. Clinical severity at baseline and comorbidity with Conduct Disorder (CD) and SUD were associated with poorer response. Logistic regression indicated that baseline severity and number of externalizing disorders were associated with a poorer outcome. Conclusions: Disentangling broader clinical conditions in more specific phenotypes can help timely and focused preventative and therapeutic interventions.
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Affiliation(s)
- Gabriele Masi
- Correspondence: ; Tel.: +39-050-886-111; Fax: +39-050-886-301
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Roley-Roberts ME, Fristad MA. Moderators of Treatment for Pediatric Bipolar Spectrum Disorders. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2020; 50:464-477. [DOI: 10.1080/15374416.2020.1772082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Mary A. Fristad
- Department of Psychiatry, The Ohio State University Wexner Medical Center
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6
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Yapıcı Eser H, Taşkıran AS, Ertınmaz B, Mutluer T, Kılıç Ö, Özcan Morey A, Necef I, Yalçınay İnan M, Öngür D. Anxiety disorders comorbidity in pediatric bipolar disorder: a meta-analysis and meta-regression study. Acta Psychiatr Scand 2020; 141:327-339. [PMID: 31899546 DOI: 10.1111/acps.13146] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Anxiety disorders (AD) are known for its comorbidity and negative impact on the course of adult bipolar disorder (BD). However, there is limited research on AD comorbidity in pediatric BD (PBD). Here, we aimed to conduct a meta-analysis and meta-regression study about the comorbidity and covariates of AD and PBD. METHOD We systematically searched relevant articles published until May 2019, as defined in PRISMA guidelines. Variables for associated features and prevalence of AD were extracted. RESULTS Thirty-seven articles represented data for the analysis. Lifetime any AD comorbidity was 44.7%; panic disorder (PD) was 12.7%; generalized anxiety disorder (GAD) was 27.4%; social phobia was 20.1%; separation anxiety disorder (SAD) was 26.1%; and obsessive-compulsive disorder (OCD) was 16.7%. Childhood-onset studies reported higher GAD and SAD comorbidity, while adolescent-onset studies reported higher PD, OCD, and social phobia. Age of onset, gender, comorbidity of ADHD, substance use, oppositional defiant disorder and conduct disorder affected each anxiety disorders' comorbidity with PBD differently. CONCLUSION Anxiety disorders are highly comorbid with PBD. Early-onset PBD increases the risk of AD. Biopsychosocial aspects of this comorbidity and its course needs to be evaluated further.
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Affiliation(s)
- H Yapıcı Eser
- School of Medicine, Department of Psychiatry, Koç University, İstanbul, Turkey.,Research Center for Translational Medicine, Koç University, İstanbul, Turkey
| | - A S Taşkıran
- School of Medicine, Department of Psychiatry, Koç University, İstanbul, Turkey.,Child Mind Institute, New York, NY, USA
| | - B Ertınmaz
- School of Medicine, Koç University, İstanbul, Turkey
| | - T Mutluer
- School of Medicine, Department of Psychiatry, Koç University, İstanbul, Turkey
| | - Ö Kılıç
- Koç University Hospital, İstanbul, Turkey
| | | | - I Necef
- Koç University Hospital, İstanbul, Turkey
| | | | - D Öngür
- Harvard Medical School, Boston, MA, USA.,McLean Hospital, Belmont, MA, USA
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Perugi G, Pallucchini A, Rizzato S, Pinzone V, De Rossi P. Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD). Expert Opin Pharmacother 2019; 20:1457-1470. [PMID: 31112441 DOI: 10.1080/14656566.2019.1618270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: ADHD is characterized by a developmentally inappropriate level of inattentiveness, impulsivity and/or hyperactivity. In adults, the disorder is frequently accompanied by Emotional Dysregulation (ED), associated to a variety of related psychiatric comorbidities, complicating its recognition and treatment management. Areas covered: This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in adults with ADHD and ED, other neurodevelopmental disorders, Bipolar Disorder (BD) and Anxiety Disorders (ADs). When controlled data are unavailable, the authors have included open-label and observational studies. Expert opinion: ED in adult patients with ADHD is a very common and impairing problem that can be treated with stimulants or atomoxetine. ADHD studies in adults with other neurodevelopment disorders are scarce; stimulants seem to be the most effective and safe drugs in treating ADHD symptoms, without worsening the core features of other neurodevelopmental disorders. In patients with ADHD and comorbid BD, the treatment of BD alone may result in residual symptoms of ADHD. Patients should be treated hierarchically: BD should be treated first, while ADHD should be treated combining ADHD medications and mood stabilizers after mood stabilization. The available evidence for treating patients with ADHD and comorbid ADs in adults supports the idea of an anti-anxiety/ADHD-specific treatment association.
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Affiliation(s)
- Giulio Perugi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa , Pisa , Italy
| | - Alessandro Pallucchini
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa , Pisa , Italy
| | - Salvatore Rizzato
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome , Rome , Italy
| | - Vito Pinzone
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome , Rome , Italy
| | - Pietro De Rossi
- NESMOS Department (Neurosciences, Mental Health, and Sensory Organs), Sapienza University of Rome, School of Medicine and Psychology, Sant'Andrea Hospital , Rome , Italy.,Department of Neurology and Psychiatry, Sapienza University of Rome , Rome , Italy.,Department of Psychiatry, ASL Roma 5 , Rome , Italy
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8
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Comorbid disorders as moderators of response to family interventions among adolescents with bipolar disorder. J Affect Disord 2019; 246:754-762. [PMID: 30623821 PMCID: PMC6363856 DOI: 10.1016/j.jad.2018.12.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/15/2018] [Accepted: 12/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND While family interventions have shown efficacy in improving mood symptoms and family functioning in pediatric bipolar disorder, few studies have examined the effects of comorbid psychiatric conditions on patients' symptomatic or functional responses to treatment. METHODS 145 adolescents with bipolar I or II disorder were randomly assigned to family-focused therapy (FFT-A) or a brief psychoeducational therapy (enhanced care; EC) and followed over 2 years. Participants received pharmacotherapy for the study's duration. We examined whether comorbid anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders (DBDs; i.e., oppositional defiant and conduct disorder) predicted the proportion of weeks that participants experienced mood symptoms during follow-up, and whether comorbid disorders moderated the effects of treatment assignment on mood symptoms and family conflict. RESULTS Comorbid anxiety was associated with a greater proportion of weeks with depressive symptoms, more severe (hypo)manic symptoms during follow-up, and greater family conflict over the 2-year study. Comorbid ADHD was associated with a greater proportion of weeks with (hypo)manic symptoms, more severe (hypo)manic symptoms, and greater family conflict. Additionally, youth with comorbid ADHD who received FFT-A had more favorable trajectories of (hypo)manic symptoms and family functioning than youth with comorbid ADHD who received EC. Comorbid DBDs were consistently associated with more severe depressive symptoms and greater family conflict throughout the study. LIMITATIONS Randomization to treatments was not stratified on comorbid disorders. The longitudinal trajectories of anxiety, attentional, and disruptive behavior symptoms were not examined. CONCLUSIONS The course of bipolar disorder in adolescents is strongly affected by comorbid disorders. Future research should examine whether adolescents with more complex presentations of bipolar disorder should be treated with different or more intensive psychosocial protocols than adolescents without these presentations.
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Musetti L, Tundo A, Benedetti A, Massimetti G, Cambiali E, Pergentini I, Del Grande C, Dell'Osso L. Lithium, valproate, and carbamazepine prescribing patterns for long-term treatment of bipolar I and II disorders: A prospective study. Hum Psychopharmacol 2018; 33:e2676. [PMID: 30311959 DOI: 10.1002/hup.2676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/11/2018] [Accepted: 09/05/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This study aims to describe the prescription patterns of the mood stabilizers most commonly used for the treatment of bipolar I and II disorders (lithium, valproate, and carbamazepine) and to analyze the treatment outcomes. METHODS Two hundred and thirty-four outpatients with bipolar disorders receiving prophylactic treatment with lithium, valproate, carbamazepine, or their combination were followed up for at least 18 months in two Italian psychiatric centers specialized in mood disorders. RESULTS The combination of lithium and valproate or carbamazepine was the most common prophylactic treatment (54.3%), followed by valproate or carbamazepine (24%) and lithium monotherapy (22%). Polytherapy was prescribed mainly to patients with bipolar I disorder, a high number of previous episodes and lifetime psychotic symptoms, whereas valproate or carbamazepine monotherapy was prescribed to patients with anxiety comorbidity. The annual frequency of recurrences decreased significantly after entering the study in the overall sample, and the reduction was significantly higher in patients on lithium plus valproate or carbamazepine compared with the valproate or carbamazepine group, but not with the lithium monotherapy group. The number of mixed recurrences during the follow-up was significantly higher in patients on lithium plus valproate or carbamazepine. CONCLUSIONS Our findings may help clinicians to personalize long-term treatment to prevent relapses of bipolar disorder according to clinical presentation.
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Affiliation(s)
- Laura Musetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandra Benedetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gabriele Massimetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erika Cambiali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Irene Pergentini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudia Del Grande
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Goldstein BI, Birmaher B, Carlson GA, DelBello MP, Findling RL, Fristad M, Kowatch RA, Miklowitz DJ, Nery FG, Perez‐Algorta G, Van Meter A, Zeni CP, Correll CU, Kim H, Wozniak J, Chang KD, Hillegers M, Youngstrom EA. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disord 2017; 19:524-543. [PMID: 28944987 PMCID: PMC5716873 DOI: 10.1111/bdi.12556] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/14/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Over the past two decades, there has been tremendous growth in research regarding bipolar disorder (BD) among children and adolescents (ie, pediatric BD [PBD]). The primary purpose of this article is to distill the extant literature, dispel myths or exaggerated assertions in the field, and disseminate clinically relevant findings. METHODS An international group of experts completed a selective review of the literature, emphasizing areas of consensus, identifying limitations and gaps in the literature, and highlighting future directions to mitigate these gaps. RESULTS Substantial, and increasingly international, research has accumulated regarding the phenomenology, differential diagnosis, course, treatment, and neurobiology of PBD. Prior division around the role of irritability and of screening tools in diagnosis has largely abated. Gold-standard pharmacologic trials inform treatment of manic/mixed episodes, whereas fewer data address bipolar depression and maintenance/continuation treatment. Adjunctive psychosocial treatment provides a forum for psychoeducation and targets primarily depressive symptoms. Numerous neurocognitive and neuroimaging studies, and increasing peripheral biomarker studies, largely converge with prior findings from adults with BD. CONCLUSIONS As data have accumulated and controversy has dissipated, the field has moved past existential questions about PBD toward defining and pursuing pressing clinical and scientific priorities that remain. The overall body of evidence supports the position that perceptions about marked international (US vs elsewhere) and developmental (pediatric vs adult) differences have been overstated, although additional research on these topics is warranted. Traction toward improved outcomes will be supported by continued emphasis on pathophysiology and novel therapeutics.
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Affiliation(s)
- Benjamin I Goldstein
- Centre for Youth Bipolar DisorderSunnybrook Health Sciences CentreTorontoCanada,Departments of Psychiatry and PharmacologyUniversity of TorontoTorontoCanada
| | - Boris Birmaher
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Gabrielle A Carlson
- Department of PsychiatryStony Brook University School of MedicineStony BrookNYUSA
| | - Melissa P DelBello
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | - Robert L Findling
- Department of Psychiatry & Behavioral SciencesThe Johns Hopkins UniversityBaltimoreMDUSA
| | - Mary Fristad
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | - Robert A Kowatch
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | | | - Fabiano G Nery
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | | | - Anna Van Meter
- Ferkauf Graduate School of PsychologyYeshiva UniversityBronxNYUSA
| | | | - Christoph U Correll
- The Zucker Hillside HospitalDepartment of PsychiatryNorthwell HealthGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineHofstra Northwell School of MedicineHempsteadNYUSA
| | - Hyo‐Won Kim
- Department of PsychiatryUniversity of Ulsan College of MedicineAsan Medical CenterSeoulKorea
| | - Janet Wozniak
- Clinical and Research Program in Pediatric PsychopharmacologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Kiki D Chang
- Department of PsychiatryStanford UniversityPalo AltoCAUSA
| | - Manon Hillegers
- Department of Child and Adolescent Psychiatry and PsychologyErasmus Medical Center‐SophiaRotterdamThe Netherlands
| | - Eric A Youngstrom
- Department of Psychology and NeuroscienceUniversity of North CarolinaChapel HillNCUSA
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11
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Donfrancesco R, Di Trani M, Andriola E, Leone D, Torrioli MG, Passarelli F, DelBello MP. Bipolar Disorder in Children With ADHD: A Clinical Sample Study. J Atten Disord 2017; 21:715-720. [PMID: 25015582 DOI: 10.1177/1087054714539999] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the impact of early-onset bipolar disorder (pediatric bipolar disorder [PBD]) on ADHD. METHOD We compared ADHD symptom severity, ADHD subtype distribution, and rates of comorbid and familial psychiatric disorders between 49 ADHD children with comorbid PBD and 320 ADHD children without PBD. RESULTS Children with ADHD and PBD showed higher scores in the Hyperactive and Inattentive subscales of the ADHD Rating Scale, than children with ADHD alone. The frequency of combined subtype was significantly higher in ADHD children with PBD, than in those with ADHD alone. ADHD children with PBD showed a higher rate of familial psychiatric disorders than ADHD children without PBD. The rate of conduct disorder was significantly greater in children with PBD and ADHD compared with children with ADHD alone. CONCLUSION ADHD along with PBD presents with several characteristics that distinguish it from ADHD alone, suggesting that these may be distinct disorders.
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12
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Giles LL, Martini DR. Challenges and Promises of Pediatric Psychopharmacology. Acad Pediatr 2016; 16:508-18. [PMID: 27064142 DOI: 10.1016/j.acap.2016.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 03/05/2016] [Accepted: 03/28/2016] [Indexed: 01/27/2023]
Abstract
Most prescriptions for psychotropic medications are written by primary care physicians, yet pediatricians, many of whom are teaching residents and medical students about pediatric psychopharmacology, often feel inadequately trained to treat mental health concerns. Over the past several decades, the number, size, and quality of psychopharmacologic studies in youth has greatly increased. Here we review the current evidence for efficacy and safety of each of the major pharmacologic drug classes in youth (psychostimulants, antidepressants, mood stabilizers, and antipsychotics). Psychostimulants have a robust body of literature supporting their evidence as first-line treatment for attention-deficit/hyperactivity disorder. Selective serotonin reuptake inhibitors (SSRIs) have documented efficacy for pediatric depression and multiple different anxiety disorders with childhood onset. Combining cognitive-behavioral therapy with SSRI treatment enhances treatment benefit and minimizes adverse events of medication. Mood stabilizers, including lithium and anticonvulsant medications, have a less robust strength of evidence and come with more problematic side effects. However, they are increasingly prescribed to youth, often to treat irritability, mood lability, and aggression, along with treatment of bipolar disorder. Antipsychotics have long been a mainstay of treatment for childhood-onset schizophrenia, and in recent years, the evidence base for providing antipsychotics to youth with bipolar mania and autistic disorder has grown. Most concerning with antipsychotics are the metabolic side effects, which appear even more problematic in youth than adults. By better understanding the evidence-based psychopharmacologic interventions, academic pediatricians will be able to treat patients and prepare future pediatrician to address the growing mental health care needs of youth.
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Affiliation(s)
- Lisa L Giles
- Departments of Pediatrics and Psychiatry, University of Utah School of Medicine and Department of Psychiatry and Behavioral Health, Primary Children's Hospital, Salt Lake City, Utah.
| | - D Richard Martini
- Departments of Pediatrics and Psychiatry, University of Utah School of Medicine and Department of Psychiatry and Behavioral Health, Primary Children's Hospital, Salt Lake City, Utah
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Frías Á, Palma C, Farriols N. Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment. J Affect Disord 2015; 174:378-89. [PMID: 25545605 DOI: 10.1016/j.jad.2014.12.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/03/2014] [Accepted: 12/04/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Research on pediatric bipolar disorder (PBD) is providing a plethora of empirical findings regarding its comorbidity. We addressed this question through a systematic review concerning the prevalence, clinical impact, etiology and treatment of main comorbid disorders involved. METHOD A comprehensive database search was performed from 1990 to August 2014. Overall, 167 studies fulfilled the inclusion criteria. RESULTS Bipolar youth tend to suffer from comorbid disorders, with highest weighted mean prevalence rate arising from anxiety disorders (54%), followed by attention deficit hyperactivity disorder (ADHD) (48%), disruptive behavior disorders (31%), and substance use disorders (SUD) (31%). Furthermore, evidence indicates that ADHD and anxiety disorders negatively affect the symptomatology, neurocognitive profile, clinical course and the global functioning of PBD. Likewise, several theories have been posited to explain comorbidity rates in PBD, specifically common risk factors, one disorder being a risk factor for the other and nosological artefacts. Lastly, randomized controlled trials highlight a stronger therapeutic response to stimulants and atomoxetine (vs. placebo) as adjunctive interventions for comorbid ADHD symptoms. In addition, research focused on the treatment of other comorbid disorders postulates some benefits from mood stabilizers and/or SGA. LIMITATIONS Epidemiologic follow-up studies are needed to avoid the risk of nosological artefacts. Likewise, more research is needed on pervasive developmental disorders and anxiety disorders, especially regarding their etiology and treatment. CONCLUSIONS Psychiatric comorbidity is highly prevalent and is associated with a deleterious clinical effect on pediatric bipolarity. Different etiological pathways may explain the presence of these comorbid disorders among bipolar youth. Standardized treatments are providing ongoing data regarding their effectiveness for these comorbidities among bipolar youth.
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Affiliation(s)
- Álvaro Frías
- FPCEE Blanquerna, University of Ramon-Llull, Císterst 34, 08022 Barcelona, Spain; Adult Outpatient Mental Health Center, Hospital of Mataró, Mataró, Spain.
| | - Cárol Palma
- FPCEE Blanquerna, University of Ramon-Llull, Císterst 34, 08022 Barcelona, Spain; Adult Outpatient Mental Health Center, Hospital of Mataró, Mataró, Spain
| | - Núria Farriols
- FPCEE Blanquerna, University of Ramon-Llull, Císterst 34, 08022 Barcelona, Spain; Adult Outpatient Mental Health Center, Hospital of Mataró, Mataró, Spain
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Ko A, Swampillai B, Timmins V, Scavone A, Collinger K, Goldstein BI. Clinical characteristics associated with lithium use among adolescents with bipolar disorder. J Child Adolesc Psychopharmacol 2014; 24:382-9. [PMID: 25010788 DOI: 10.1089/cap.2013.0120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Little is known regarding demographic and/or clinical characteristics associated with the use of lithium among adolescents with bipolar disorder (BP) in naturalistic clinical settings. We therefore examined factors associated with lithium among adolescents with BP presenting to a tertiary outpatient clinic. METHODS Participants were 100 adolescents 13-19 years of age, with BP-I, BP-II, or BP not otherwise specified (BP-NOS). Diagnoses and lifetime medication exposure were determined using the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (KSADS-PL). Analyses examined for demographic and clinical correlates of lifetime lithium exposure. RESULTS Twenty percent of participants reported lifetime lithium use. Participants with, versus those without, lifetime lithium use were significantly older and significantly more likely to have BP-I, lifetime history of psychiatric hospitalization, and psychosis. Lithium-treated participants were significantly more likely to report use of second-generation antipsychotics (SGAs) and antimanic anticonvulsants. In contrast, participants with lithium exposure were significantly less likely to have BP-II, self-injurious behavior, and a family history of depression. Adolescents with lithium exposure had significantly less parent-reported family conflict and mood lability, and significantly less self-reported impulsivity, emotional dysregulation, identity confusion, and interpersonal problems. In multivariable analyses, lithium use was associated with greater lifetime SGA use, lower parent-reported family conflict, and lower adolescent-reported interpersonal problems. CONCLUSIONS Lithium was infrequently used among adolescents with BP in this sample. Although constrained by retrospective methodology and a single site, our findings suggest that clinicians may be deferring lithium use until late in treatment. The fact that there are lower rates of lithium use among adolescents with suicidal ideation, impulsivity, mood lability, and family history of depression suggests potential missed opportunities for use of lithium among high-risk adolescents with BP.
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Affiliation(s)
- Athena Ko
- Centre for Youth Bipolar Disorder , Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Abstract
This review focuses mainly on published articles regarding the treatment of school-aged children and adolescents with pediatric bipolar disorder. In light of systematic reviews, large randomized controlled trial data are emphasized wherever possible. This review addresses the treatment of acute manic/mixed episodes, including combination treatment, the preliminary literature regarding bipolar depression among youth, treatment in the face of comorbid conditions, and maintenance treatment. Suggestions regarding future directions are offered. A clinical vignette describing a teen with bipolar disorder is presented and bipolar medications, dosing, efficacy, side effects, contraindications, and succinct comments on each medication are summarized.
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Vitiello B, Riddle MA, Yenokyan G, Axelson DA, Wagner KD, Joshi P, Walkup JT, Luby J, Birmaher B, Ryan ND, Emslie G, Robb A, Tillman R. Treatment moderators and predictors of outcome in the Treatment of Early Age Mania (TEAM) study. J Am Acad Child Adolesc Psychiatry 2012; 51:867-78. [PMID: 22917200 PMCID: PMC3427533 DOI: 10.1016/j.jaac.2012.07.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 06/21/2012] [Accepted: 07/02/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Both the diagnosis and treatment of bipolar disorder in youth remain the subject of debate. In the Treatment of Early Age Mania (TEAM) study, risperidone was more effective than lithium or divalproex in children diagnosed with bipolar mania and highly comorbid with attention-deficit/hyperactivity disorder (ADHD). We searched for treatment moderators and predictors of outcome. METHOD TEAM was a multi-site, 8-week, randomized clinical trial of risperidone, lithium, or divalproex in 279 medication-naïve patients, aged 6 through 15 years, with a DSM-IV diagnosis of bipolar disorder currently in manic or mixed phase. Outcome measures included binary end-of-treatment responder status and change in the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Mania Rating Scale (KMRS). Baseline demographics and clinical characteristics were tested as modifiers of treatment effect and as overall predictors of outcome. RESULTS Moderator effects were detected for site, ADHD, and obesity. Across sites, the response ratio (RR) for risperidone versus lithium ranged from 1.2 (95% confidence interval [CI] = 0.8-1.7) to 8.3 (95% CI = 1.1-60.8), and for risperidone versus divalproex from 1.3 (95% CI = 0.8-2.2) to 10.5 (95% CI = 1.4-77.7). The RR for risperidone versus lithium was 2.1 for patients with ADHD, but 1.0 for those without ADHD, and 2.3 (95% CI = 1.6-3.3) for nonobese patients, but 1.1 (95% CI = 0.6-2.0) for obese ones. Older age and less severe ADHD symptoms were associated with greater improvement on the KMRS. CONCLUSIONS Risperidone was more effective than lithium or divalproex across the demographics and clinical characteristics of the sample, but the magnitude of its effect was influenced by site-related characteristics and presence of ADHD. Clinical trial registration information--Treatment of Early Age Mania; http://clinicaltrials.gov/; NCT00057681.
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Strawn JR, Patel NC, Chu WJ, Lee JH, Adler CM, Kim MJ, Bryan HS, Alfieri DC, Welge JA, Blom TJ, Nandagopal JJ, Strakowski SM, DelBello MP. Glutamatergic effects of divalproex in adolescents with mania: a proton magnetic resonance spectroscopy study. J Am Acad Child Adolesc Psychiatry 2012; 51:642-51. [PMID: 22632623 PMCID: PMC4499458 DOI: 10.1016/j.jaac.2012.03.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 02/28/2012] [Accepted: 03/27/2012] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study used proton magnetic resonance spectroscopy ((1)H MRS) to evaluate the in vivo effects of extended-release divalproex sodium on the glutamatergic system in adolescents with bipolar disorder, and to identify baseline neurochemical predictors of clinical remission. METHOD Adolescents with bipolar disorder who were experiencing a manic or mixed episode (N = 25) were treated with open-label, extended-release divalproex (serum levels 85-125 μg/mL) and underwent (1)H MRS scanning at baseline (before treatment) and on days 7 and 28. Healthy comparison subjects (n = 15) also underwent (1)H MRS scanning at the same time points. Glutamate (Glu) and glutamate+glutamine (Glx) concentrations were measured in three voxels: anterior cingulate cortex (ACC), left ventrolateral prefrontal cortex (LVLPFC), and right ventrolateral prefrontal cortex (RVLPFC), and were compared between bipolar and healthy subjects. Within the bipolar subjects, Glu and Glx concentrations at baseline and each time point were also compared between remitters and nonremitters after divalproex treatment. RESULTS At baseline, no differences in Glu or Glx concentrations between bipolar and healthy subjects were observed. Group (HC vs. BP) by time effects revealed an interaction for Glu in the ACC, and change over time effects for Glx were noted in the ACC in patients with bipolar disorder (increase from day 0 to day 7 and then a decrease from day 7 to day 28) but not in HC. Remitters had significantly lower baseline Glx concentrations in LVLPFC, and in remitters the change in LVLPFC Glu correlated with the change in YMRS score. CONCLUSIONS Successful treatment of mania with divalproex may be predicted by lower baseline concentrations of Glx in the LVLPFC. In addition, in remitters, the degree of symptomatic improvement is related to the change in Glu concentrations in this region, suggesting that divalproex may work via modulation of the prefrontal glutamatergic system in youth with bipolar disorder.
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Affiliation(s)
- Jeffrey R Strawn
- University of Cincinnati, College of Medicine, Cincinnati, OH 45267, USA
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Cummings CM, Fristad MA. Anxiety in children with mood disorders: a treatment help or hindrance? JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2012; 40:339-51. [PMID: 21912843 PMCID: PMC4340699 DOI: 10.1007/s10802-011-9568-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examined the role of comorbid anxiety in treatment outcome for children with mood disorders (N = 165; age 8-11) participating in Multi-Family Psychoeducational Psychotherapy (MF-PEP). Assessments occurred at baseline, 6, 12, and 18 months for two randomly assigned groups: immediate treatment and 1-year wait-list. Most children (69%) had comorbid anxiety disorders. Baseline comorbid anxiety, as reported on the Children's Interview for Psychiatric Syndromes (ChIPS), was associated with higher Children's Depression Rating Scale- Revised (CDRS-R) scores but not Young Mania Rating Scale (YMRS) scores. Higher levels of anxiety symptoms were associated with lower Children's Global Assessment Scale (C-GAS) scores. Participation in MF-PEP did not significantly reduce anxiety symptoms (p = 0.62). However, presence of comorbid anxiety did not impede reduction in depressive (CDRS-R, p = 0.74) or manic (YMRS scores, p = 0.94) symptoms following MF-PEP. More baseline anxiety symptoms were associated with greater improvement in C-GAS scores post-treatment (p = 0.02). Implications are discussed.
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Affiliation(s)
- Colleen M Cummings
- Department of Psychology, Temple University, Weiss Hall, 1701 N. 13th St., Philadelphia, PA 19122, USA.
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Donfrancesco R, Miano S, Martines F, Ferrante L, Melegari MG, Masi G. Bipolar disorder co-morbidity in children with attention deficit hyperactivity disorder. Psychiatry Res 2011; 186:333-7. [PMID: 20692046 DOI: 10.1016/j.psychres.2010.07.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Revised: 07/05/2010] [Accepted: 07/08/2010] [Indexed: 11/30/2022]
Abstract
The present study aimed at: (1) exploring rate and clinical features of superimposed bipolar disorder (BD) in Italian children with attention deficit hyperactivity disorder (ADHD), compared with a community sample, matched for age and gender; (2) exploring predictors of BD in ADHD children, by comparing ADHD children with or without superimposed BD. We studied 173 consecutive drug-naïve outpatients with ADHD (156 males and 17 females, mean age of 9.2 ± 2.3years, age range 6-17.5 years), diagnosed with a clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL)); the control group consisted of a community-based sample of 100 healthy children. The rate of children with a diagnosis of BD was higher in the ADHD group (29/173, 16.7%) compared with controls (1/100, 1%), (P<0.001). Among the 29 children with ADHD+BD, 16 (55.2%) had a Bipolar Disorder-Not Otherwise Specified (BD-NOS), and 11 (37.9%) showed ultrarapid cycling. Compared with children with ADHD without BD, they showed a higher rate of combined sub-type (21/29, 72.4%), a higher score at ADHD-Rating Scale (total score and hyperactivity subscale), higher rates of major depression, oppositional defiant disorder and conduct disorder. In summary, children with ADHD present a higher risk for developing a superimposed BD. The identification of clinical features with an increased risk of BD can improve diagnosis, prognosis and treatments.
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Masi G, Mucci M, Pias P, Muratori F. Managing bipolar youths in a psychiatric inpatient emergency service. Child Psychiatry Hum Dev 2011; 42:1-11. [PMID: 20644996 DOI: 10.1007/s10578-010-0197-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Among the youths referred to our Psychiatric Inpatient Emergency Service, we focused on bipolar disorder (BD), to explore predictive elements for the outcome. Fifty-one patients (30 males, 21 females, age range 8-18 years, mean age 14.2 ± 3.1 years) received a diagnosis of BD, according to historical information, prolonged observations, and a structured clinical interview (K-SADS-PL). Twenty-seven patients (52.9%) were responders at the end of hospitalization according to CGI-I 1 or 2 and 50% decrease of both Brief Psychiatric Rating Scale (BPRS) and Young Mania Rating Scale (YMRS). Responders received a longer hospitalization. Non responders were more severe at baseline, had higher scores at BPRS (namely positive symptoms), and were more aggressive. Environmental/social stressors and comorbidities were frequent, but they did not affect the outcome. In summary, BD in emergency settings may represent a subtype with clinical and therapeutic peculiarities, and specific challenges for mental health services.
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Affiliation(s)
- Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Via dei Giacinti 2, 56018 Calambrone, Pisa, Italy.
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