Bipolar offspring: a window into bipolar disorder evolution

Differentiating white matter measures that protect against vs. predispose to bipolar disorder and other psychopathology in at-risk youth

Bipolar disorder (BD) is highly heritable. Identifying objective biomarkers reflecting pathophysiological processes predisposing to, versus protecting against BD, can help identify BD risk in offspring of BD parents. We recruited 21 BD participants with a first-degree relative with BD, 25 offspring of BD parents, 27 offspring of comparison parents with non-BD psychiatric disorders, and 32 healthy offspring of healthy parents. In at-risk groups, 23 had non-BD diagnoses and 29, no Axis-I diagnoses(healthy). Five at-risk offspring who developed BD post scan(Converters) were included. Diffusion imaging(dMRI) analysis with tract segmentation identified between-group differences in the microstructure of prefrontal tracts supporting emotional regulation relevant to BD: forceps minor, anterior thalamic radiation(ATR), cingulum bundle(CB), and uncinate fasciculus(UF). BD participants showed lower fractional anisotropy (FA) in the right CB (anterior portion) than other groups (q < 0.05); and in bilateral ATR (posterior portion) versus at-risk groups (q < 0.001). Healthy, but not non-BD, at-risk participants showed significantly higher FA in bilateral ATR clusters than healthy controls (qs < 0.05). At-risk groups showed higher FA in these clusters than BD participants (qs < 0.05). Non-BD versus healthy at-risk participants, and Converters versus offspring of BD parents, showed lower FA in the right ATR cluster (qs < 0.05). Low anterior right CB FA in BD participants versus other groups might result from having BD. High bilateral ATR FA in at-risk groups, and in healthy at-risk participants, versus healthy controls might protect against BD/other psychiatric disorders. Absence of elevated right ATR FA in non-BD versus healthy at-risk participants, and in Converters versus non-converter offspring of BD parents, might lower protection against BD in at-risk groups.

Medication exposure and predictors of first mood episode in offspring of parents with bipolar disorder: a prospective study

OBJECTIVES

To prospectively investigate whether baseline clinical characteristics and medication exposure predict development of major depressive disorder or bipolar disorder in offspring of parents with bipolar disorder.

METHODS

Youth aged 9-20 years with at least one biological parent with bipolar disorder and no prior history of mood or psychotic episodes (n=93) were prospectively evaluated and treated naturalistically during the study. Participants were divided into two groups: converters, defined as those who met DSM-IV criteria for a mood episode during follow-up (n=19); or non-converters (n=74). Logistic regression models were used to investigate associations between baseline clinical variables and medication exposure during follow-up and risk of developing a first mood episode (conversion).

RESULTS

Multivariate regression analyses showed that baseline anxiety disorders and subsyndromal mood disorders were associated with increased risk of conversion during follow-up. Adding medication exposure to the multivariate model showed that exposure to antidepressants during follow-up was associated with increased risk of conversion.

CONCLUSIONS

Caution should be used when treating bipolar offspring with anxiety and/or emerging depressive symptoms using antidepressant agents, given the increased risk of developing a major mood disorder.

Parental bipolar disorder, family environment, and offspring psychiatric disorders: A systematic review

BACKGROUND

Our objective was to systematically review non-experimental studies of parental bipolar disorder (BD), current family environment, and offspring psychiatric disorders to identify characteristics of family environment associated with parental BD and risk for offspring psychiatric disorders.

METHODS

CINAHL, Embase, PsycINFO, and PubMed were searched using MeSH terms to identify studies on offspring of BD parents published through September 2017. We followed PRISMA guidelines and used the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS). We calculated prevalence ratios and 95% confidence intervals to compare offspring psychiatric disorders within and across studies.

RESULTS

Of 10,454 unique documents retrieved, we included 13 studies. The most consistent finding was lower parent-reported cohesion in families with a BD parent versus no parental psychiatric disorders. Family environment did not differ between BD parents and parents with other disorders. Offspring of BD parents had higher prevalence of psychiatric disorders than offspring of parents without psychiatric disorders but did not differ from offspring of parents with other disorders. Families with a BD child had higher conflict than families without a BD child.

LIMITATIONS

Comparisons between studies were qualitative. A single reviewer conducted screening, data extraction, and bias assessment.

CONCLUSIONS

Family environment in families with a BD parent is heterogeneous. The pattern of findings across studies also suggests that family problems may be associated with parental psychiatric illness generally rather than parental BD in particular. Few studies included offspring-reported measures. Given the association of family conflict with offspring mood disorders, further study is merited on children's perceptions of the family environment in the BD high-risk context.

Early recognition of bipolar disorder

Bipolar disorders are frequently not diagnosed until long after their onset, leaving patients with no or correspondingly inadequate treatment. The course of the disorder is all the more severe and the negative repercussions for those affected all the greater. Concerted research effort is therefore going into learning how to recognize bipolar disorders at an early stage. Drawing on current research results, this paper presents considerations for an integrative Early Symptom Scale with which persons at risk can be identified and timely intervention initiated. This will require prospective studies to determine the predictive power of the risk factors integrated into the scale.

The use of component-wise gradient boosting to assess the possible role of cognitive measures as markers of vulnerability to pediatric bipolar disorder

BACKGROUND AND AIMS

Cognitive impairments are primary hallmarks symptoms of bipolar disorder (BD). Whether these deficits are markers of vulnerability or symptoms of the disease is still unclear. This study used a component-wise gradient (CGB) machine learning algorithm to identify cognitive measures that could accurately differentiate pediatric BD, unaffected offspring of BD parents, and healthy controls.

METHODS

59 healthy controls (HC; 11.19 ± 3.15 yo; 30 girls), 119 children and adolescents with BD (13.31 ± 3.02 yo, 52 girls) and 49 unaffected offspring of BD parents (UO; 9.36 ± 3.18 yo; 22 girls) completed the CANTAB cognitive battery.

RESULTS

CGB achieved accuracy of 73.2% and an AUROC of 0.785 in classifying individuals as either BD or non-BD on a dataset held out for validation for testing. The strongest cognitive predictors of BD were measures of processing speed and affective processing. Measures of cognition did not differentiate between UO and HC.

CONCLUSIONS

Alterations in processing speed and affective processing are markers of BD in pediatric populations. Longitudinal studies should determine whether UO with a cognitive profile similar to that of HC are at less or equal risk for mood disorders. Future studies should include relevant measures for BD such as verbal memory and genetic risk scores.

Differences in Psychopathology between Offspring of Parents with Bipolar I Disorder and Those with Bipolar II Disorder: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to evaluate differences in psychopathology between offspring of parents with bipolar I disorder (BP-I) and those with bipolar II disorder (BP-II).

METHODS

The sample included 201 offspring between 6 and 17 years of age who had at least one parent with BP-I or BP-II. The offspring were diagnostically evaluated using the Korean Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version. Psychopathology and Clinical characteristics were evaluated, including lifetime DSM-5 diagnoses, depression, and childhood trauma. Lifetime DSM-5 diagnoses were also compared between schoolchildren aged 6 to 11 years and adolescents aged 12 to 17 years.

RESULTS

In lifetime DSM-5 diagnoses, offspring of parents with BP-I had significantly increased risk of developing MDD and BP-I than those with BP-II. Regarding clinical characteristics, ADHD rating scale and childhood trauma scale were significantly higher in offspring of parents with BP-I than that in those with BP-II.

CONCLUSION

The present study supports that BP-I may be etiologically distinct from BP-II by a possible genetic liability. Our findings indicate that additional research related to bipolar offspring is needed to enhance understanding of differences between BP-I and BP-II.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Neurocognitive functioning in individuals with bipolar disorder and their healthy siblings: A preliminary study

BACKGROUND

Cognitive deficits have been consistently reported in individuals with bipolar disorder (BD). The cognitive profile of siblings of individuals with BD is, however, less clearly established possibly due to the heterogeneity of neuropsychological measures used in previous studies. The aim of this exploratory study was to assess the cognitive function of siblings of individuals with BD and compare it with that of their first-degree relatives suffering with BD, and healthy controls (HC) using the Cambridge Neuropsychological Test Automated Battery (CANTAB) - a comprehensive and validated computerized cognitive battery.

METHODS

We recruited 23 HC (33.52±10.29 years, 8 males), 27 individuals with BD (34.26±10.19 years, 9 males, 25 BDI, 1BDII and 1 BD-NOS), and 15 of their biologically related siblings (37.47±13.15 years, 4 males). Siblings had no current or lifetime history of mental disorders. Participants performed the CANTAB and completed questionnaires assessing mood and global functioning. Multivariate analyses compared CANTAB measures across the three participant groups.

RESULTS

Individuals with BD and their siblings were less accurate in a task of sustained attention (Rapid Visual Processing) when compared to HC. Further, individuals with BD displayed pronounced deficits in affective processing (Affective Go/No-Go) compared to HC. There were no cognitive differences between siblings and individuals with BD. After correcting for current depressive symptoms, these results did not reach statistical significance.

CONCLUSIONS

Subthreshold depressive symptoms may be associated with reduced sustained attention in healthy siblings of BD patients. This preliminary result needs to be corroborated by large-scale, longitudinal studies assessing the relationship between cognition and mood in vulnerable individuals.

Wellbeing and resilience: mechanisms of transmission of health and risk in parents with complex mental health problems and their offspring--The WARM Study

The WARM study is a longitudinal cohort study following infants of mothers with schizophrenia, bipolar disorder, depression and control from pregnancy to infant 1 year of age.

BACKGROUND

Children of parents diagnosed with complex mental health problems including schizophrenia, bipolar disorder and depression, are at increased risk of developing mental health problems compared to the general population. Little is known regarding the early developmental trajectories of infants who are at ultra-high risk and in particular the balance of risk and protective factors expressed in the quality of early caregiver-interaction.

METHODS/DESIGN

We are establishing a cohort of pregnant women with a lifetime diagnosis of schizophrenia, bipolar disorder, major depressive disorder and a non-psychiatric control group. Factors in the parents, the infant and the social environment will be evaluated at 1, 4, 16 and 52 weeks in terms of evolution of very early indicators of developmental risk and resilience focusing on three possible environmental transmission mechanisms: stress, maternal caregiver representation, and caregiver-infant interaction.

DISCUSSION

The study will provide data on very early risk developmental status and associated psychosocial risk factors, which will be important for developing targeted preventive interventions for infants of parents with severe mental disorder.

TRIAL REGISTRATION

NCT02306551, date of registration November 12, 2014.

Affective Processing in Pediatric Bipolar Disorder and Offspring of Bipolar Parents

BACKGROUND

Bipolar disorder (BD) is characterized by biased processing of emotional information. However, little research in this area has been conducted in youth with BD and at-risk individuals. The goal of this study was to determine whether children with BD displayed comparable or more severe manifestations of this bias relative to offspring of parents with BD.

MATERIALS AND METHODS

The sample (n = 57 children and adolescents) included 18 individuals with BD (age: 13.63 ± 2.99; 8 females), 16 offspring of parents with BD (age: 11.83 ± 2.96; 9 females) and 23 healthy controls (HC) (age: 12.789 ± 3.087; 8 females). All participants performed the Affective Go/No-Go (AGN) and the Rapid Visual Processing (RVP) tasks of the Cambridge Neuropsychological Test Automated Battery (CANTAB).

RESULTS

Relative to HC, individuals with BD responded faster to correct trials and committed an elevated number of commission errors across all affective conditions of the AGN task. By contrast, BD offspring showed intact performance accuracy but quicker response times than HC. Post-hoc analyses revealed that this behavioral pattern was observed in BD offspring with mental health problems but not in healthy BD offspring. Overall, mean reaction times and total number of errors in the RVP task were comparable across groups.

CONCLUSIONS

In line with previous findings, subjects with BD encountered difficulties in processing affective information. The tendency toward faster but accurate responses to affective stimuli observed in BD offspring may be a marker of attentional bias toward affective information and constitute a vulnerability marker for mood disorder.

Using structural MRI to identify individuals at genetic risk for bipolar disorders: a 2-cohort, machine learning study

BACKGROUND

Brain imaging is of limited diagnostic use in psychiatry owing to clinical heterogeneity and low sensitivity/specificity of between-group neuroimaging differences. Machine learning (ML) may better translate neuroimaging to the level of individual participants. Studying unaffected offspring of parents with bipolar disorders (BD) decreases clinical heterogeneity and thus increases sensitivity for detection of biomarkers. The present study used ML to identify individuals at genetic high risk (HR) for BD based on brain structure.

METHODS

We studied unaffected and affected relatives of BD probands recruited from 2 sites (Halifax, Canada, and Prague, Czech Republic). Each participant was individually matched by age and sex to controls without personal or family history of psychiatric disorders. We applied support vector machines (SVM) and Gaussian process classifiers (GPC) to structural MRI.

RESULTS

We included 45 unaffected and 36 affected relatives of BD probands matched by age and sex on an individual basis to healthy controls. The SVM of white matter distinguished unaffected HR from control participants (accuracy = 68.9%, p = 0.001), with similar accuracy for the GPC (65.6%, p = 0.002) or when analyzing data from each site separately. Differentiation of the more clinically heterogeneous affected familiar group from healthy controls was less accurate (accuracy = 59.7%, p = 0.05). Machine learning applied to grey matter did not distinguish either the unaffected HR or affected familial groups from controls. The regions that most contributed to between-group discrimination included white matter of the inferior/middle frontal gyrus, inferior/middle temporal gyrus and precuneus.

LIMITATIONS

Although we recruited 126 participants, ML benefits from even larger samples.

CONCLUSION

Machine learning applied to white but not grey matter distinguished unaffected participants at high and low genetic risk for BD based on regions previously implicated in the pathophysiology of BD.

Association of Anxiety Symptoms in Offspring of Bipolar Parents with Serotonin Transporter-Linked Polymorphic Region (5-HTTLPR) Genotype

OBJECTIVE

Offspring of parents with bipolar disorder (BD) have been shown to be at high risk for BD. Anxiety symptoms, even at subclinical levels, have been associated with increased risk for BD in these youth. The s-allele of the serotonin transporter-linked polymorphic region (5-HTTLPR) has been implicated in the pathophysiology of both BD and anxiety disorders and has been associated with pharmacological treatment response and increased risk for antidepressant side effects. Therefore, we aimed to explore 1) whether anxiety symptoms in offspring of BD parents were associated with presence of the 5-HTTLPR s-allele and 2) whether anxiety symptoms in the offspring of BD parents according to the 5-HTTLPR genotypes are related to antianxiety medication status.

METHODS

A total of 64 offspring of BD parents (mean age: 13.7 years) and 51 healthy controls (HC) (mean age: 13.7 years) were compared genetically and on the Multidimensional Anxiety Scale for Children (MASC).

RESULTS

Offspring of BD parents showed higher levels of overall anxiety than did the HC group. Only antianxiety medication naïve offspring of BD parents were found to have an association between 5-HTTLPR genotypes and anxiety symptoms. The antianxiety medication naïve offspring of BD parents with the s-allele showed higher level of overall anxiety than offspring of BD parents with the l/l genotype. No significant differences in anxiety symptoms or their association with the 5-HTTLPR genotype were found in the HC group.

CONCLUSIONS

This study indicated that there may be an association between 5-HTTLPR genotypes and anxiety symptoms in offspring of BD parents, and that antianxiety medication status may affect anxiety symptoms in the offspring of BD patients according to genotype.

Early risk factors for adult bipolar disorder in adolescents with mood disorders: a 15-year follow-up of a community sample

BACKGROUND

We aimed to outline the early risk factors for adult bipolar disorder (BPD) in adolescents with mood disorders.

METHODS

Adolescents (16-17 years old) with mood disorders (n = 287; 90 participants with hypomania spectrum episodes and 197 with major depressive disorder [MDD]) were identified from a community sample. Fifteen years later (at 30-33 years of age), mood episodes were assessed (n = 194). The risk of developing BPD (n = 22), compared with MDD (n = 104) or no mood episodes in adulthood (n = 68), was estimated via logistic regression. Adolescent mood symptoms, non-mood disorders, and family characteristics were assessed as potential risk factors.

RESULTS

Among the adolescents with mood disorders, a family history of BPD was the strongest predictor of developing BPD compared with having no mood episodes in adulthood (OR = 5.94; 95% CI = 1.11-31.73), whereas disruptive disorders significantly increased the risk of developing BPD compared with developing MDD (OR = 2.94; CI = 1.06-8.12). The risk that adolescents with MDD would develop adult BPD, versus having no mood episodes in adulthood, was elevated among those with an early disruptive disorder (OR = 3.62; CI = 1.09-12.07) or multiple somatic symptoms (OR = 6.60; CI = 1.70-25.67). Only disruptive disorders significantly predicted adult BPD among adolescents with MDD versus continued MDD in adulthood (OR = 3.59; CI = 1.17-10.97). Only a few adolescents with hypomania spectrum episodes continued to have BPD as adults, and anxiety disorders appeared to increase this risk.

CONCLUSIONS

Although most of the identified potential risk factors are likely general predictors of continued mood disorders, disruptive disorders emerged as specific predictors of developing adult BPD among adolescents with MDD.

Amygdala enlargement in unaffected offspring of bipolar parents

BACKGROUND

Bipolar disorder (BD) is a devastating disorder with a strong genetic component. While the frontolimbic profile of individuals suffering from BD is relatively well-established, there is still disagreement over the neuroanatomical features of unaffected BD offspring.

MATERIAL AND METHODS

Brain volumetric measures were obtained for 82 children and adolescents including 18 unaffected BD offspring (10.50 ± 3.37 years), 19 BD offspring suffering from psychiatric disorders (12.87 ± 3.28 years) and 45 healthy controls (HC-10.50 ± 3.37 years). Clinical diagnoses were established according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Cortical reconstruction and volumetric segmentation were performed with the Freesurfer image analysis suite. Profile analyses compared frontolimbic volumes across groups. Age, gender, testing site, ethnicity and intracranial volume were entered as covariates.

RESULTS

The right amygdala was significantly larger in unaffected BD offspring compared to BD offspring with psychiatric disorders and HC. Volumes of striatal, hippocampal, cingulate, and temporal regions were comparable across groups.

DISCUSSION

The size of the amygdala may be a marker of disease susceptibility in offspring of BD parents. Longitudinal studies are needed to examine rates of conversion to BD as related to specific pre-morbid brain abnormalities.

The role of social relationships in bipolar disorder: a review

Social relationships and attachment are core developmental elements of human existence and survival that evolve over the lifetime of an individual. The internal and external factors that influence them include the presence of illness in the individual or in their immediate environment. The developmental aspects of attachment and social relationships have become increasingly of interest and relevance in light of early developmental epigenetic modification of gene expression patterns that may influence subsequent behavioral patterns and outcomes. This review examines extant literature on attachment and social relationships in bipolar cohorts. Despite many methodological challenges, the findings indicate that social relationships and capacity for attachment are significantly compromised in individuals with bipolar disorder compared to other mood disorders and normal controls. Though extant research is limited, research clearly points toward the importance of social relationships on the etiology, course, and consequences of bipolar disorder. We highlight a number of key considerations for future research.

Divalproex sodium in the treatment of pediatric psychiatric disorders

Divalproex sodium is an anticonvulsant that is used extensively in adults with indications for epilepsy, acute mania and migraine prophylaxis. It has been used in children and adolescents as a first-line agent for mania in bipolar disorder. Its efficacy as a mood stabilizer has been established, and there have been studies outlining its efficacy as an agent effective in the treatment of conduct disorder, disruptive behavior disorders, aggression and explosive disorder. Longer-acting formulations are now available that cause less gastrointestinal side effects and can also be taken once a day, thus potentially increasing adherence, an important factor in this patient population. Future directions would include developing a more potent valproic acid formulation with fewer side effects, completing randomized controlled trials to establish the efficacy of divalproex sodium in various other pediatric psychiatric disorders, establishing the relative efficacy of the compound in head-to-head comparisons with other mood stabilizers, examining systematically the value of the compound in multimodal pediatric psychiatric treatment packages, and complete effectiveness trials that demonstrate the short- and long-term effectiveness of the compound in the real world of clinicians. In this drug profile, divalproex sodium and its uses in the pediatric population for psychiatric conditions are reviewed.

Deformations of amygdala morphology in familial pediatric bipolar disorder

OBJECTIVE

Smaller amygdalar volumes have been consistently observed in pediatric bipolar disorder subjects compared to healthy control subjects. Whether smaller amygdalar volume is a consequence or antecedent of the first episode of mania is not known. Additionally, smaller volume has not been localized to specific amygdala subregions.

METHODS

We compared surface contour maps of the amygdala between 22 youths at high risk for bipolar disorder, 26 youths meeting full diagnostic criteria for pediatric familial bipolar disorder, and 24 healthy control subjects matched for age, gender, and intelligence quotient. Amygdalae were manually delineated on three-dimensional spoiled gradient echo images by a blinded rater using established tracing protocols. Statistical surface mesh modeling algorithms supported by permutation statistics were used to identify regional surface differences between the groups.

RESULTS

When compared to high-risk subjects and controls, youth with bipolar disorder showed surface deformations in specific amygdalar subregions, suggesting smaller volume of the basolateral nuclei. The high-risk subjects did not differ from controls in any subregion.

CONCLUSIONS

These findings support previous reports of smaller amygdala volume in pediatric bipolar disorder and map the location of abnormality to specific amygdala subregions. These subregions have been associated with fear conditioning and emotion-enhanced memory. The absence of amygdala size abnormalities in youth at high risk for bipolar disorder suggests that reductions might occur after the onset of mania.

What differentiates children visiting outpatient mental health services with bipolar spectrum disorder from children with other psychiatric diagnoses?

OBJECTIVES

To determine the contribution of parent-reported manic symptoms, family history, stressful life events, and family environment in predicting diagnosis of bipolar spectrum disorders (BPSD) in youth presenting to an outpatient psychiatric clinic.

METHODS

A total of 707 6- to 12-year-old children [621 with elevated symptoms of mania (ESM+) based on screening via the Parent General Behavior Inventory 10-item Mania Scale (PGBI-10M) and 86 without ESM (ESM-)] received a comprehensive assessment.

RESULTS

Of the 629 with complete data, 24% (n = 148) had BPSD. Compared to those without BPSD (n = 481), children with BPSD: were older (Cohen's d = 0.44) and more likely to be female (Cohen's d = 0.26); had higher parent-endorsed manic symptom scores at screening (Cohen's d = 0.36) and baseline (Cohen's d = 0.76), more biological parents with a history of manic symptoms (Cohen's d = 0.48), and greater parenting stress (Cohen's d = 0.19). Discriminating variables, in order, were: baseline PGBI-10M scores, biological parent history of mania, parenting stress, and screening PGBI-10M scores. Absence of all these factors reduced risk of BPSD from 24% to 2%.

CONCLUSIONS

  History of parental manic symptoms remains a robust predictor of BPSD in youth seeking outpatient care, even after accounting for parent report of manic symptoms in the child at screening. However, the risk factors identified as associated with BPSD, together had limited value in accurately identifying individual participants with BPSD, highlighting the need for careful clinical assessment.

Premorbid school performance in twins concordant and discordant for bipolar disorder

BACKGROUND

Although the genetic risk to develop bipolar disorder is present from conception, the first frank symptoms of the illness generally become evident in late adolescence or early adulthood. However, except for pediatric bipolar disorder (PBD), it is still unclear when the first signs of the illness in adults become apparent and whether these are related to the genetic risk to develop bipolar disorder. This study examined whether underperformance at school precedes the onset of the illness and is a genetically related risk marker for developing bipolar disorder.

METHODS

Information on school performance was obtained using objective archival data from 53 bipolar twin pairs (24 monozygotic (MZ), 29 dizygotic (DZ)) and 42 healthy matched control twin pairs (23 MZ, 19 DZ).

RESULTS

Affected twin pairs completed significantly fewer years of education than did control twin pairs with no difference between bipolar patients and their non-bipolar cotwins. The underperformance at school in the affected twin pairs occurred in early adolescence at a significantly younger age than the control twin pairs and preceded the onset of the first frank episode of bipolar disorder by thirteen years. Median age at onset of underperformance was not different in the patients and their non-bipolar cotwins. The association between liability of bipolar disease and age of first underperformance was significant and could be explained by genetic factors.

LIMITATIONS

The sample is not a population based twin sample.

CONCLUSION

Underperformance at school during early adolescence may be a genetic marker for the vulnerability to develop bipolar disorder.

Amygdalar, hippocampal, and thalamic volumes in youth at high risk for development of bipolar disorder

Children of parents with bipolar disorder (BD), especially those with attention deficit hyperactivity disorder (ADHD) and symptoms of depression or mania, are at significantly high risk for developing BD. As we have previously shown amygdalar reductions in pediatric BD, the current study examined amygdalar volumes in offspring of parents (BD offspring) who have not yet developed a full manic episode. Youth participating in the study included 22 BD offspring and 22 healthy controls of comparable age, gender, handedness, and IQ. Subjects had no history of a manic episode, but met criteria for ADHD and moderate mood symptoms. MRI was performed on a 3T GE scanner, using a 3D volumetric spoiled gradient echo series. Amygdalae were manually traced using BrainImage Java software on positionally normalized brain stacks. Bipolar offspring had similar amygdalar volumes compared to the control group. Exploratory analyses yielded no differences in hippocampal or thalamic volumes. Bipolar offspring do not show decreased amygdalar volume, possibly because these abnormalities occur after more prolonged illness rather than as a preexisting risk factor. Longitudinal studies are needed to determine whether amygdalar volumes change during and after the development of BD.

Preschool onset attention-deficit/hyperactivity disorder: course and predictors of stability over 24 months

OBJECTIVE

The present study examined the course of ADHD over 24 months in a preschool population.

METHOD

n=48 preschoolers with ADHD, aged 3.0-5.11 years, subjects included in a larger sample of preschoolers with depression and other disorders (n=306) were comprehensively assessed at 3 annual time points over 24 months in a prospective longitudinal follow-up study.

RESULTS

Baseline diagnoses of preschool MDD, ODD, and CD were risk factors for ADHD diagnosis over 24 months in this preschool population. Among older preschoolers and after controlling for key demographic variables, ADHD predicted later ADHD diagnosis, along with other significant risk factors - baseline diagnosis of ODD, and/or family history of disruptive disorders, and stressful life events.

CONCLUSIONS

ADHD showed greater homotypic continuity at later rather than earlier preschool ages. Other disruptive comorbidities also emerged as key predictors of stable ADHD course. Study findings may help to inform which preschool ADHD populations to target for early intervention. Larger sample sizes are needed to confirm these findings and to further explore the stability, course, and predictors of outcome of preschool onset ADHD.

Relationship of persistent manic symptoms to the diagnosis of pediatric bipolar spectrum disorders

OBJECTIVE

The diagnosis of bipolar spectrum disorders (BPSDs [bipolar I and II disorders, cyclothymic disorder, and bipolar disorder not otherwise specified]) in youth remains controversial. The present study evaluated the possibility that the presence of persistent manic symptoms over a relatively short interval may increase the probability of a BPSD DSM diagnosis.

METHOD

Data were obtained from the screening and baseline assessments collected from 2005 through 2008 of an ongoing prospective, longitudinal study (Longitudinal Assessment of Manic Symptoms) examining the diagnosis and phenomenology of youth (N = 692) presenting to outpatient centers at ages 6-12 years. Youth were assessed for elevated symptoms of mania (ESM) with the Parent General Behavior Inventory-10-Item Mania Scale (PGBI-10M), the primary outcome measure. Screening and baseline scores separated individuals into those with ESM (ESM+; PGBI-10M score ≥ 12) and a control group of youth without ESM (ESM-; PGBI-10M score < 12). Youth were classified into 4 groups: persistent ESM+, remitted ESM+, persistent ESM-, and progressed to ESM+.

RESULTS

Individuals with persistent ESM+ were more likely to have a BPSD (relative risk = 3.04; 95% CI, 2.15-4.30). Using 2 administrations of the PGBI-10M spaced over a relatively brief interval (median = 4.0, mean = 6.1, SD = 5.9 weeks) improved the prediction of BPSD over using only the first administration (ΔR(2) = 0.10, Δχ(2)(1) = 50.06, P < .001). Likelihood ratios indicated that persistent ESM- substantially decreased the probability of BPSD. While high levels of persistent ESM+ increased the probability of a BPSD diagnosis, the final positive predictive value was only sufficient to signify the need for more thorough clinical evaluation.

CONCLUSIONS

In many cases, obtaining repeated parent report of mania symptoms substantially altered the probability of a BPSD diagnosis and may be a useful adjunct to a careful clinical evaluation. Future waves of data collection from this longitudinal study will be crucial for devising clinically useful methods for identifying or ruling out pediatric BPSD.

Neurochemical deficits in the cerebellar vermis in child offspring of parents with bipolar disorder

OBJECTIVES

We aimed to compare concentrations of N-acetyl aspartate, myo-inositol, and other neurometabolites in the cerebellar vermis of offspring at risk for bipolar disorder (BD) and healthy controls to examine whether changes in these neuronal metabolite concentrations occur in at-risk offspring prior to the onset of mania.

METHODS

A total of 22 children and adolescents aged 9-17 years with a familial risk for bipolar I or II disorder [at-risk offspring with non-bipolar I disorder mood symptoms (AR)], and 25 healthy controls (HC) were examined using proton magnetic resonance spectroscopy at 3T to study metabolite concentrations in an 8-cc voxel in the cerebellar vermis.

RESULTS

Decreased myo-inositol and choline concentrations in the vermis were seen in the AR group compared to HC (p<0.01).

CONCLUSIONS

Decreased cellular metabolism and interference with second messenger pathways may be present in the cerebellar vermis in youth at risk for BD as evident by decreased myo-inositol and choline concentrations in this region. These results may be limited by a cross-sectional design, co-occurring diagnoses, and medication exposure. Longitudinal studies are necessary to determine whether early neurochemical changes can predict the development of mania. Improved methods for identifying children with certain neurochemical vulnerabilities may inform preventive and early intervention strategies prior to the onset of mania.

Early psychosocial intervention for youth at risk for bipolar I or II disorder: a one-year treatment development trial

OBJECTIVES

Previous studies have identified behavioral phenotypes that predispose genetically vulnerable youth to a later onset of bipolar I or II disorder, but few studies have examined whether early psychosocial intervention can reduce risk of syndromal conversion. In a one-year open trial, we tested a version of family-focused treatment adapted for youth at high risk for bipolar disorder (FFT-HR).

METHODS

A referred sample of 13 children (mean 13.4±2.69 years; 4 boys, 9 girls) who had a parent with bipolar I or II disorder participated at one of two outpatient specialty clinics. Youth met DSM-IV criteria for major depressive disorder (n=8), cyclothymic disorder (n=1), or bipolar disorder not otherwise specified (n=4), with active mood symptoms in the past month. Participants were offered FFT-HR (12 sessions in four months) with their parents, plus psychotropic medications as needed. Independent evaluators assessed depressive symptoms, hypomanic symptoms, and global functioning at baseline and then every four months for one year, with retrospective severity and impairment ratings made for each week of the follow-up interval.

RESULTS

Families were mostly adherent to the treatment protocol (85% retention), and therapists administered the FFT-HR manual with high levels of fidelity. Youth showed significant improvements in depression, hypomania, and psychosocial functioning scores on the Adolescent Longitudinal Interval Follow-up Evaluation. They also showed significant improvements in Young Mania Rating Scale and Children's Depression Rating Scale scores.

CONCLUSIONS

FFT-HR is a promising intervention for youth at high risk for BD. Larger-scale randomized trials that follow youth into young adulthood will be necessary to determine whether early psychosocial intervention can reduce the probability of developing bipolar I or II disorder among genetically vulnerable youth.

Twelve-month follow-up of family communication and psychopathology in children and adolescents with a first psychotic episode (CAFEPS study)

We analyzed the potential influence of family relationships and history of psychiatric disorders on the presentation and course of early psychotic disorders. We recruited 110 subjects aged 9-17 years with a first psychotic episode and 98 matched healthy controls, and followed them for 1 year. Data were collected through clinical interviews and the Parent-Adolescent Communication Inventory. A family history of psychosis-related disorders was more common in patients' families, with a five-fold higher risk for psychoses related disorders than families of healthy controls. If we consider psychoses related disorder in first-degree relatives, the risk is even higher, rising to 15-fold. The families of patients with a first psychotic episode score themselves worse in communication than the families of healthy controls. More problems in communication at baseline correlated with a higher degree of psychopathology and a lower clinical improvement after 12 months of follow-up.

Preventative strategies for early-onset bipolar disorder: towards a clinical staging model

Bipolar disorder is a chronic and typically recurring illness with significant psychosocial morbidity. Although the aetiological factors that contribute to the onset of mania, and by definition bipolar I disorder, are poorly understood, it most commonly occurs during the adolescent period. Putative risk factors for developing bipolar disorder include having a first-degree relative with a mood disorder, physical/sexual abuse and other psychosocial stressors, substance use disorders, psychostimulant and antidepressant medication exposure and omega-3 fatty acid deficiency. Prominent prodromal clinical features include episodic symptoms of depression, anxiety, hypomania, anger/irritability and disturbances in sleep and attention. Because prodromal mood symptoms precede the onset of mania by an average of 10 years, and there is low specificity of risk factors and prodromal features for mania, interventions initiated prior to onset of the disorder (primary prevention) or early in the course of the disorder (early or secondary prevention) must be safe and well tolerated upon long-term exposure. Indeed, antidepressant and psychostimulant medications may precipitate the onset of mania. Although mood stabilizers and atypical antipsychotic medications exhibit efficacy in youth with bipolar I disorder, their efficacy for the treatment of prodromal mood symptoms is largely unknown. Moreover, mood stabilizers and atypical antipsychotics are associated with prohibitive treatment-emergent adverse effects. In contrast, omega-3 fatty acids have neurotrophic and neuroprotective properties and have been found to be efficacious, safe and well tolerated in the treatment of manic and depressive symptoms in children and adolescents. Together, extant evidence endorses a clinical staging model in which subjects at elevated risk for developing mania are treated with safer interventions (i.e. omega-3 fatty acids, family-focused therapy) in the prodromal phase, followed by pharmacological agents with potential adverse effects for nonresponsive cases and secondary prevention. This approach warrants evaluation in prospective longitudinal trials in youth determined to be at ultra-high risk for bipolar I disorder.

Characterisation of the prodrome to a first episode of psychotic mania: results of a retrospective study

BACKGROUND

Little is known about the early phases of bipolar disorders (BPAD) and most of current knowledge derives from putative "high-risk" studies conducted in populations of bipolar off-spring; such information may therefore be relevant only to a sub-group of at-risk subjects.

METHODS

Retrospective assessment of the phase preceding the emergence of mania and of premorbid characteristics of patients treated for a first episode of psychotic mania. The collected data was used mainly to generate hypotheses.

RESULTS

Before onset of a first episode of psychotic mania, patients go through a phase of change from previous mental state where they present mood symptoms, sleep disruption and general functional decline. These clinical manifestations are however likely to have low specificity. However, their occurrence in patients presenting certain risk factors or markers of vulnerability that were identified at a relatively high prevalence in our sample, may be an indicator of impending first episode mania.

LIMITATIONS

This is a retrospective study, in a small sample of patients presenting with psychotic mania. Criteria identified need therefore to be validated in larger prospective studies.

CONCLUSIONS

Early identification of patients at risk to develop a first episode of psychotic mania is unlikely to be possible on the basis of symptoms alone. However, the occurrence of certain clinical characteristics in patients who have risk factors or markers of vulnerability to BPAD could be a sign of impending first episode mania.

Brain glutamatergic characteristics of pediatric offspring of parents with bipolar disorder

We wished to determine whether decreases in prefrontal glutamate concentrations occur in offspring of parents with bipolar disorder with and at high risk for mania. Sixty children and adolescents, 9-18 years old, of parents with bipolar I or II disorder (20 offspring with established history of mania, "BD", 20 offspring with symptoms subsyndromal to mania, "SS", and 20 healthy controls "HC") were examined using proton magnetic resonance spectroscopy at 3T to study glutamatergic metabolite concentrations in the anterior cingulate cortex (ACC). A signal for reductions in absolute glutamate concentrations in the ACC was seen in the BD compared with HC and SS groups. No other statistically significant differences among groups were found. Offspring of parents with BD with prior histories of mania may have disruptions in glutamatergic function compared with HC or children at risk for BD who have not yet developed mania. Longitudinal studies are necessary to confirm whether prefrontal glutamate decreases only after the onset of full mania.

Psychotropic medication exposure and age at onset of bipolar disorder in offspring of parents with bipolar disorder

OBJECTIVE

Exposure to psychotropic medications before the onset of bipolar disorder (BD) in children may have profound effects on the course of illness. Both antidepressant and stimulant exposure have been proposed to hasten the course of BD development, whereas mood stabilizers have been proposed as protective. We sought to describe psychotropic medication exposure in a cohort of children at risk for BD and retrospectively determine the effect of medication exposure on age at onset (AAO) of BD.

METHODS

Subjects were 106 children and adolescents who had at least 1 parent with BD. Of these, 63 had BD I or BD II and 43 had subsyndromal symptoms of BD. AAO was determined as nearest month of first manic or hypomanic episode. Past psychotropic medication exposure prior to AAO was determined through interview and chart review.

RESULTS

Both groups had high rates of exposure to psychotropic medications. Antidepressant or stimulant exposure was not correlated with an earlier AAO of BD. However, mood stabilizer exposure was associated with a later AAO.

CONCLUSIONS

Children with full or subsyndromal BD are frequently exposed to a variety of psychotropic medications before their first manic episode. Our findings do not support that early stimulant or antidepressant exposure leads to an earlier AAO of BD. However, early mood stabilizer exposure may be associated with delayed AAO. Longitudinal studies are needed to clarify these results.

Early intervention in bipolar disorders: clinical, biochemical and neuroimaging imperatives

In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.

Effect of divalproex on brain morphometry, chemistry, and function in youth at high-risk for bipolar disorder: a pilot study

OBJECTIVE

Divalproex has been found efficacious in treating adolescents with and at high risk for bipolar disorder (BD), but little is known about the effects of mood stabilizers on the brain itself. We sought to examine the effects of divalproex on the structure, chemistry, and function of specific brain regions in children at high-risk for BD.

METHODS

A total of 24 children with mood dysregulation but not full BD, all offspring of a parent with BD, were treated with divalproex monotherapy for 12 weeks. A subset of 11 subjects and 6 healthy controls were scanned with magnetic resonance imaging (MRI, magnetic resonance spectroscopy [MRS], and functional MRI [fMRI]) at baseline and after 12 weeks.

RESULTS

There were no significant changes in amygdalar or cortical volume found over 12 weeks. Furthermore, no changes in neurometabolite ratios were found. However, we found the degree of decrease in prefrontal brain activation to correlate with degree of decrease in depressive symptom severity.

CONCLUSIONS

Bipolar offspring at high risk for BD did not show gross morphometric, neurometabolite, or functional changes after 12 weeks of treatment with divalproex. Potential reasons include small sample size, short exposure to medications, or lack of significant neurobiological impact of divalproex in this particular population.

Current research in child and adolescent bipolar disorder

Although recently more research has considered children with bipolar disorder than in the past, much controversy still surrounds the validity of the diagnosis. Furthermore, questions remain as to whether or not childhood expressions of bipolarity are continuous with adult manifestations of the illness. In order to advance current knowledge of bipolar disorders in children, researchers have begun to conduct phenomenological, longitudinal, treatment, and neuroimaging studies in youths who exhibit symptoms of bipolar illness, as well as offspring of parents with bipolar disorders. Regardless of the differences between research groups regarding how bipolar disorder in children is defined, it is agreed that pediatric bipolarity is a serious and pernicious illness. With early intervention during the period of time in which youths are exhibiting subsyndromal symptoms of pediatric bipolarity, it appears that the progression of the illness to the more malignant manifestation of the disorder may be avoided. This paper will review what is currently known and what still is left to learn about clinically salient topics that pertain to bipolar disorder in children and adolescents.

Early intervention in bipolar disorder, part II: therapeutics

Recent evidence has shown that early pharmacological and psychosocial treatment dramatically ameliorates poor prognosis and outcome for individuals with psychotic disorders, reducing conversion rates to full-blown illness and decreasing symptom severity. In a companion paper, we discussed methodological issues pertaining to early intervention in bipolar disorder (BPD), reviewed clinical studies that focus on high-risk subjects as well as first-episode patients, and reviewed findings from brain imaging studies in the offspring of individuals with BPD as well as in first-episode patients. In this paper, we discuss how drugs that modulate cellular and neural plasticity cascades are likely to benefit patients in the very early stages of BPD, because they target some of the core pathophysiological mechanisms of this devastating illness. Cellular and molecular mechanisms of action of agents with neurotrophic and neuroplastic properties are discussed, with a particular emphasis on lithium and valproate. We also discuss their potential use as early intervention strategies for improving symptoms and functioning in patients in the earliest stages of BPD, as well as high-risk individuals.

Early intervention in bipolar disorder, part I: clinical and imaging findings

The concept of prevention is not new to psychiatry and has long been recognized in general medicine. Recent evidence has highlighted that early pharmacological and psychosocial treatment dramatically ameliorates poor prognosis and outcome for individuals with psychotic disorders, reducing conversion rates to full-blown illness and decreasing symptom severity. Nevertheless, despite the many recent advances in our thinking about early intervention, the need for early intervention in bipolar disorder (BPD) is an area that has been relatively neglected. This review attempts to synthesize what is currently known about early intervention in BPD. We discuss methodological issues pertaining to this topic, review clinical studies that focus on high-risk subjects as well as first-episode patients and review findings from brain imaging studies in the offspring of individuals with BPD as well as in first-episode patients. A companion paper discusses the cellular and molecular mechanisms of action of agents with neurotrophic and neuroplastic properties, with a particular emphasis on lithium and valproate.

The proximal prodrome to first episode mania--a new target for early intervention

OBJECTIVE

Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention.

METHODS

Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature.

RESULTS

Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified.

CONCLUSIONS

In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

Mood and disruptive behavior disorders and symptoms in the offspring of patients with bipolar I disorder

The study aimed to ascertain the prevalence of mood and disruptive behavior disorders and symptoms in 35 children of 29 adult outpatients with a DSM-IV diagnosis of bipolar I disorder, compared with 33 children of 29 healthy adults, matched with patients on age, socioeconomic status and education. The offspring of bipolar patients had a 9.48 fold higher risk of receiving a psychiatric diagnosis. While only two children of patients with bipolar disorder were diagnosed with a mood disorder, 30.9% displayed mild depressed mood, compared with 8.8% of the controls, a statistically significant difference. The bipolar offspring also scored significantly higher on the hyperactivity and conduct problems subscales as well as the ADHD index of the Conners' Teacher Rating Scale. The disruptive behavior and mood symptoms observed in early life in the offspring of bipolar patients may indicate the need for early psychosocial intervention.

Retrospective parent report of psychiatric histories: do checklists reveal specific prodromal indicators for postpubertal-onset pediatric bipolar disorder?

OBJECTIVES

This study retrospectively investigated the relationship between prodromal symptoms described in the literature for pediatric bipolar disorder (BD) and the diagnosis of BD by comparing adolescents with BD to those in control and attention-deficit hyperactivity disorder (ADHD) groups.

METHODS

Semi-structured interviews [Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version (K-SADS-PL) and Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)] and checklists (Conners' Rating Scales and Child Behavior Checklist) identified participants (13-17 years) as either normal controls (NC; n = 28), ADHD (n = 29) or BD (n = 25). Bipolar disorder included BD I, BD II and BD not otherwise specified (NOS). Parents completed a widely used but unvalidated symptom checklist published by Papolos and Papolos (The Bipolar Child: the Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder) assessing across three developmental periods (preschool, latency, adolescence) for the presence/absence of psychiatric symptoms, many of which have been described in the literature as prodromal to the emergence of manic symptoms.

RESULTS

While both clinical groups had more psychiatric symptoms than the NC group, more problems were reported in the ADHD group, most of which were symptoms seen as cardinal features of ADHD (e.g., being easily distracted, interrupting, having trouble concentrating). Differences were present by the latency period. Depressed mood was higher in the BD group during latency, and elated mood and fire-setting were higher in the BD group during adolescence. Results were more similar when comparing adolescents with BD only versus those with both ADHD and BD. Frequency of symptoms was comparable regardless of whether or not there was a family history of BD. Frequency of symptoms was also similar across the BD subtypes.

CONCLUSIONS

Using retrospective parent report, a cluster of prodromal psychiatric symptoms specific to BD was not identified, which both questions the utility of a widely used yet unvalidated clinical scale and encourages caution when interpreting information collected via retrospective checklists. Although these data suggest that the presence of prodromal non-specific psychiatric symptoms flags a more global risk for psychopathology, significant limitations exist when using retrospective report and, as such, further prospective research is required to investigate the progression of psychiatric symptoms across childhood disorders.

Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis

OBJECTIVE

To find, review, and critically evaluate evidence pertaining to the phenomenology of pediatric bipolar disorder and its validity as a diagnosis.

METHODS

The present qualitative review summarizes and synthesizes available evidence about the phenomenology of bipolar disorder (BD) in youths, including description of the diagnostic sensitivity and specificity of symptoms, clarification about rates of cycling and mixed states, and discussion about chronic versus episodic presentations of mood dysregulation. The validity of the diagnosis of BD in youths is also evaluated based on traditional criteria including associated demographic characteristics, family environmental features, genetic bases, longitudinal studies of youths at risk of developing BD as well as youths already manifesting symptoms on the bipolar spectrum, treatment studies and pharmacologic dissection, neurobiological findings (including morphological and functional data), and other related laboratory findings. Additional sections review impairment and quality of life, personality and temperamental correlates, the clinical utility of a bipolar diagnosis in youths, and the dimensional versus categorical distinction as it applies to mood disorder in youths.

RESULTS

A schema for diagnosis of BD in youths is developed, including a review of different operational definitions of 'bipolar not otherwise specified.' Principal areas of disagreement appear to include the relative role of elated versus irritable mood in assessment, and also the limits of the extent of the bipolar spectrum--when do definitions become so broad that they are no longer describing 'bipolar' cases?

CONCLUSIONS

In spite of these areas of disagreement, considerable evidence has amassed supporting the validity of the bipolar diagnosis in children and adolescents.

Differences between prepubertal- versus adolescent- onset bipolar disorder in a Spanish clinical sample

OBJECTIVE

To examine patients attended and diagnosed with bipolar disorder (BD) at a child and adolescent psychiatry service; to record age of diagnosis and age of onset, and to study clinical differences between prepubertal and adolescent onset groups.

METHODS

All patients currently attended for BD type I, type II or non specified BD were reviewed and divided into two age groups: prepubertal onset (beginning before age 13) and adolescent onset (beginning at or above age 13).

RESULTS

The sample were 43 patients with BD. Fourteen (32.6%) with prepubertal onset and 29 (67.4%) with adolescent onset. Time between onset of symptoms and diagnosis was longer in the prepubertal onset group (1.2 years versus 0.8 years respectively, P = .05). Patients with prepubertal onset BD more frequently presented previous symptoms such as irritability and conduct problems and had a higher rate of comorbidity (more frequently attention-deficit/hyperactivity disorder-ADHD). The adolescent onset group more often presented psychotic symptoms.

CONCLUSION

The clinical characteristics of patients with bipolar disorder differ according to whether onset is prepubertal or adolescent.

Aggression, hostility, and irritability in children at risk for bipolar disorder

OBJECTIVES

To assess aggression, irritability and hostility in children at risk for bipolar disorder (BP).

METHODS

Using the parent and the child versions of the Children's Hostility Inventory (CHI), we assessed aggression, hostility, and irritability in 300 offspring aged 6-18 years old of BP parents and 169 children of community controls.

RESULTS

Children of BP parents have significantly higher scores on the total CHI and its subscales than do children of control parents. After adjusting for demographic variables, both parents' non-BP psychopathology, child psychopathology, and within-family correlations, three factors remain significant: total CHI by parent rating, irritability subscale by parent rating, and irritability by child self-report. The hostility subscale by parent rating became a trend.

CONCLUSIONS

Children of BP parents score higher on ratings of hostility and irritability than children of community control parents, independent of child psychopathology and non-BP parental psychopathology. Follow-up of these children to evaluate whether these symptoms are markers for the development of BP or mood disorders is warranted.

Adult bipolar disorder is continuous with pediatric bipolar disorder

Considerable debate exists regarding the continuity of bipolar disorder (BD) in children and adolescents. Do affected children continue to have BD as adults? Are pediatric forms of BD distinct from adult forms of the disorder? Here, I argue that, in fact, strictly defined BD I and II in children and adolescents is continuous with adult BD. First, if we take developmental differences into account, children and adults share similar symptoms, since they are both diagnosed according to DSM-IV criteria. Next, retrospective studies indicate that 50% to 66% of adults with BD had onset of their disorder before age 19 years. Early prospective data indicate that adolescents with BD progress to become young adults with BD. Further, family studies of pediatric BD probands find high rates of BD in adult relatives, and pediatric offspring of parents with BD have elevated rates of BD, compared with control subjects. Finally, biological characteristics of pediatric BD (such as treatment response, neurobiology, and genetics) are either shared with adults having BD or fit logically into developmental models of BD. Thus, while not conclusive, a preponderance of data support the hypothesis that pediatric BD is continuous with adult BD. Prospective studies incorporating phenomenological and biological assessment are needed to decisively address this issue.

Diagnóstico e tratamento de transtorno bipolar e TDAH na infância: desafios na prática clínica

O transtorno de humor bipolar (THB) e o transtorno do déficit de atenção e hiperatividade (TDAH) são enfermidades graves, de evolução crônica e que geram forte impacto social, familiar e educacional. Por compartilharem sintomas comuns e freqüentemente se apresentarem em comorbidade, o seu diagnóstico diferencial torna-se difícil, porém imprescindível, visto que medicamentos utilizados no tratamento do TDAH podem agravar a bipolaridade em crianças não tratadas. São encontradas taxas que variam de 49% a 87% de diagnóstico de TDAH em crianças e adolescentes com THB. Crianças com ambos os transtornos têm um curso geralmente mais grave. São indivíduos com taxas maiores de sintomas psicóticos, depressão, problemas escolares, hospitalização, ansiedade e comportamentos disruptivos. A criança com transtorno de humor bipolar TDAH deve iniciar o tratamento com estabilizadores de humor, visto que o impacto dos sintomas maníacos é maior do que o dos sintomas de TDAH. Se os sintomas de desatenção, impulsividade e hiperatividade persistem após a estabilização do humor, pode-se preconizar o tratamento para o TDAH com o uso de psicoestimulantes.

Prevention of Pediatric Bipolar Disorder: Integration of Neurobiological and Psychosocial Processes

Bipolar disorder (BD) is a prevalent condition in the United States that typically begins before the age of 18 years and is being increasingly recognized in children and adolescents. Despite great efforts in discovering more effective treatments for BD, it remains a difficult-to-treat condition with high morbidity and mortality. Therefore, it appears prudent to focus energies into developing interventions designed to prevent individuals from ever fully developing BD. Such interventions early in the development of the illness might prevent inappropriate interventions that may worsen or hasten development of BD, delay the onset of first manic episode, and/or prevent development of full BD. Studies of populations at high-risk for BD development have indicated that children with strong family histories of BD, who are themselves experiencing symptoms of attention-deficit/hyperactive disorder (ADHD) and/or depression or have early mood dysregulation, may be experiencing prodromal states of BD. Understanding the neurobiological and genetic underpinnings that create risk for BD development would help with more accurate identification of this prodromal population, which could then lead to suitable preventative interventions. Such interventions could be pharmacologic or psychosocial in nature. Reductions in stress and increases in coping abilities through psychosocial interventions could decrease the chance of a future manic episode. Similarly, psychotropic medications may decrease negative sequelae of stress and have potential for neuroprotective and neurogenic effects that may contribute to prevention of fully expressed BD. Further research into the biologic and environmental mechanisms of BD development as well as controlled early intervention studies are needed to ameliorate this significant public health problem.

Divalproex sodium reduces overall aggression in youth at high risk for bipolar disorder

INTRODUCTION

The psychopharmacology of aggression in youth is relatively unexplored, even though such maladaptive aggression manifests across many different diagnoses.

METHODS

This study was a 12-week, open-label trial with divalproex sodium (DVPX) in 24 bipolar offspring 6-18 years of age (mean age = 11.3 years; 17 boys) with mixed diagnoses of major depression, cyclothymia, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). The Overt Aggression Scale (OAS) was used to measure aggression in 4-week intervals. We measured serum gamma-butyric acid (GABA) and glutamate levels at baseline and week 12.

RESULTS

Seventy-one percent of evaluable subjects were considered responders to DVPX treatment by the OAS. There was a significant correlation between the Young Mania Rating Scale (YMRS) and OAS scores at week 0 (p = 0.036) and week 12 (p = 0.025). Serum DVPX level did not correlate with treatment response.

CONCLUSIONS

These youths who are at high risk for bipolar disorder experienced an overall decrease in aggressive behavior in response to DVPX. Age or gender did not predict a positive response to DVPX. This study is the first report of treatment efficacy of a mood stabilizer for aggression in youth at high risk for bipolar disorder.

Family environment in families with versus families without parental bipolar disorder: a preliminary comparison study

OBJECTIVES

To compare family environmental characteristics of families with at least one bipolar parent and families with parents without any Axis I disorder.

METHODS

Family environment of 24 families with at least one parent with bipolar disorder (BPD) and 27 families with healthy parents (healthy families, HF) were assessed using the Family Environment Scale (FES). We compared FES subscale scores between BPD and HF. We also compared FES normative scores with scores of BPD families.

RESULTS

Seventeen (71%) of the 24 BPD families had at least one child with a mood disorder and one (3.7%) of the 27 HF had a child with a mood disorder. Families with BPD reported lower cohesion (p = 0.009) and expressiveness (p = 0.03) scores compared with HF, after controlling for group socioeconomic status differences. Bilineal BPD families had higher cohesion scores than unilineal BPD families (p = 0.05). We found no significant differences in any subscales between BPD families with (n = 9) versus without (n = 15) children with BPD. Compared with normative FES data BPD families reported lower cohesion (C) (p = 0.02) and independence (IND) (p = 0.004) scores and higher conflict (CON) (p = 0.02), intellectual-cultural orientation (ICO) (p = 0.05), moral-religious emphasis (MRE) (p < 0.001) and control (CTL) (p < 0.001) scores.

CONCLUSION

Our results suggest that members of BPD families may have difficulty communicating effectively with one another, suggesting that interventions aimed at improving this may be beneficial to patients with BPD. Results suggest that the impact of different lifestyles in different communities may influence FES scores, and thus it is important to use demographically matched comparison groups.

N-acetylaspartate levels in bipolar offspring with and at high-risk for bipolar disorder

OBJECTIVES

Studies have reported decreased N-acetylaspartate (NAA) in dorsolateral prefrontal cortex (DLPFC) of adults and children with bipolar disorder (BD), suggesting decreased neuronal density in this area. However, it is unclear if this finding represents neurodegeneration after or a trait marker present before BD onset. To address this question, we used proton magnetic resonance spectroscopy ((1)H-MRS) to compare DLPFC levels of NAA among bipolar offspring with early-onset BD, bipolar offspring with subsyndromal symptoms of BD and healthy children.

METHODS

Participants were 9-18 years old, and included 60 offspring of parents with bipolar I or II disorder (32 with BD and 28 with subsyndromal symptoms of BD), and 26 healthy controls. (1)H-MRS at 3 T was used to study 8-cm(3) voxels placed in left and right DLPFC.

RESULTS

There were no significant group differences in mean right or left DLPFC NAA/Cr ratios. Exploratory analyses of additional metabolites (myoinositol, choline) also yielded no significant group differences. NAA/Cr ratios were not correlated with age, duration of illness, or exposure to lithium or valproate.

CONCLUSIONS

Our findings suggest that DLPFC NAA/Cr ratios cannot be used as a trait marker for BD. Although we did not find decreased DLPFC NAA/Cr ratios in children and adolescents with BD, it is still possible that such levels begin to decrease after longer durations of illness into adulthood. Longitudinal neuroimaging studies of patients with BD accounting for developmental and treatment factors are needed to further clarify the neurodegenerative aspects of BD.

Early symptoms of mania and the role of parental risk

OBJECTIVES

The objectives of this study were to: (i) describe the phenomenology of youths diagnosed with subsyndromal bipolar disorders; (ii) describe the phenomenology of youngsters who are the children of bipolar parents, who are also experiencing subsyndromal symptoms of bipolar disorder (patients with 'cyclotaxia'); and (iii) explore which symptoms may be most useful in identifying youths with cyclotaxia.

METHODS

Four hundred outpatients between the ages of 5 and 17 years received a diagnostic assessment and psychometric questionnaires pertaining to mood symptomatology and psychosocial functioning. Parental diagnostic information was also obtained. Children and adolescents were assigned to one of three diagnostic groups: a 'syndromal bipolar disorder (BP)' group (n = 118), a 'sub-syndromal bipolar (SUB-BP)' group (n = 75), or a 'non-bipolar (NON-BP)' group (n = 207). In addition, based on parental diagnoses, youths were assigned to either a high genetic risk group (n = 167) or a low genetic risk group (n = 233).

RESULTS

Youths with subsyndromal bipolar disorders were found to have intermediate degrees of manic symptoms than youths with bipolar disorder and youths without a bipolar diagnosis. Offspring of parents having a bipolar disorder were more likely to show symptoms of hypomania and mania than youths without a bipolar parent. Youths at genetic risk for developing a bipolar disorder were not found to be at higher risk for having a diagnosis of attention-deficit hyperactivity disorder or a disruptive behavior disorder. Finally, results suggest that elevated mood with irritability and rapid mood fluctuations are the key distinguishing characteristics of 'cyclotaxia'.

CONCLUSIONS

There exists a group of youngsters who are the offspring of a parent/parents with a bipolar disorder who do not suffer from BP 1 or BP 2, yet have elevated mood symptoms and psychosocial dysfunction. As a result of these observations, treatment studies are needed for youths with 'cyclotaxia'.

Psychopathology in the offspring of parents with bipolar disorder: a controlled study

BACKGROUND

To examine the risk for psychopathology in offspring at risk for bipolar disorder and the course of psychiatric disorders in these youth.

METHODS

Using structured diagnostic interviews (Structured Clinical Interview for DSM-IV [SCID] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS]), psychiatric diagnoses of 117 nonreferred offspring of parents with diagnosed bipolar disorder were compared with those of 171 age- and gender-matched offspring of parents without bipolar disorder or major depression.

RESULTS

Compared with offspring of parents without mood disorders, high-risk youth had elevated rates of major depression and bipolar disorder, anxiety, and disruptive behavior disorders. High-risk offspring also had significantly more impaired Global Assessment of Functioning (GAF) scores, higher rates of psychiatric treatment, and higher rates of placement in special education classes. Disruptive behavior disorders, separation anxiety disorder, generalized anxiety disorder (GAD), social phobia, and depression tended to have their onset in early or middle childhood, whereas bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, and substance use disorder had onset most frequently in adolescence.

CONCLUSIONS

These findings support the hypothesis that offspring of parents with bipolar disorder are at significantly increased risk for developing a wide range of severe psychiatric disorders and accompanying dysfunction. Early disruptive behavior and anxiety disorders, as well as early-onset depression, may be useful markers of risk for subsequent bipolar disorder in high-risk samples.