Developmental differences according to age at onset in juvenile bipolar disorder

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

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.

Prevalence and correlates of childhood-onset bipolar disorder among adolescents

AIM

Early-onset bipolar disorder (BD) is associated with a more severe illness as well as a number of clinical factors among adults. Early-onset can be categorized as childhood- (age < 13) or adolescent- (age ≥ 13) onset, with the two displaying different clinical profiles. We set out to examine differences in clinical, and familial characteristics among adolescents with childhood- versus adolescent-onset BD.

METHODS

The study included 195 adolescents with BD, ages 14-18 years. Age of onset was determined retrospectively by self-report. Participants completed the semi-structured K-SADS-PL diagnostic interviews along with self-reported dimensional scales. Analyses examined between-group differences for clinical and familial variables. Variables associated with age of onset at p < 0.1 in univariate analyses were evaluated in a logistic regression model.

RESULTS

Approximately one-fifth of participants had childhood-onset BD (n = 35; 17.9%). A number of clinical and familial factors were significantly associated with childhood-onset BD. However, there were no significant differences in depressive and manic symptom severity. In multivariate analyses, the variables most strongly associated with childhood-onset were police contact, and family history of suicidal ideation. Smoking and psychiatric hospitalization were associated with adolescent-onset.

CONCLUSIONS

In this large clinical sample of adolescents with BD, one-fifth reported childhood-onset BD. Correlates of childhood-onset generally aligned with those observed in the literature. Future research is warranted to better understand the genetic and environmental implications of high familial loading of psychopathology associated with childhood-onset, and to integrate age-related treatment and prevention strategies.

Development of bipolar disorder in patients with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis of prospective studies

BACKGROUND

Increasing attention has been recently paid to precursors of bipolar disorder (BD). Symptoms of attention-deficit/hyperactivity disorder (ADHD) have been reported among the most common prodromes of BD. The aim of this study was to estimate the risk of BD in youths affected by ADHD based on prospective studies.

METHODS

A systematic review was conducted according to the PRISMA guidelines. A meta-analysis of single proportions was performed to compute the overall occurrence of BD in ADHD individuals. Binary outcome data were used to calculate risk estimates of BD occurrence in ADHD subjects versus Healthy Controls (HC).

RESULTS

An overall proportion of BD occurrence of 10.01% (95%-confidence interval [CI]: 6.47%-15.19%; I² = 82.0%) was found among 1248 patients with ADHD over 10 prospective studies. A slightly higher proportion was found when excluding one study based on jack-knife sensitivity analysis (11.96%, 95%-CI: 9.15%-15.49%; I² = 54.1%) and in three offspring studies (12.87%, 95%-CI: 8.91%-18.23%). BD occurrence was not significantly associated with mean follow-up duration (p-value = 0.2118). A greater risk of BD occurrence in ADHD versus HC from six studies was found (risk ratio: 8.97, 95%-CI: 4.26-18.87, p-value < 0.0001).

LIMITATIONS

Few prospective studies have been retrieved in our search and most were not specifically aimed at assessing BD in followed-up ADHD patients.

CONCLUSIONS

Greater clinical attention should be paid to ADHD as an early precursor of BD since a substantial proportion of ADHD patients is expected to be diagnosed with BD during the developmental age.

A Naturalistic Study of Youth Referred to a Tertiary Care Facility for Acute Hypomanic or Manic Episode

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.

Does childhood experience of attention-deficit hyperactivity disorder symptoms increase sleep/wake cycle disturbances as measured with actigraphy in adult patients with bipolar disorder?

Childhood attention-deficit hyperactivity disorder (ADHD) is a common precursor of adult bipolar disorders (BD). Furthermore, actigraphy studies demonstrate that each disorder may be associated with abnormalities in sleep and activity patterns. This study investigates whether the presence or absence of self-reported childhood experiences of ADHD symptoms is associated with different sleep and activity patterns in adults with BD. A sample of 115 euthymic adult patients with BD was assessed for childhood ADHD symptoms using the Wender Utah Rating Scale (WURS) and then completed 21 days of actigraphy monitoring. Actigraphic measures of sleep quantity and variability and daytime activity were compared between BD groups classified as ADHD+ (n = 24) or ADHD- (n = 91), defined according to established cutoff scores for the WURS; then we examined any associations between sleep-wake cycle parameters and ADHD dimensions (using the continuous score on the WURS). Neither approach revealed any statistically significant associations between actigraphy parameters and childhood ADHD categories or dimensions. We conclude that the sleep and activity patterns of adult patients with BD do not differ according to their self-reported history of ADHD symptoms. We discuss the implications of these findings and suggest how future studies might confirm or refute our findings.

Association between childhood dimensions of attention deficit hyperactivity disorder and adulthood clinical severity of bipolar disorders

BACKGROUND

Clinical features of attention deficit hyperactivity disorder can be frequently observed in cases with bipolar disorders and associated with greater severity of bipolar disorders. Although designed as a screening tool for attention deficit hyperactivity disorder, the Wender Utah Rating Scale could, given its factorial structure, be useful in investigating the early history of impulsive, inattentive or mood-related symptoms among patients with bipolar disorders.

METHODS

We rated the Wender Utah Rating Scale in 276 adult bipolar disorder cases and 228 healthy controls and tested its factorial structure and any associations with bipolar disorder phenomenology.

RESULTS

We confirmed a three-factor structure for the Wender Utah Rating Scale (' impulsivity/temper', ' inattentiveness' and ' mood/self-esteem'). Cases and controls differed significantly on Wender Utah Rating Scale total score and sub-scale scores ( p-values < 10^-5). About 23% of bipolar disorder cases versus 5% of controls were classified as ' WURS positive' (odds ratio = 5.21 [2.73-9.95]). In bipolar disorders, higher Wender Utah Rating Scale score was associated with earlier age at onset, severity of suicidal behaviors and polysubstance misuse; multivariate analyses, controlling for age and gender, confirmed the associations with age at onset ( p = 0.001) and alcohol and substance misuse ( p = 0.001).

CONCLUSION

Adults with bipolar disorders who reported higher levels of childhood symptoms on the Wender Utah Rating Scale presented a more severe expression of bipolar disorders in terms of age at onset and comorbidity. The Wender Utah Rating Scale could be employed to screen for attention deficit hyperactivity disorder but also for ' at-risk behaviors' in adult bipolar disorder cases and possibly for prodromal signs of early onset in high-risk subjects.

Understanding Early Age of Onset: a Review of the Last 5 Years

The age at onset of bipolar disorder ranging from childhood to adolescent to adult has significant implications for frequency, severity and duration of mood episodes, comorbid psychopathology, heritability, response to treatment, and opportunity for early intervention. There is increasing evidence that recognition of prodromal symptoms in at-risk populations and mood type at onset are important variables in understanding the course of this illness in youth. Very early childhood onset of symptoms including anxiety/depression, mood lability, and subthreshold manic symptoms, along with family history of a parent with early onset bipolar disorder, appears to predict the highest risk of early onset disorder with the most severe course.

Is There a Bipolar Prodrome Among Children and Adolescents?

Bipolar disorder in youth substantially impairs behavior, family, and social functioning and interferes with developmental course. There is increasing interest in defining a bipolar prodrome similar to that reported in early-onset psychosis that will allow for earlier intervention and reduction in overall morbidity and mortality. Several lines of research have addressed this important issue including studies of offspring of bipolar parents, high-risk cohorts, and longitudinal follow-up of subjects with major depressive disorder (MDD), ADHD, and bipolar spectrum disorder. The development and validation of bipolar prodrome rating scales also shows promise. Recent attempts to intervene at earlier stages of bipolar disorder have led to some positive outcomes. However, a controversy remains concerning the identification and management of the earliest symptoms. Further research is needed to fully validate a bipolar prodrome and to determine the optimal course of action at various stages of illness.

Attention-deficit hyperactivity disorder, its pharmacotherapy, and the risk of developing bipolar disorder: A nationwide population-based study in Taiwan

In this study, we aimed to evaluate the relationship between attention-deficit/hyperactivity disorder (ADHD) during childhood and subsequent diagnoses of bipolar disorder (BD), as well as to determine whether the pharmacotherapy for ADHD (methylphenidate and atomoxetine) influence the risks of developing BD. A nationwide cohort of patients newly diagnosed with ADHD (n = 144,920) and age- and gender-matching controls (n = 144,920) were found in Taiwan's National Health Insurance database from January 2000 to December 2011. Both patients and controls were observed until December 31, 2011. To determine the effect that the duration of methylphenidate and atomoxetine exposure had on BD, the difference in the risk of developing BD was compared among non-users, short-term users (≤ 365 days), and long-term users (>365 days). In comparison to the control group, the ADHD group showed a significantly increased risk of developing BD (ADHD: 2.1% vs.

CONTROLS

0.4%; aHR: 7.85, 95% CI: 7.09-8.70), and had a younger mean age at the time of first diagnosis (ADHD: 12.0 years vs.

CONTROLS

18.8 years). Compared to ADHD patients that had never taken methylphenidate, patients with long-term use of methylphenidate were less likely to be diagnosed with BD (aOR: 0.72, 95% CI: 0.65-0.80). However, the duration of exposure to atomoxetine did not have a significant relationship to a BD diagnosis. The results suggested that a previous diagnosis of ADHD was a powerful indicator of BD, particularly juvenile-onset BD. Nevertheless, the exact mechanisms of the relationships among ADHD, its pharmacotherapy, and BD require further clarification in the future.

Conversion from depression to bipolar disorder in a cohort of young people in England, 1999-2011: A national record linkage study

OBJECTIVE

To estimate the conversion rate from unipolar depression (ICD10 codes F32-F33) to bipolar disorder (BP) (ICD10 codes F31) in an English national cohort. It was hypothesised that early-onset BP (age <18 years) is a more severe form of the disorder, with a more rapid, and higher rate of conversion from depression to BP.

METHOD

This record linkage study used English national Hospital Episode Statistics (HES) covering all NHS inpatient and day case admissions between 1999 and 2011.

RESULTS

The overall rate of conversion from depression to BP for all ages was 5.65% (95% CI: 5.48-5.83) over a minimum 4-year follow-up period. The conversion rate from depression to BP increased in a linear manner with age from 10-14 years - 2.21% (95% C: 1.16-4.22) to 30-34 years - 7.06% (95% CI: 6.44-7.55) (F1,23=77.6, p=0.001, R(2)=0.77). The time to conversion was constant across the age range. The rate of conversion was higher in females (6.77%; 95% CI: 6.53-7.02) compared to males, (4.17%; 95% CI: 3.95-4.40) (χ(2)=194, p<0.0001), and in those with psychotic depression 8.12% (95% CI: 7.65-8.62) compared to non-psychotic depression 5.65% (95% CI: 5.48-5.83) (χ(2)=97.0, p<0.0001).

LIMITATIONS

The study was limited to hospital discharges and diagnoses were not standardised.

CONCLUSIONS

Increasing conversion rate from depression to bipolar disorder with age, and constant time for conversion across the age range does not support the notion that early-onset BP is a more severe form of the disorder.

Early stages of pediatric bipolar disorder: retrospective analysis of a Czech inpatient sample

BACKGROUND

Approximately 30%-60% of adults diagnosed with bipolar disorder (BD) report onset between the ages 15 and 19 years; however, a correct diagnosis is often delayed by several years. Therefore, investigations of the early features of BD are important for adequately understanding the prodromal stages of the illness.

METHODS

A complete review of the medical records of 46 children and adolescents who were hospitalized for BD at two psychiatric teaching centers in Prague, Czech Republic was performed. Frequency of BD in all inpatients, age of symptom onset, phenomenology of mood episodes, lifetime psychiatric comorbidity, differences between very-early-onset (<13 years of age) and early-onset patients (13-18 years), and differences between the offspring of parents with and without BD were analyzed.

RESULTS

The sample represents 0.83% of the total number of inpatients (n=5,483) admitted during the study period at both centers. BD often started with depression (56%), followed by hypomania (24%) and mixed episodes (20%). The average age during the first mood episode was 14.9 years (14.6 years for depression and 15.6 years for hypomania). Seven children (15%) experienced their first mood episode before age 13 years (very early onset). Traumatic events, first-degree relatives with mood disorders, and attention deficit hyperactivity disorder were significantly more frequent in the very-early-onset group vs the early-onset group (13-18 years) (P≤0.05). The offspring of bipolar parents were significantly younger at the onset of the first mood episode (13.2 vs 15.4 years; P=0.02) and when experiencing the first mania compared to the offspring of non-BD parents (14.3 vs 15.9 years; P=0.03). Anxiety disorders, substance abuse, specific learning disabilities, and attention deficit hyperactivity disorder were the most frequent lifetime comorbid conditions.

CONCLUSION

Clinicians must be aware of the potential for childhood BD onset in patients who suffer from recurrent depression, who have first-degree relatives with BD, and who have experienced severe psychosocial stressors.

Characteristics and profiles of bipolar I patients according to age-at-onset: findings from an admixture analysis

BACKGROUND

Many studies have used admixture analysis to separate age-at-onset (AAO) subgroups in bipolar patients, but few have looked at the phenomenological characteristics of these subgroups, in order to find out phenotypic markers.

METHODS

Admixture analysis was applied to identify the model best fitting the observed AAO distribution of a sample of 1082 consecutive DSM-IV bipolar I manic inpatients who were assessed for demographic, clinical, course of illness, comorbidity, and temperamental characteristics.

RESULTS

The model best fitting the observed distribution of AAO was a mixture of three Gaussian distributions. We could identify three AAO subgroups: early, intermediate, and late age-at-onset (EAO, IAO, and LAO, respectively). Patients in the EAO subgroup were more often single young males exhibiting severe mania with psychotic features, a subcontinuous course of illness with substance use and panic comorbidity, more suicide attempts, and temperamental components sharing hypomanic features. Patients with LAO showed a less severe picture with more depressive temperamental components, alcohol use and comorbid general medical conditions. A less typical phenotype was present in IAO patients.

LIMITATIONS

The following are the limitations of this study: retrospective design, and bias toward preferential enrollment of patients with manic predominant polarity.

CONCLUSIONS

This study confirms that bipolar I disorder can be subdivided into three subgroups based on AAO distribution and shows that patients from these subgroups differ in phenotypes.

Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: a systematic review of prevalence and incidence rates, correlates, and targeted interventions

OBJECTIVE

Pediatric bipolar disorder (PBD) is associated with poor outcomes, including suicidal ideation (SI) and suicide attempt (SA). However, frequencies and risk factors of SI/SA and targeted intervention trials for SI/SA in PBD have not been reviewed systematically.

METHODS

We conducted a systematic PubMed review, searching for articles reporting on prevalences/incidences, correlates and intervention studies targeting SI/SA in PBD. Weighted means were calculated, followed by an exploratory meta-regression of SI and SA correlates.

RESULTS

Fourteen studies (n = 1595), in which 52.1% of patients were male and the mean age was 14.4 years, reported data on SI/SA prevalence (N = 13, n = 1508) and/or correlates (N = 10, n = 1348) in PBD. Weighted mean prevalences were: past SI = 57.4%, past SA = 21.3%, current SI = 50.4%, and current SA = 25.5%; incidences (mean 42 months of follow-up) were: SI = 14.6% and SA = 14.7%. Regarding significant correlates, SI (N = 3) was associated with a higher percentage of Caucasian race, narrow (as opposed to broad) PBD phenotype, younger age, and higher quality of life than SA. Significant correlates of SA (N = 10) included female sex, older age, earlier illness onset, more severe/episodic PBD, mixed episodes, comorbid disorders, past self-injurious behavior/SI/SA, physical/sexual abuse, parental depression, family history of suicidality, and poor family functioning. Race, socioeconomic status, living situation, and life events were not clearly associated with SA. In a meta-regression analysis, bipolar I disorder and comorbid attention-deficit hyperactivity disorder were significantly associated with SA. Only one open label study targeting the reduction of SI/SA in PBD was identified.

CONCLUSIONS

SI and SA are very common but under-investigated in PBD. Exploration of predictors and protective factors is imperative for the establishment of effective preventive and intervention strategies, which are urgently needed.

The significance of at-risk or prodromal symptoms for bipolar I disorder in children and adolescents

While in the early identification and intervention of psychosis-specific instruments and risk criteria have been generated and validated, research into indicated preventive strategies for bipolar I disorder (BD I) has only recently gained momentum. As the first signs of BD I often start before adulthood, such efforts are especially important in the vulnerable pediatric population. Data are summarized regarding the presence and nature of potentially prodromal, that is, subsyndromal, symptoms prior to BD I, defined by first-episode mania, focusing on pediatric patients. Research indicates the possibility of early identification of youth at clinical high risk for BD. Support for this proposition comes from retrospective studies of BD I patients, as well as prospective studies of community samples, offspring of BD I subjects, youth with depressive disorders, and patients at high risk for psychosis or with bipolar spectrum disorders without lifetime history of mania. These data provide essential insight into potential signs and symptoms that may enable presyndromal identification of BD I in youth. However, except for offspring studies, broader prospective approaches that focus on youth at clinical high risk for BD I and on developing specific interviews and (or) rating scales and risk criteria are mostly missing, or in their early stage. More work is needed to determine valid and sufficiently specific clinical high-risk criteria, to distinguish risk factors, endophenotypes, and comorbidities from prodromal symptomatology, and to develop phase-specific interventions that titrate the risk of intervention to the risk of transition to mania and to functional impairment or distress. Moreover, studies are needed that determine potential differences in prodromal symptoms and trajectories between children, adolescents, and adults, and the best phase-specific interventions.

[Age at Onset as a Marker of Subtypes of Manic-Depressive Illness]

INTRODUCTION

Age at onset of bipolar disorder has been reported as a variable that may be associated with different clinical subtypes.

OBJECTIVE

To identify patterns in the distributions of age at onset of bipolar disease and to determine whether age at onset is associated with specific clinical characteristics.

METHODS

Admixture analysis was applied to identify bipolar disorder subtypes according to age at onset. The EMUN scale was used to evaluate clinical characteristics and principal components were estimated to evaluate the relationship between subtypes according to age at onset and symptoms in the acute in the acute phase, using multivariable analyses.

RESULTS

According to age at onset, three distributions have been found: early onset: 17.7 years (S.D. 2.4); intermediate-onset: 23.9 years (S.D. 5.6); late onset: 42.8 years (S.D. 12.1). The late-onset group is antisocial, with depressive symptoms, thinking and language disorders, and socially disruptive behaviors.

CONCLUSIONS

In patients having bipolar disorder, age at onset is antisocial with three groups having specific clinical characteristics.

Do we really know how to treat a child with bipolar disorder or one with severe mood dysregulation? Is there a magic bullet?

Background. Despite controversy, bipolar disorder (BD) is being increasingly diagnosed in under 18s. There is scant information regarding its treatment and uncertainty regarding the status of "severe mood dysregulation (SMD)" and how it overlaps with BD. This article collates available research on treatment of BD in under 18s and explores the status of SMD. Methods. Literature on treatment of BD in under 18s and on SMD were identified using major search engines; these were then collated and reviewed. Results. Some markers have been proposed to differentiate BD from disruptive behaviour disorders (DBD) in children. Pharmacotherapy restricted to short-term trials of mood-stabilizers and atypical-antipsychotics show mixed results. Data on maintenance treatment and non-pharmacological interventions are scant. It is unclear whether SMD is an independent disorder or an early manifestation of another disorder. Conclusions. Valproate, lithium, risperidone, olanzapine, aripiprazole and quetiapine remain first line treatments for acute episodes in the under 18s with BD. Their efficacy in maintenance treatment remains unclear. There is no validated treatment for SMD. It is likely that some children who are currently diagnosed with BD and DBD and possibly most children currently diagnosed with SMD will be subsumed under the proposed category in the DSM V of disruptive mood dysregulation disorder with dysphoria.

Bipolar Disorder in Children and Adolescents Recognised in the UK: A Clinic-Based Study

BACKGROUND

  Diagnoses of paediatric bipolar disorder have increased over the last two decades in the United States, where high levels of comorbidity with ADHD have also been reported.

AIMS

  To explore how British clinicians apply these diagnoses.

METHOD

  We compared 378 young people under the age of 18 who received a diagnosis of bipolar disorder and/or ADHD from a large NHS mental health trust between 1992 and 2007.

RESULTS

  Children with bipolar disorder were rare in this sample (n = 35, 1.0%), particularly under the age of 13 (n = 9, 0.3%). Children with bipolar disorder presented more often with affective and psychotic symptoms than children with ADHD. Irritability was common in both disorders. Core ADHD symptoms were prevalent in both conditions but occurred in a greater proportion of children with ADHD.

CONCLUSION

  Our findings suggest that psychiatrists in England use the traditional adult criteria of bipolar disorder rather than the broader criteria being adopted by some practitioners in the US.

Bipolar disorder co-morbidity in children with attention deficit hyperactivity disorder

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.

Depressive and adjustment disorders - some questions about the differential diagnosis: case studies

BACKGROUND

Diagnosis and treatment of mood disorders in youth are still problematic because in this age the clinical presentation is atypical, and the diagnostic tools and the therapies are the same as that used for the adults. Mood disorders are categorically divided into unipolar disorders (major depressive disorder and dysthymic disorder) and bipolar disorder in Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision), but mood symptoms are also comprised in the diagnostic criteria of the adjustment disorder (AD), which occur in many different psychiatric disorders, and may also be found in some physical conditions. The differential diagnosis is not much addressed in the midst of clinical investigation and so remains the major problem in the clinical practice.

AIMS

The associations between some variables and the depressive disorder and AD were analyzed to make considerations about differential diagnosis.

PATIENTS AND METHODS

We reported a retrospective study of 60 patients affected by depressive disorder and AD. The analysis has evaluated the association between some variables and the single diagnostic categories. We have considered 10 variables, of which 6 are specific to the disorders, and 4 have been considered related problems.

RESULTS

The statistical analysis showed significant results for the associations of 3 variables (prevalent symptoms, treatment, and family history) with the single diagnostic categories.

CONCLUSION

The discriminate analysis resulted in statistically significant differences between patients with depressive disorders and those with AD on 3 variables, of which 2 are specific to the disorders, and 1 is included in the related problems. The other variables were weakly associated with the single diagnostic categories without any statistically significant differences. The 3 variables that were associated with the single diagnostic categories support the distinct construct validity of the 2 diagnostic categories, but, to date, it is difficult to establish if these variables can be considered diagnostic predictors. On the other hand, the other variables did not support the distinct construct validity of the 2 diagnostic categories, which suggest an overlapping and dimensional concept. The spectrum approach could unify categorical classification that is essential with a dimensional view. Combination of dimensional and categorical principles for classifying mood disorders may help to reduce the problems of underdiagnosis and undertreatment.

"Folie circulaire" vs "Folie à double forme": contribution from a French national study

OBJECTIVE

To check whether the presence or not of free intervals between episodes could help differentiate subtypes of bipolar disorder, as suggested by the seminal controversy between Falret and Baillarger.

METHODS

From 1090 bipolar I patients included in a French national study, 981 could be classified as with or without free intervals and assessed for demographic and illness characteristics.

RESULTS

Compared with patients with free intervals (n=722), those without (n=259) had an earlier age at onset, more episodes, suicide attempts, cyclothymic and irritable temperaments. The following independent variables were associated with no free intervals: being single or divorced, delay to mood stabilizer treatment, multiple hospitalizations, incongruent psychotic features, panic and generalized anxiety disorder.

CONCLUSION

"Folie à double forme" (without free intervals) and "folie circulaire" (with free intervals) may actually refer to early and later onset bipolar subtypes, insofar as most differences we found between them were previously evidenced between the latter two. We cannot, however, exclude that they might simply be two separate subtypes, whose main characteristics could be accounted for by different explanatory factors.

Früh beginnende bipolare Störungen, ADHS oder Störung der Affektregulation?

Die Arbeit gibt einen Überblick über die Hintergründe der Kontroverse und leitet daraus konkrete Schlussfolgerungen für die klinische Praxis ab. Bei der Diagnostik früher bipolarer Störungen ist vorrangig auf das Auftreten von abgrenzbaren Episoden mit eindeutigen Stimmungsänderungen und Veränderungen von Verhalten und Kognition zu achten. Das Mischbild aus ADHS und begleitender affektiver Dysregulation sollte nicht im Sinne einer beginnenden bipolaren Störung interpretiert werden, bedarf aber stärkerer Beachtung, insbesondere bei der Entwicklung geeigneter psycho- und pharmakotherapeutischer Ansätze. Erläutert werden zudem Gemeinsamkeiten und Unterschiede von bipolaren Störungen mit Schizophrenie, Depression, ADHS, Borderline-Persönlichkeitsstörung und Substanzmissbrauch.

Pharmacological response in juvenile bipolar disorder subtypes: A naturalistic retrospective examination

This study reports on the naturalistic pharmacotherapy of 266 youths with bipolar disorder (BP), manic or hypomanic episode (158 males and 108 females, 13.8+/-2.8 years), first treated with monotherapy on valproic acid (VPA) (n=158, 59.4%), lithium (n=90, 33.8%) or atypical antipsychotics (n=18, 6.8%). Among the patients receiving mood stabilizers, 59.5% of those treated with VPA and 47.8% of those receiving lithium did not need other antimanic agents (mood stabilizers and/or atypical antipsychotics). Lower severity was associated with a greater persistence of both VPA and lithium monotherapy. Factors associated with greater persistence of VPA monotherapy were BP II and co-occurring generalized anxiety disorder, separation anxiety disorder and simple phobias. On the contrary, BP I and co-occurring psychotic symptoms and/or conduct disorder were associated with a lower persistence of VPA monotherapy. Factors associated with lower persistence of lithium monotherapy were younger age and the association with attention deficit hyper-activity disorder (ADHD). Type of BP and presence of psychotic symptoms and conduct disorder did not affect the lithium monotherapy. Overall, predictors of non-response (multiple stepwise logistic regression) in both VPA and lithium groups were baseline Clinical Global Impression (CGI) Severity score and comorbid conduct disorder; while psychotic symptoms and absence of comorbid generalized anxiety disorder were predictors of poorer treatment response only in the VPA group, and chronic course, comorbid ADHD and absence of comorbid panic disorder were predictors only in the lithium group. Such naturalistic data from an ordinary clinical setting have relevance to clinical practice.

Earliest symptoms discriminating juvenile-onset bipolar illness from ADHD

OBJECTIVES

Controversy surrounds the diagnosis and earliest symptoms of childhood-onset bipolar illness, emphasizing the importance of prospective longitudinal studies. To acquire a preliminary, more immediate view of symptom evolution, we examined the course of individual symptoms over the first 10 years of life in juvenile-onset bipolar illness (JO-BP) compared with attention-deficit hyperactivity disorder (ADHD).

METHODS

Parents of formally diagnosed children retrospectively rated 37 symptoms in each year of the child's life based on the degree of dysfunction in their child's usual family, social, or educational roles. A subset of children with onset of bipolar disorder prior to age 9 (JO-BP) compared with those with ADHD was the focus of this analysis.

RESULTS

Brief and extended periods of mood elevation and decreased sleep were strong early differentiators of JO-BP and ADHD children. Depressive and somatic symptoms were later differentiators. Irritability and poor frustration tolerance differentiated the two groups only in their greater incidence and severity in JO-BP compared with a moderate occurrence in ADHD. In contrast, hyperactivity, impulsivity, and decreased attention showed highly similar trajectories in the two groups.

CONCLUSIONS

Elevated mood and decreased sleep discriminated JO-BP and ADHD as early as age 3, while classic ADHD symptoms were parallel in the groups. These retrospective results provide preliminary insights into symptom differences and their temporal evolution between bipolar disorder and ADHD in the first 10 years of life.

Practitioner review: the assessment of bipolar disorder in children and adolescents

BACKGROUND

An increasing number of youth are being diagnosed with, and treated for, bipolar disorder (BD). Controversy exists about whether youth with non-episodic irritability and symptoms of attention deficit hyperactivity disorder (ADHD) should be considered to have a developmental presentation of mania.

METHOD

A selective review of the literature related to this question, along with recommendations to guide clinical assessment.

RESULTS

Data indicate differences between youth with episodic mania and those with non-episodic irritability in longitudinal diagnostic associations, family history, and pathophysiology. In youth with episodic mania, elation and irritability are both common during manic episodes.

CONCLUSIONS

In diagnosing mania in youth, clinicians should focus on the presence of episodes that consist of a distinct change in mood accompanied by concurrent changes in cognition and behavior. BD should not be diagnosed in the absence of such episodes. In youth with ADHD, symptoms such as distractibility and agitation should be counted as manic symptoms only if they are markedly increased over the youth's baseline symptoms at the same time that there is a distinct change in mood and the occurrence of other associated symptoms of mania. Although different techniques for diagnosing comorbid illnesses have not been compared systematically, it appears most rational to diagnose co-occurring illnesses such as ADHD only if the symptoms of the co-occurring illness are present when the youth is euthymic.

Comparison of manic and depressive symptoms between children and adolescents with bipolar spectrum disorders

OBJECTIVE

To compare the most severe lifetime (current or past) mood symptoms, duration of illness, and rates of lifetime comorbid disorders among youth with bipolar spectrum disorders [BP (bipolar-I, bipolar-II and bipolar-not otherwise specified)].

METHODS

A total of 173 children (<12 years) with BP, 101 adolescents with childhood-onset BP, and 90 adolescents with adolescent-onset BP were evaluated with standardized instruments.

RESULTS

Depression was the most common initial and frequent episode for both adolescent groups, followed by mania/hypomania. Adolescents with childhood-onset BP had the longest illness, followed by children and then adolescents with adolescent-onset BP. Adjusting for sex, socioeconomic status, and duration of illness, while manic, both adolescent groups showed more 'typical' and severe manic symptoms. Mood lability was more frequent in childhood-onset and adolescents with early-onset BP. While depressed, both adolescent groups showed more severe depressive symptoms, higher rates of melancholic and atypical symptoms, and suicide attempts than children. Depressed children had more severe irritability than depressed adolescents. Early BP onset was associated with attention-deficit hyperactivity disorder, whereas later BP onset was associated with panic, conduct, and substance use disorders. Above-noted results were similar when each BP subtype was analyzed separately.

CONCLUSIONS

Older age was associated with more severe and typical mood symptomatology. However, there were differences and similarities in type, intensity, and frequency of BP symptoms and comorbid disorders related to age of onset and duration of BP and level of psychosocial development. These factors and the normal difficulties youth have expressing and modulating their emotions may explain existing complexities in diagnosing and treating BP in youth, particular in young children, and suggest the need for developmentally sensitive treatments.

Assessment and diagnostic issues in pediatric bipolar disorder

The purpose of this article is to provide clinicians with detailed information on pediatric bipolar disorder (PBD) in children and adolescents to aid in the accurate assessment and diagnosis of the disorder. PBD is a complex condition that presents with a wide array of features, making it a difficult disorder to diagnose and treat. The debilitating nature of PBD makes it necessary for clinicians to address the disorder as early as possible to help ensure positive outcomes. The assessment and diagnostic process is an integral step toward determining appropriate treatment interventions. This article presents an overview of the assessment and diagnostic process, including diagnostic criteria, epidemiology, comorbidities, differential diagnoses, and risk factors. The distinctive childhood features of PBD and the diagnostic controversies are also addressed.

Three-dimensional mapping of hippocampal anatomy in adolescents with bipolar disorder

OBJECTIVE

Early-onset bipolar disorder is thought to be a particularly severe variant of the illness. Continuity with the adult form of illness remains unresolved, but preliminary evidence suggests similar biological underpinnings. Recently, we observed localized hippocampal decreases in unmedicated adults with bipolar disorder that were not detectable with conventional volumetric measures. Using the same three-dimensional mapping methods, we sought to investigate whether a similar pattern exists in adolescents with bipolar disorder.

METHOD

High-resolution brain magnetic resonance images were acquired from 16 adolescents meeting DSM-IV criteria for bipolar disorder (mean age 15.5 +/- 3.4 years, 50% female) and 20 demographically matched, typically developing control subjects. Three-dimensional parametric mesh models of the hippocampus were created from manual tracings of the hippocampal formation.

RESULTS

Controlling for total brain volume, total hippocampal volume was significantly smaller in adolescent patients with bipolar disorder relative to controls (by 9.2%). Statistical mapping results, confirmed by permutation testing, revealed significant localized deformations in the head and tail of the left hippocampus in adolescents with bipolar disorder, relative to normal controls. In addition, there was a significant positive correlation between hippocampal size and age in patients with bipolar disorder, whereas healthy controls showed an inverse relation.

DISCUSSION

Localized hippocampal deficits in adolescent patients with bipolar disorder suggest a possible neural correlate for memory deficits observed in this illness. Moreover, age-related increases in hippocampal size in patients with bipolar disorder, not observed in healthy controls, may reflect abnormal developmental mechanisms in bipolar disorder. This possibility must be confirmed by longitudinal studies.

Pre-pubertal paediatric bipolar disorder: a controversy from America

OBJECTIVE

The aim of this paper was to explore the rapid rise in the diagnosis of bipolar disorder (BD) in the paediatric, particularly pre-pubertal, age group, in the USA over the past decade and to look at associated controversies.

CONCLUSIONS

There has been a very marked rise in the diagnosis of BD among pre-pubertal children, and to a lesser extent adolescents, in the USA since the mid 1990s. The rise appears to have been driven by a reconceptualizing of clusters of emotional and behavioural symptoms in the paediatric age group by some academic child psychiatry departments, most notably in St Louis, Boston and Cincinnati. There is controversy in both the academic literature and public media centring on diagnostic methods, epidemiological studies, adverse effects of medication including media-reported fatalities, and pharmaceutical company influence. With some exceptions, the traditional view of BD as being very rare prior to puberty and uncommon in adolescence appears accepted beyond the USA, though whether this is changing is as yet uncertain, and thus there are implications for Australian and New Zealand child and adolescent psychiatry.

Clinical implications of DSM-IV subtyping of bipolar disorders in referred children and adolescents

OBJECTIVE

According to DSM-IV, bipolar disorders (BDs) include four subtypes, BD I, BD II, cyclothymic disorder, and BD not otherwise specified (NOS). We explore the clinical implications of this subtyping in a naturalistic sample of referred youths with BD I, BD II, and BD-NOS.

METHOD

The sample consisted of 217 patients, 135 males and 82 females, ages between 8 and 18 years (mean age, 13.6 +/- 2.9 years), diagnosed according to historical information, prolonged observations, and a structured clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version). The location of the study was the Stella Maris Scientific Institute of Child Neurology and Psychiatry of Pisa (Italy).

RESULTS

Seventy-eight patients (35.9%) had BD I, 97 (44.7%) had BD II, and 42 (19.4%) had BD-NOS. Patients with BD I presented more frequently psychotic symptoms and elated rather than irritable mood. Patients with BD II were less severely impaired, presented more frequently depression as the intake affective episode, and had the highest comorbidity with anxiety disorders. Patients with BD-NOS presented an earlier onset of the disorder, a chronic rather than episodic course, an irritable rather than an elated mood, and a more frequent comorbidity with attention-deficit/hyperactivity disorder and oppositional defiant disorder.

CONCLUSIONS

DSM-IV categorization of BD may have meaningful implications in youths, but needs to be detailed further.