Development of bipolar disorder and other comorbidity among youth with attention-deficit/hyperactivity disorder

Practice Pearls for Stimulant Treatment of Attention-Deficit/Hyperactivity Disorder in Youth

Over half of youth with attention-deficit/hyperactivity disorder (ADHD) have co-occurring psychiatric or medical conditions that present treatment challenges. Stimulants are the most effective pharmacologic treatment of ADHD for preschoolers to adults but questions about safety with co-occurring conditions frequently arise. In addition, stigma surrounding diagnosis and treatment can negatively impact care. This manuscript presents evidence-based practice pearls to guide treatment decisions for youth with ADHD and common coexisting psychiatric and medical conditions. Recommendations address specific stimulant adverse effects (i.e., anxiety, cardiac, growth, mania, psychosis) along with management strategies. Pearls were developed for the most common clinical questions, controversial topics, or therapeutic issues that may not be widely known. The goals of this manuscript are to: 1) provide a detailed resource for interprofessional teams regarding stimulant use in youth with ADHD, 2) improve therapeutic outcomes for youth with ADHD and co-occurring psychiatric and/or medical conditions through evidence-based recommendations, and 3) decrease stigma associated with stimulant use through education.

Meta-analysis of personal and familial co-occurrence of Attention Deficit/Hyperactivity Disorder and Bipolar Disorder

BACKGROUND

Attention Deficit Disorder / Hyperactivity (ADHD) and Bipolar Disorder (BD) are highly comorbid disorders. Studies have raised the hypothesis of shared genetic, neurobiological, and clinical factors. This would entail an excess risk of co-occurrence of both disorders.

OBJECTIVE

We present the first meta-analysis of individual and familial associations between ADHD and BD.

METHODS

From 2688 references, 59 were included, with a total of 550,379 ADHD patients, 57,799 BD patients and 12,608,137 controls.

RESULTS

Personal history of ADHD increased the risk of BD (OR = 6.06), and conversely individuals with BD had an increased risk of ADHD (OR = 8.94). First-degree relatives of ADHD patients had an increased risk of BD (OR = 1.94). Offspring of individuals with BD had a higher risk for ADHD (OR = 2.33). Finally, first-degree relatives of BD patients had an increased risk of ADHD (OR = 2.71).

CONCLUSION

We show a clear epidemiological overlap between ADHD and BD, as well as a strong familial association which advocates in favor of a more systematic screening.

Enhancing DLG2 Implications in Neuropsychiatric Disorders: Analysis of a Cohort of Eight Patients with 11q14.1 Imbalances

Neurodevelopmental disorders (NDDs) are considered synaptopathies, as they are due to anomalies in neuronal connectivity during development. DLG2 is a gene involved insynaptic function; the phenotypic effect of itsalterations in NDDs has been underestimated since few cases have been thoroughly described.We report on eight patients with 11q14.1 imbalances involving DLG2, underlining its potential effects on clinical presentation and its contribution to NDD comorbidity by accurate neuropsychiatric data collection. DLG2 is a very large gene in 11q14.1, extending over 2.172 Mb, with alternative splicing that gives rise to numerous isoforms differentially expressed in brain tissues. A thorough bioinformatic analysis of the altered transcripts was conducted for each patient. The different expression profiles of the isoforms of this gene and their influence on the excitatory–inhibitory balance in crucial brain structures could contribute to the phenotypic variability related to DLG2 alterations. Further studies on patients would be helpful to enrich clinical and neurodevelopmental findings and elucidate the molecular mechanisms subtended to NDDs.

Diagnostic progression to bipolar disorder in 17,285 adolescents and young adults with attention deficit hyperactivity disorder: A longitudinal follow-up study

OBJECTIVE

We investigated the diagnostic progression to bipolar disorder (BD) among adolescents and young adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Using the Taiwan National Health Insurance Research Database, we enrolled adolescents and young adults aged 10-29 years with ADHD between January 1, 2001, and December 31, 2010, who were followed up until December 31, 2011, to determine progression to BD. Cox regression analysis was used to examine candidate risk and protective factors.

RESULTS

At the 11-year follow-up, the progression rate from ADHD to BD was 5.12%. Of the participants who progressed, 62.16% (322/518) progressed within the first 3 years. Risk factors for progression were as follows: older age (hazard ratio [HR], 1.058; 95% confidence interval [CI], 1.033-1.084), comorbidity with autistic spectrum disorder (HR, 1.839; 95% CI, 1.415-2.391), disruptive behavior disorder (HR, 1.434; 95% CI, 1.132-1.816), intelligence disability (HR, 1.744; 95% CI, 1.399-2.176), depressive disorder (HR, 1.978; 95% CI, 1.577-2.482), alcohol use disorder (HR, 1.705; 95% CI, 1.057-2.751), cluster A (HR, 2.508; 95% CI, 1.167-5.391) or B (HR, 2.718; 95% CI, 1.974-3.741) personality disorder, and a family history of BD (HR, 2.618; 95% CI, 1.823-3.758) Identified protective factors were male sex (HR, 0.771; 95% CI, 0.630-0.943) and cluster C personality disorder (HR, 0.278; 95% CI, 0.086-0.898).

CONCLUSION

The study demonstrated the specific risk and protective factors for BD progression among adolescents and young adults with ADHD. It is important for clinician and mental health care providers to recognize identified factors to focus on early detection and prompt intervention.

A Longitudinal Study of Psychiatric Disorders in Offspring of Parents With Bipolar Disorder From Preschool to Adolescence

OBJECTIVE

To compare the prevalence of psychopathology, particularly bipolar disorder (BD), between preschool offspring of parents with BD and community controls.

METHOD

A total of 116 offspring of BD-I/II parents and 98 controls (53 parents with non-BD psychopathology and 45 healthy parents) were recruited at ages 2 to 5 years and followed on average 9.6 years (on average: 2-5: 1.6 times; after age 5: 4 times) (average ages at intake/last follow-up: 3.8/13.4, retention: 98%). Participants were evaluated with standardized instruments blinded to parental diagnoses.

RESULTS

After adjusting for confounders, offspring of BD parents only showed more attention-deficit/hyperactivity disorder (ADHD) during ages 2 to 5 years than the other 2 groups. After age 5, offspring of BD parents did not differ from offspring of parents with non-BD psychopathology, but they had more anxiety, ADHD, and behavior problems than offspring of healthy parents. Only offspring of BD parents developed BD-I/II: 3.4% (n = 4) and BD-not-otherwise-specified (BD-NOS): 11.2% (n = 13), with mean onset ages 11.4 and 7.4, respectively. About 70% of offspring with BD had non-BD disorders before BD. Only ADHD, diagnosed before age 6 years, and early-onset parental BD were significantly associated with BD risk.

CONCLUSION

Most offspring of BD parents did not develop BD, but they were at specific high risk for developing BD, particularly those with preschool ADHD and early-onset parental BD. BD symptoms were scarce during the preschool years and increased throughout the school age, mainly in the form of BD-NOS, a disorder that conveys poor prognosis and high risk to develop BD-I/II. Developing early interventions to delay or, ideally, to prevent its onset are warranted.

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.

Comorbidity of ADHD and adult bipolar disorder: A systematic review and meta-analysis

Attention-deficit / hyperactivity disorder (ADHD) and Bipolar Disorder (BD) are common mental disorders with a high degree of comorbidity. However, no systematic review with meta-analysis has aimed to quantify the degree of comorbidity between both disorders. To this end we performed a systematic search of the literature in October 2020. In a meta-analysis of 71 studies with 646,766 participants from 18 countries, it was found that about one in thirteen adults with ADHD was also diagnosed with BD (7.95 %; 95 % CI: 5.31-11.06), and nearly one in six adults with BD had ADHD (17.11 %; 95 % CI: 13.05-21.59 %). Substantial heterogeneity of comorbidity rates was present, highlighting the importance of contextual factors: Heterogeneity could partially be explained by diagnostic system, sample size and geographical location. Age of BD onset occurred earlier in patients with comorbid ADHD (3.96 years; 95 % CI: 2.65-5.26, p < 0.001). Cultural and methodological differences deserve attention for evaluating diagnostic criteria and clinicians should be aware of the high comorbidity rates to prevent misdiagnosis and provide optimal care for both disorders.

The Greater Houston Area Bipolar Registry-Clinical and Neurobiological Trajectories of Children and Adolescents With Bipolar Disorders and High-Risk Unaffected Offspring

The aims of this article are to discuss the rationale, design, and procedures of the Greater Houston Area Bipolar Registry (HBR), which aims at contributing to the effort involved in the investigation of neurobiological mechanisms underlying bipolar disorder (BD) as well as to identify clinical and neurobiological markers able to predict BD clinical course. The article will also briefly discuss examples of other initiatives that have made fundamental contributions to the field. This will be a longitudinal study with participants aged 6-17 at the time of enrollment. Participants will be required to meet diagnostic criteria for BD, or to be offspring of a parent with BD. We will also enroll healthy controls. Besides clinical information, which includes neurocognitive performance, participants will be asked to provide blood and saliva samples as well as to perform neuroimaging exams at baseline and follow-ups. Several studies point to the existence of genetic, inflammatory, and brain imaging alterations between individuals at higher genetic risk for BD compared with healthy controls. Longitudinal designs have shown high conversion rates to BD among high-risk offspring, with attempts to identify clinical predictors of disease onset, as well as clarifying the burden associated with environmental stressors. The HBR will help in the worldwide effort investigating the clinical course and neurobiological mechanisms of affected and high-risk children and adolescents with BD.

Comorbidity and patterns of familial aggregation in attention-deficit/hyperactivity disorder and bipolar disorder in a family study of affective and anxiety spectrum disorders

The aim of this study is to examine the familial aggregation of Attention-deficit/hyperactivity disorder (ADHD) and its cross-transmission with bipolar disorder (BD) in a community-based family study of mood spectrum disorders. A clinically-enriched community sample of 562 probands recruited from the greater Washington, DC metropolitan area and their 698 directly interviewed relatives were included in analyses. Inclusion criteria were English speaking and consent to contact at least two first-degree relatives. Standard family study methodology was used and DSM-IV classified mental disorders were ascertained through a best-estimate procedure based on direct semi-structured interviews and multiple family history reports. There was specificity of familial aggregation of both bipolar I disorder (BD I) and bipolar II disorder (BD II) (i.e., BD I OR = 6.08 [1.66, 22.3]; BD II OR = 2.98 [1.11, 7.96]) and ADHD (ADHD OR = 2.13 [1.16, 3.95]). However, there was no evidence for cross-transmission of BD and ADHD in first degree relatives (i.e., did not observe increased rates of BD in relatives of those with ADHD and vice versa; all ps > 0.05). The specificity of familial aggregation of ADHD and BD alongside the absence of shared familial risk are consistent with the notion that the comorbidity between ADHD and BD may be attributable to diagnostic artifact, could represent a distinct BD suptype characterized by childhood-onset symptoms, or the possibility that attention problems serve as a precursor or consequence of BD.