Psychiatric disorders in preschool offspring of parents with bipolar disorder: the Pittsburgh Bipolar Offspring Study (BIOS)

Putative Risk Biomarkers of Bipolar Disorder in At-risk Youth

Bipolar disorder is a highly heritable and functionally impairing disease. The recognition and intervention of BD especially that characterized by early onset remains challenging. Risk biomarkers for predicting BD transition among at-risk youth may improve disease prognosis. We reviewed the more recent clinical studies to find possible pre-diagnostic biomarkers in youth at familial or (and) clinical risk of BD. Here we found that putative biomarkers for predicting conversion to BD include findings from multiple sample sources based on different hypotheses. Putative risk biomarkers shown by perspective studies are higher bipolar polygenetic risk scores, epigenetic alterations, elevated immune parameters, front-limbic system deficits, and brain circuit dysfunction associated with emotion and reward processing. Future studies need to enhance machine learning integration, make clinical detection methods more objective, and improve the quality of cohort studies.

Systematic Review and Meta-Analysis: Risks of Anxiety Disorders in Offspring of Parents With Mood Disorders

OBJECTIVE

To examine the risk of anxiety disorders in offspring of parents with mood disorders.

METHOD

We conducted a systematic review and meta-analysis. We searched 4 electronic databases (Medline, Embase, PsycINFO, and Web of Science [core collection]) to identify cross-sectional and cohort studies that examined the association between parental mood disorders (including bipolar disorder and unipolar depression) and risk of anxiety disorders in offspring. Pooled risk ratios (RRs) of overall and specific anxiety disorders were synthesized using a random effects model. Subgroup analyses and meta-regression were performed to identify moderation factors.

RESULTS

A total of 35 studies were included in the final analysis. Our results showed higher risks of all types of anxiety disorders in the offspring of parents with mood disorders (any anxiety disorder, RR = 1.82, 95% CI = 1.47-2.26), except for agoraphobia (RR = 1.08, 95% CI = 0.56-2.08), and with an especially elevated risk of panic disorder (RR = 3.07, 95% CI = 2.19-4.32). Subgroup analysis demonstrated no significant difference between the risks of anxiety disorders across the offspring of parents with bipolar disorder as opposed to unipolar depression. The absence of anxiety disorders in control parents, younger offspring age, and specific parent/offspring sex were associated with higher RRs for some anxiety disorders in offspring of parents with mood disorders.

CONCLUSION

Our findings suggest a robust relationship between parental mood disorders and offspring anxiety disorders, and highlight the potential value of prevention and early intervention for anxiety disorders in this context.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list.

STUDY PREREGISTRATION INFORMATION

Anxiety Disorders in Offspring of Parents with Mood Disorders: A Systematic Review; https://www.crd.york.ac.uk/prospero/; CRD42021215058.

Anxiety and Disruptive Behavior Symptoms and Disorders in Preschool-Age Offspring of Parents With and Without Bipolar Disorder: Associations With Parental Comorbidity

OBJECTIVE

We examined the relative contribution of parental bipolar disorder (BPD) and psychiatric comorbidities (disruptive behavior disorders [DBD] and anxiety disorders) in predicting psychiatric symptoms and disorders in 2-5-year-old offspring.

METHODS

Participants were 60 families with a parent with BPD and 78 offspring and 70 comparison families in which neither parent had a mood disorder and 91 offspring. Parent and offspring diagnoses and symptoms were assessed using standardized diagnostic interviews and measures, with offspring assessors masked to parental diagnoses.

RESULTS

Offspring of parents with BPD had significant elevations in behavioral, mood and anxiety disorders and symptoms. Both parental BPD and DBD contributed to elevations in child disruptive behavioral symptoms, whereas child anxiety symptoms were more strongly predicted by comorbid parental anxiety. Parental BPD was a stronger predictor than comorbid DBD of child DBDs.

CONCLUSION

Some of the elevated risk for disorders in preschoolers is accounted for by parental comorbidity.

Sleep patterns among preschool offspring of parents with and without psychopathology: Association with the development of psychopathology in childhood

BACKGROUND

Disturbed sleep during early childhood predicts social-emotional problems. However, it is not known how various early childhood sleep phenotypes are associated with the development of childhood psychopathology, nor whether these relationships vary as a function of parental psychopathology. We identified sleep phenotypes among preschool youth; examined whether these phenotypes were associated with child and parent factors; and determined if early sleep phenotypes predicted later childhood psychopathology.

METHODS

Using data from the Pittsburgh Bipolar Offspring study, parents with bipolar disorder (BD), non-BD psychopathology, and healthy controls reported about themselves and their offspring (n = 218) when their children were ages 2-5. Offspring and parents were interviewed directly approximately every 2 years from ages 6-18. Latent class analysis (LCA) identified latent sleep classes; we compared these classes on offspring demographics, parental sleep variables, and parental diagnoses. Kaplan-Meier survival models estimated hazard of developing any new-onset Axis-I disorders, as well as BD specifically, for each class.

RESULTS

The optimal LCA solution featured four sleep classes, which we characterized as (1) good sleep, (2) wake after sleep onset problems, (3) bedtime problems (e.g., trouble falling asleep, resists going to bed), and (4) poor sleep generally. Good sleepers tended to have significantly less parental psychopathology than the other three classes. Risk of developing new-onset Axis-I disorders was highest among the poor sleep class and lowest among the good sleep class.

CONCLUSIONS

Preschool sleep phenotypes are an important predictor of the development of psychopathology. Future work is needed to understand the biopsychosocial processes underlying these trajectories.

Preventive interventions for individuals at risk of developing bipolar disorder: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to explore whether early interventions can reduce affective symptoms and have long-term benefits among individuals at risk of bipolar disorder (BD).

METHODS

The PubMed, Embase, and Web of Science databases were searched. The primary outcome was continuous symptom scores before and after treatment. Random effects meta-analyses were conducted for each outcome arm studied and pooled mean difference estimates were calculated.

RESULTS

The search identified 10 controlled studies involving 425 participants and 6 single-arm studies involving 90 participants. For controlled trials, meta-analysis showed that the interventions led to greater reduction in clinical global score than placebo (standardized mean differences (SMD) = -0.96, 95 % CI:-1.32, -0.60), and supported a long-term longitudinal effect for pharmacotherapy (SMD = -0.42, 95 % CI: -0.79, -0.05). For single-arm trials, both pharmacotherapy and psychotherapy showed efficacy for depressive symptoms, while pharmacotherapy only showed efficacy for hypomania symptoms (effect size (ES) = -9.16, 95 % CI:-11.29, -7.04). Discontinuation of pharmacotherapy due to adverse effects did not show a difference.

LIMITATIONS

The primary limitations are the small number of RCTs and the influence of medication dosage.

CONCLUSIONS

Based on the limited available data, early interventions show efficacy for individuals at risk of BD. Psychological therapy might be more beneficial for depressive symptoms and have long-term benefits for hypomania. Pharmacotherapy may be appropriate in situations of severe hypomanic symptoms and the poor functioning. Large, well-designed, double-blind -controlled trials are needed to make solid conclusions about the efficacy of early interventions.

Risk of psychosis in autism spectrum disorder individuals exposed to psychosocial stressors: A 9-year chart review study

Psychosocial stressors have been suggested to precipitate psychotic episodes in patients with pre-existing psychosis and otherwise healthy subjects. However, such a risk has never been formally investigated in individuals with autism spectrum disorder (ASD). Sixty-nine autistic adolescents hospitalized for psychotic/manic symptoms (PSY) and other mental health issues (NPSY) over a 9-year period were compared with reference to their previous exposure to psychosocial stressors. ASD diagnoses satisfied the International Classification of Diseases (ICD)-10 criteria. Psychotic/manic symptom assessment followed the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). Psychosocial stressor exposure was collected separately at each admission. Preliminarily, univariate between-group comparisons were conducted. Then, a binomial model was adopted to investigate associations with previous exposure to psychosocial stressors. Results were reported with a change in AIC (ΔAIC). PSY patients presented with higher previous exposure to adverse life events (30.43% vs. 6.52%, OR = 6.079 [1.209, 40.926], p = 0.013) and school/work difficulties (30.43% vs. 8.70%, OR = 4.478 [0.984, 23.846], p = 0.034) than NPSY ones. Admissions for psychotic/manic symptoms occurred more likely in the context of family disturbances (OR = 2.275 [1.045, 5.045], p = 0.030) and adverse life events (OR = 3.489 [1.194, 11.161], p = 0.014). The fitted binomial model was found to be significant compared to the random effects model (ΔAIC = -1.962; χ2 10  = 21.96, p = 0.015), with the risk of presenting psychotic/manic symptoms being increased by family disturbances (z = +4.118) and school/work difficulties (z = +2.455). The results suggest a potential psychosis-inducing effect of psychosocial stressors in ASD, which has clinical and policy implications.

Prevalence and clinical correlates of co-morbid attention deficit hyperactivity disorder in euthymic adults with bipolar disorder: A cross-sectional study

Background

Bipolar disorders (BDs) are co-morbid with attention deficit hyperactivity disorder (ADHD), making diagnosis and management more difficult and associated with poorer outcomes. So, this study was planned to find the prevalence and clinical implication of co-morbid ADHD in BD.

Materials and Methods

In this cross-sectional study, a total of 110 euthymic BD patients were taken. They were screened for childhood ADHD symptoms and adult ADHD symptoms using the Wender Utah Rating Scale for ADHD and Adult ADHD Self-Report Screening Scale for DSM-5. Those were divided into three groups: Group A included BD patients without ADHD, Group B included bipolar patients with co-morbid adult ADHD (BD-aADHD), and Group C included bipolar patients who had a diagnosis of childhood ADHD (BD-cADHD).

Results

The ADHD prevalence of 27% was found in bipolar patients. The age of onset of an episode of BD was significantly earlier and the total duration of illness was significantly higher in BD-aADHD and BD-cADHD compared to the BD without ADHD. The BD-aADHD and BD-cADHD groups showed a significantly higher number of total, manic and major depressive episodes as compared to the BD without ADHD group. BD-aADHD showed a significant greater number of hypomanic episodes as compared to BD without ADHD.

Conclusions

The present study concludes that ADHD is a lifetime co-morbid condition in adults with BD. These patients have a more chronic and disabling course of BD which underscores the need to understand the potential benefit of controlling ADHD symptoms in this population.

Early indicators of bipolar risk in preschool offspring of parents with bipolar disorder

BACKGROUND

Offspring of parents with bipolar disorder (BD-I/II) are at increased risk to develop the disorder. Previous work indicates that bipolar spectrum disorder (BPSD) is often preceded by mood/anxiety symptoms. In school-age offspring of parents with BD, we previously built a risk calculator to predict BPSD onset, which generates person-level risk scores. Here, we test whether preschool symptoms predict school-age BPSD risk.

METHODS

We assessed 113 offspring of parents with BD 1-3 times during preschool years (2-5 years old) and then approximately every 2 years for a mean of 10.6 years. We used penalized (lasso) regression with linear mixed models to assess relationships between preschool mood, anxiety, and behavioral symptoms (parent-reported) and school-age predictors of BPSD onset (i.e., risk score, subthreshold manic symptoms, and mood lability), adjusting for demographics and parental symptomatology. Finally, we conducted survival analyses to assess associations between preschool symptoms and school-age onset of BPSD and mood disorder.

RESULTS

Of 113 preschool offspring, 33 developed new-onset mood disorder, including 19 with new-onset BPSD. Preschool irritability, sleep problems, and parental factors were lasso-selected predictors of school-age risk scores. After accounting for demographic and parental factors, preschool symptoms were no longer significant. Lasso regressions to predict mood lability and subthreshold manic symptoms yielded similar predictors (irritability, sleep problems, and parental affective lability), but preschool symptoms remained predictive even after adjusting for parental factors (ps < .005). Exploratory analyses indicated that preschool irritability univariately predicted new-onset BPSD (p = .02) and mood disorder (p = .02).

CONCLUSIONS

These results provide initial prospective evidence that, as early as preschool, youth who will develop elevated risk scores, mood lability, and subthreshold manic symptoms are already showing symptomatology; these preschool symptoms also predict new-onset BPSD. While replication of findings in larger samples is warranted, results point to the need for earlier assessment of risk and development of early interventions.

Developmental manifestations of polygenic risk for bipolar disorder from infancy to middle childhood

Knowledge on how genetic risk for bipolar disorder manifests in developmental, emotional or behavioral traits during childhood is lacking. This issue is important to address to inform early detection and intervention efforts. We investigated whether polygenic risk for bipolar disorder is associated with developmental outcomes during early to middle childhood in the general population, and if associations differ between boys and girls. Our sample consisted of 28 001 children from the Norwegian Mother, Father and Child Cohort study, a prospective pregnancy cohort with available genotype and developmental data. Mothers reported on a range of developmental outcomes in their children at 6 and 18 months, 3, 5 and 8 years. Polygenic risk scores reflecting common variant liability to bipolar disorder were calculated. Linear regression models were used in a multi-group framework to investigate associations between polygenic risk score and developmental outcomes, using sex as a grouping variable. We found robust evidence for an association between polygenic risk scores for bipolar disorder and conduct difficulties (β = 0.041, CI = 0.020-0.062) and oppositional defiant difficulties (β = 0.032, CI = 0.014-0.051) at 8 years. Associations with most other outcomes were estimated within the region of practical equivalence to zero (equivalence range D = -0.1 to 0.1), with the exceptions of negative association for activity levels (β = -0.028, CI = -0.047- -0.010) at age 5 and benevolence (β = -0.025, CI = -0.043 to -0.008) at age 8, and positive association for motor difficulties (β = 0.025, CI = 0.008-0.043) at age 3, inattention (β = 0.021, CI = 0.003-0.041) and hyperactivity (β = 0.025, CI = 0.006-0.044) at age 8. Our results suggest that genetic risk for bipolar disorder manifests as disruptive behaviors like oppositional defiant and conduct difficulties in childhood in the general population.

Genetic nurture versus genetic transmission of risk for ADHD traits in the Norwegian Mother, Father and Child Cohort Study

Identifying mechanisms underlying the intergenerational transmission of risk for attention-deficit/hyperactivity disorder (ADHD) traits can inform interventions and provide insights into the role of parents in shaping their children's outcomes. We investigated whether genetic transmission and genetic nurture (environmentally mediated effects) underlie associations between polygenic scores indexing parental risk and protective factors and their offspring's ADHD traits. This birth cohort study included 19,506 genotyped mother-father-offspring trios from the Norwegian Mother, Father and Child Cohort Study. Polygenic scores were calculated for parental factors previously associated with ADHD, including psychopathology, substance use, neuroticism, educational attainment, and cognitive performance. Mothers reported on their 8-year-old children's ADHD traits (n = 9,454 children) using the Parent/Teacher Rating Scale for Disruptive Behaviour Disorders. We found that associations between ADHD maternal and paternal polygenic scores and child ADHD traits decreased significantly when adjusting for the child polygenic score (pΔβ = 9.95 × 10-17 for maternal and pΔβ = 1.48 × 10-14 for paternal estimates), suggesting genetic transmission of ADHD risk. Similar patterns suggesting genetic transmission of risk were observed for smoking, educational attainment, and cognition. The maternal polygenic score for neuroticism remained associated with children's ADHD ratings even after adjusting for the child polygenic score, indicating genetic nurture. There was no robust evidence of genetic nurture for other parental factors. Our findings indicate that the intergenerational transmission of risk for ADHD traits is largely explained by the transmission of genetic variants from parents to offspring rather than by genetic nurture. Observational associations between parental factors and childhood ADHD outcomes should not be interpreted as evidence for predominantly environmentally mediated effects.

Risk of autism spectrum disorder in offspring with parental schizophrenia: a systematic review and meta-analysis

BACKGROUND

The effect of parental schizophrenia on the risk of Autism Spectrum Disorders (ASD) in offspring has been evaluated in previous studies. However, to our knowledge, no systematic review and meta-analysis have assessed this association. In this study, we aimed to evaluate the risk of ASD in offspring with parental schizophrenia.

METHODS

The electronic databases EMBASE, PubMed, and Scopus were systematically searched. We administered the Newcastle Ottawa quality assessment scale (NOS) to assess the quality of all selected studies. Combined effect values, as well as their 95% confidence intervals (CI), were calculated. We evaluated heterogeneity using Q and I² statistics. The publication bias was evaluated by funnel plot and Egger's regression test. In addition, a leave-one-out sensitivity analysis was performed to assess the robustness of the finding.

RESULTS

A total of 12 observational studies (10 cohorts and two case-control) were included. Our study found a high risk of ASD in offspring exposed to parental schizophrenia [RR = 2.38 (CI%95 2.0-2.83)]. Subgroup and sensitivity analysis confirmed the robustness of our main analysis.

CONCLUSION

The risk of ASD is considerably higher in offspring with parental schizophrenia. Our findings may suggest a shared pathologic pathway between schizophrenia and ASD.

Examining selection bias in a population-based cohort study of 522 children with familial high risk of schizophrenia or bipolar disorder, and controls: The Danish High Risk and Resilience Study VIA 7

PURPOSE

Knowledge about representativity of familial high-risk studies of schizophrenia and bipolar disorder is essential to generalize study conclusions. The Danish High Risk and Resilience Study (VIA 7), a population-based case-control familial high-risk study, creates a unique opportunity for combining assessment and register data to examine cohort representativity.

METHODS

Through national registers, we identified the population of 11,959 children of parents with schizophrenia (FHR-SZ) or bipolar disorder (FHR-BP) and controls from which the 522 children participating in The VIA 7 Study (202 FHR-SZ, 120 FHR-BP and 200 controls) were selected. Socio-economic and health data were obtained to compare high-risk groups and controls, and participants versus non-participants. Selection bias impact on results was analyzed through inverse probability weights.

RESULTS

In the total sample of 11,959 children, FHR-SZ and FHR-BP children had more socio-economic and health disadvantages than controls (p < 0.001 for most). VIA 7 non-participants had a poorer function, e.g. more paternal somatic and mental illness (p = 0.02 and p = 0.04 for FHR-SZ), notifications of concern (FHR-BP and PBC p < 0.001), placements out of home (p = 0.03 for FHR-SZ), and lower level of education (p ≤ 0.01 for maternal FHR-SZ and FHR-BP, p = 0.001 for paternal FHR-BP). Inverse probability weighted analyses of results generated from the VIA Study showed minor changes in study findings after adjustment for the found selection bias.

CONCLUSIONS

Familial high-risk families have multiple socio-economic and health disadvantages. In The VIA 7 Study, although comparable regarding mental illness severity after their child's birth, socioeconomic and health disadvantages are more profound amongst non-participants than amongst participants.

Associations between parental psychiatric disorders and autism spectrum disorder in the offspring

Whether parental psychiatric disorders are associated with autism spectrum disorder (ASD) in offspring has remained inconclusive. We examined the associations of parental psychiatric disorders with ASD in offspring. This population-based case-control study used Taiwan's National Health Insurance Research Database to identify a cohort of children born from 2004 to 2017 and their parents. A total of 24,279 children with ASD (diagnostic ICD-9-CM code: 299.x or ICD-10 code F84.x) and 97,715 matched controls were included. Parental psychiatric disorders, including depressive disorders, bipolar spectrum disorders, anxiety disorders, obsessive-compulsive disorder, schizophrenia, substance use disorders, autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD), and adjustment disorders were identified. Conditional logistic regressions with covariate adjustment were performed. The results suggest that parental diagnosis with any of the psychiatric disorders is associated with ASD in offspring (adjusted odds ratio [AOR] = 1.45, 95%CI: 1.40-1.51 for mothers; and AOR = 1.12, 95%CI: 1.08-1.17 for fathers). ASD in offspring was associated with schizophrenia, depressive disorders, obsessive-compulsive disorder, adjustment disorders, ADHD and ASD in both parents. The relationship between parental psychiatric disorders and the timing of the child's birth and ASD diagnosis varied across the different psychiatric disorders. The present study provides supportive evidence that parental psychiatric disorders are associated with autistic children. Furthermore, because the associations between parental psychiatric disorders and the timing of child's birth and ASD diagnosis varied across psychiatric disorders, the observed relationships may be affected by both genetic and environmental factors. Future studies are needed to disentangle the potential influence of genetic and environmental factors on the observed associations.

Long term outcomes of pediatric Bipolar-I disorder: A prospective follow-up analysis attending to full syndomatic, subsyndromal and functional types of remission

OBJECTIVE

To examine patterns of remission of pediatric bipolar I (BP-I) disorder attending to syndromatic, symptomatic, and functional outcomes from childhood to adolescent and young adult years.

METHODS

We analyzed data from a six-year prospective follow-up study of youths aged 6-17 years with BP-I disorder. Subjects were comprehensively assessed at baseline and subsequently at four, five, and six years thereafter. Assessments included structured diagnostic interviews and measures of psychosocial and educational functioning. Patterns of remission were calculated attending to whether syndromatic, symptomatic, and functional remission were achieved.

RESULTS

Kaplan-Meier failure functions revealed that the probability of functional recovery from pediatric BP-I disorder was very low. Of the 88 youths assessed, only 6% (N = 5) of the sample were euthymic with normal functioning during the year prior to their last follow-up assessment (average follow-up time = 5.8 ± 1.8 years).

CONCLUSIONS

These results provide compelling evidence of the high level of persistence of pediatric BP-I disorder. Symptomatic and functional remission were uncommon and most subjects continued to demonstrate high morbidity into late adolescence and early adulthood.

Mental and pediatric disorders among children 0-6 years of parents with severe mental illness

OBJECTIVE

Parental severe mental illness (SMI) increases the lifetime risk of mental and pediatric disorders in the offspring but little is known about specific disorders during early childhood. The primary aim was to investigate the incidence of mental and pediatric disorders among children 0-6 years old exposed to parental SMI, and secondarily to investigate the distribution of disorders on specific child age.

METHODS

A nationwide, register-based cohort study of 1,477,185 children born in Denmark between 1994.01.01 and 2016.12.31. Incidence rate ratios were calculated using Poisson regression analysis for any and specific mental and pediatric disorders.

RESULTS

IRR for any psychiatric disorder was elevated by a factor 2-5 among SMI offspring. Maternal schizophrenia resulted in the highest IRR = 5.23 (4.80-5.69) of any child psychiatric disorder. The risk of anxiety/OCD and attachment disorder among offspring exposed to parental, and in particular maternal, SMI was markedly raised with IRRs for anxiety/OCD between 7.59 and 17.02 and attachment disorders between 6.26 and 15.40. IRRs of mental disorders were highest at age 0-1 year and declined with age. IRR for any pediatric disorder was also elevated with IRRs between 1.01 and 1.28. Disorders of the digestive system and ill-defined symptoms were associated with the highest IRRs. Maternal (vs. paternal) SMI was associated with higher IRRs. IRRs declined slightly with child age.

CONCLUSION

Children exposed to parental SMI are at increased risk of mental and pediatric disorders during early childhood, particularly anxiety/OCD and attachment disorders. If associations are estimates of a modifiable causal relationship, our results indicate a need for early intervention to promote mental and pediatric health among SMI offspring.

A systematic review and meta-analysis of sleep and circadian rhythms disturbances in individuals at high-risk of developing or with early onset of bipolar disorders

Sleep and circadian rhythms disturbances (SCRD) in young people at high risk or with early onset of bipolar disorders (BD) are poorly understood. We systematically searched for studies of self, observer or objective estimates of SCRD in asymptomatic or symptomatic offspring of parents with BD (OSBD), individuals with presentations meeting recognized BD-at-risk criteria (BAR) and youth with recent onset of full-threshold BD (FT-BD). Of 76 studies eligible for systematic review, 35 (46%) were included in random effects meta-analyses. Pooled analyses of self-ratings related to circadian rhythms demonstrated greater preference for eveningness and more dysregulation of social rhythms in BAR and FT-BD groups; analyses of actigraphy provided some support for these findings. Meta-analysis of prospective studies showed that pre-existing SCRD were associated with a 40% increased risk of onset of BD, but heterogeneity in assessments was a significant concern. Overall, we identified longer total sleep time (Hedges g: 0.34; 95% confidence intervals:.1,.57), especially in OSBD and FT-BD and meta-regression analysis indicated the effect sizes was moderated by the proportion of any sample manifesting psychopathology or receiving psychotropic medications. This evolving field of research would benefit from greater attention to circadian rhythm as well as sleep quality measures.

Bipolar women's antepartum psychotropic exposure and offspring risk of attention-deficit/hyperactivity disorder and autism spectrum disorder

BACKGROUND

Women with bipolar disorder (BD) may continue psychotropics during pregnancy. The association of exposure to antidepressant, antipsychotics, and mood stabilizers with offspring risks of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) remains unexplored in mothers with BD.

METHODS

A total of 5669 pregnant women with BD and 5669 psychiatrically healthy controls were identified between 2002 and 2011 from the Taiwan Longitudinal Health Insurance Database. We analyzed the odds ratios (ORs) of psychotropic types and exposure periods (3 months before pregnancy [3MbPreg] and first, second, and third trimesters [T1, T2, T3, respectively]) on the risk of ADHD and ASD by using adjusted logistic regression analyses.

RESULTS

Antidepressant exposure during 3MbPreg (OR=2.15, 95% CI=1.45-3.20), T1 (OR=2.62, 95% CI=1.68-4.09), T2 (OR=2.33, 95% CI=1.18-4.63), and T3 (OR=2.33, 95% CI=1.67-6.61) was associated with increased offspring risk of ADHD, particularly for selective serotonin reuptake inhibitor and serotonin norepinephrine reuptake inhibitor. Mood stabilizer exposure during 3MbPreg increased the risks of ADHD (OR=2.39, 95% CI=1.45-3.95) and ASD (OR=3.89, 95% CI=1.30-11.65); a higher ADHD risk was associated with valproic acid (OR=2.43, 95% CI=1.32-4.47) and lamotrigine exposure (OR=8.24, 95% CI = 1.49-45.67); ASD risk was higher for lithium exposure (OR=6.75, 95% CI=1.41-32.28).

LIMITATION

In claims-data analyses, several clinical parameters or potential confounders may be incompletely captured.

CONCLUSIONS

Antidepressants were associated with higher offspring risk of ADHD over all gestation periods among mothers with BD than psychiatrically healthy controls, while mood stabilizers were associated with higher risk of ADHD and ASD during 3MbPreg.

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.

High risk for psychiatric disorders in bipolar offspring. A four years prospective study

Bipolar disorder (BD) has a large hereditary component. It is a disorder that begins in early adulthood, but about which it has been described a premorbid period preceding the onset of BD. During this herald expression psychiatric disorders and symptoms, such as depressive, manic, psychotic, anxious and others, may appear.

OBJECTIVE

To determine the psychopathological profile of a Bipolar Offspring (BO) group compared with the Community Control Offspring (CCO) group, and its evolution over time, including subthreshold symptoms and mental disorders.

METHODS

We conducted an observational mixed cohort study, with a prospective design. We included subjects from six to 30 years of age, from the region of Antioquia, Colombia. A total of 131 subjects from the risk group BO and 150 subjects from the CCO group were evaluated through validated psychiatric diagnostic interviews (K-SADS-PL and DIGS) at baseline and at 4 years follow up. All interviews were carried out by a staff blind to parent diagnoses. Follow-up assessment were complete in 72% of the offspring. Forty-two subjects were excluded as they surpassed the age of 30 years, and only 46 subjects were not followed (change of address or did not consent to participate).

RESULTS

Compared with the CCO group, the BO group had a higher frequency of affective disorder, psychotic disorder, externalizing disorders and use of the psychoactive substances during both assessments at time 1 and 2. The magnitude of the differences between the groups increased when they reach time 2. The BO group had a greater risk for presenting subthreshold symptoms and definitive psychiatric disorders, such as affective disorders, psychotic disorders and externalizing disorders. In addition, the BO group had a younger age of onset for psychoactive substances consumption.

CONCLUSION

During the follow-up period, the BO group had a higher risk of presenting mental disorders compared with the CCO group. The most relevant symptoms and disorders that could precede the onset of BD were depressive, bipolar not otherwise specified, psychotic and substance use.

Generalizing the Prediction of Bipolar Disorder Onset Across High-Risk Populations

OBJECTIVE

Risk calculators (RC) to predict clinical outcomes are gaining interest. An RC to estimate risk of bipolar spectrum disorders (BPSD) could help reduce the duration of undiagnosed BPSD and improve outcomes. Our objective was to adapt an RC previously validated in the Pittsburgh Bipolar Offspring Study (BIOS) sample to achieve adequate predictive ability in both familial high-risk and clinical high-risk youths.

METHOD

Participants (aged 6-12 years at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study (N = 473) were evaluated semi-annually. Evaluations included a Kiddie Schedule for Affective Disorders (K-SADS) interview. After testing an RC that closely approximated the original, we made modifications to improve model prediction. Models were trained in the BIOS data, which included biennial K-SADS assessments, and tested in LAMS. The final model was then trained in LAMS participants, including family history of BPSD as a predictor, and tested in the familial high-risk sample.

RESULTS

Over follow-up, 65 youths newly met criteria for BPSD. The original RC identified youths who developed BPSD only moderately well (area under the curve [AUC] = 0.67). Eliminating predictors other than the K-SADS screening items for mania and depression improved accuracy (AUC = 0.73) and generalizability. The model trained in LAMS, including family history as a predictor, performed well in the BIOS sample (AUC = 0.74).

CONCLUSION

The clinical circumstances under which the assessment of symptoms occurs affects RC accuracy; focusing on symptoms related to the onset of BPSD improved generalizability. Validation of the RC under clinically realistic circumstances will be an important next step.

Early detection of bipolar disorders and treatment recommendations for help-seeking adolescents and young adults: Findings of the Early Detection and Intervention Center Dresden

Background

Early identification and intervention of individuals with risk factors for or subtle prodromal symptoms of bipolar disorders (BD) may improve the illness course and prevent adverse long-term consequences.

Methods

We examined sociodemographic, clinical and psychopathological characteristics of help-seeking adolescents and young adults who consulted the Early Detection and Intervention Center Dresden at the University of Dresden (Germany) and presented with or without pre-defined at-risk criteria for BD. The standardized diagnostic procedure for all help-seeking youth included a comprehensive psychiatric history and a structured clinical interview. When BD at-risk state was suspected, early detection instruments (EPIbipolar, BPSS-FP) were applied. Treatment recommendations were formulated in multi-professional case conferences.

Results

Out of 890 help-seeking persons between 05/2009 and 04/2018, 582 (65%) completed the diagnostic process. Of these, 24 (4%) had manifest BD and 125 (21%) fulfilled at-risk BD criteria (age = 23.9 ± 0.6 years, female = 62%). Of the pre-defined main risk factors, family history for BD was reported in 22% of the at-risk persons, (hypo-)mania risk state in 44%, and increasing cyclothymic mood swings with increased activity in 48%. The most common secondary risk factors were decreased psychosocial functioning (78%), lifetime diagnosis of depressive disorder (67%) and specific sleep/circadian rhythm disturbances (59%). Substance use was very common in subjects at-risk for BD (cannabis = 50%, alcohol = 33%) and highest in patients with BD (cannabis = 75%, alcohol = 40%). Psychiatric treatment history, including psychopharmacological therapy, was similar between the groups, while treatment recommendations differed, with more advice for psychotherapy and antidepressants in the at-risk group with a lifetime diagnosis of depression and more advice for specialized BD treatment including mood stabilizers in patients with BD.

Conclusion

This analysis on the phenomenology of different BD at-risk stages suggests that early detection of individuals presenting with suggested risk factors for the development of BD is feasible in help-seeking young people. Future research should further develop/test stage-specific prevention and early targeted intervention approaches that were described in a naturalistic setting.

The Management of Prodromal Symptoms of Bipolar Disorder: Available Options and Future Perspectives

The onset of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder could be considered as an important alarm bell for the development of the disease and should be carefully detected. The management of prodromes in bipolar high-risk patients appears to be an important means of prevention; nevertheless, at the moment, there aren’t clear and widely shared treatment indications. The aim of this review is to summarize the available treatment options (pharmacological, psychosocial and nutraceutical) for the management of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder.

Clinical and neurostructural characteristics among youth with familial and non-familial bipolar disorder: Family history and youth bipolar disorder

BACKGROUND

Bipolar disorder (BD) is highly heritable and often severe, particularly when illness onset occurs early in life. There is limited knowledge regarding the clinical and neurostructural correlates of family history of BD among youth with BD.

METHODS

Clinical characteristics were evaluated in 197 youth with BD, ages 13-20 years, including 87 with familial BD and 110 with non-familial BD. Structural neuroimaging was examined in a subsample of familial BD (n=39), non-familial BD (n=42), and healthy control (HC, n=58) youth. Region of interest (ROI) analyses of anterior cingulate cortex (ACC), inferior frontal gyrus (IFG), and amygdala were complemented by whole-brain vertex-wise analyses.

RESULTS

Youth with familial BD had more family history of other psychiatric disorders, less severe worst manic episode, and less treatment with lithium, selective serotonin reuptake inhibitor (SSRI) antidepressants, and any lifetime psychiatric medications. None of these findings survived after correction for multiple comparisons. There were no significant between-group differences in ROI analyses. In whole-brain analyses, significant differences in cortical thickness were as follows: familial and non-familial BD < HC in left precentral gyrus and right inferior parietal lobe; familial BD < HC in left superior frontal gyrus; non-familial BD < HC in right precentral gyrus.

LIMITATIONS

Relatives did not complete full diagnostic interviews.

CONCLUSIONS

There were relatively few differences in clinical and neurostructural correlates related to family history of BD in youth with BD. Current findings suggest that family history of BD is not a strong contributor to the clinical or neuroimaging phenotypes in youth with BD.

Psychiatric assessment

Studies have consistently reported an increased prevalence of psychiatric comorbidity (PC) in individuals with neurodevelopmental disorders (NDDs) compared with typically developing controls, with high rates of anxiety disorders in autism spectrum disorders and challenging behaviors in children and adolescent with intellectual disability. Psychiatric assessment in this population should include multiple sources of information, derived from multiple contexts and using multiple methods, with accurate detection of contributing and trigger factors. It is important to focus on detecting change from the child's baseline functioning and to use, when possible, ad hoc instruments for assessing PC in the NDD population. Modifications in the setting and assessment procedures should be scheduled based on the child's age, developmental level, and sensory sensitivities. Simultaneously, validated screening instruments, which dimensionally assess the symptomatology of several NDDs and psychiatric disorders, are warranted to not only assist in the identification of PCs in NDDs but also discriminate among different NDDs. Changes from DSM-IV-TR to DSM-5 have had an impact on the diagnosis of several disorders in children and adolescents and, subsequently, on the current diagnostic tools, requiring appropriate and prompt modifications of the available instruments.

Genetic Associations Between Childhood Psychopathology and Adult Depression and Associated Traits in 42 998 Individuals: A Meta-analysis

Importance

Adult mood disorders are often preceded by behavioral and emotional problems in childhood. It is yet unclear what explains the associations between childhood psychopathology and adult traits.

Objective

To investigate whether genetic risk for adult mood disorders and associated traits is associated with childhood disorders.

Design, Setting, and Participants

This meta-analysis examined data from 7 ongoing longitudinal birth and childhood cohorts from the UK, the Netherlands, Sweden, Norway, and Finland. Starting points of data collection ranged from July 1985 to April 2002. Participants were repeatedly assessed for childhood psychopathology from ages 6 to 17 years. Data analysis occurred from September 2017 to May 2019.

Exposures

Individual polygenic scores (PGS) were constructed in children based on genome-wide association studies of adult major depression, bipolar disorder, subjective well-being, neuroticism, insomnia, educational attainment, and body mass index (BMI).

Main Outcomes and Measures

Regression meta-analyses were used to test associations between PGS and attention-deficit/hyperactivity disorder (ADHD) symptoms and internalizing and social problems measured repeatedly across childhood and adolescence and whether these associations depended on childhood phenotype, age, and rater.

Results

The sample included 42 998 participants aged 6 to 17 years. Male participants varied from 43.0% (1040 of 2417 participants) to 53.1% (2434 of 4583 participants) by age and across all cohorts. The PGS of adult major depression, neuroticism, BMI, and insomnia were positively associated with childhood psychopathology (β estimate range, 0.023-0.042 [95% CI, 0.017-0.049]), while associations with PGS of subjective well-being and educational attainment were negative (β, -0.026 to -0.046 [95% CI, -0.020 to -0.057]). There was no moderation of age, type of childhood phenotype, or rater with the associations. The exceptions were stronger associations between educational attainment PGS and ADHD compared with internalizing problems (Δβ, 0.0561 [Δ95% CI, 0.0318-0.0804]; ΔSE, 0.0124) and social problems (Δβ, 0.0528 [Δ95% CI, 0.0282-0.0775]; ΔSE, 0.0126), and between BMI PGS and ADHD and social problems (Δβ, -0.0001 [Δ95% CI, -0.0102 to 0.0100]; ΔSE, 0.0052), compared with internalizing problems (Δβ, -0.0310 [Δ95% CI, -0.0456 to -0.0164]; ΔSE, 0.0074). Furthermore, the association between educational attainment PGS and ADHD increased with age (Δβ, -0.0032 [Δ 95% CI, -0.0048 to -0.0017]; ΔSE, 0.0008).

Conclusions and Relevance

Results from this study suggest the existence of a set of genetic factors influencing a range of traits across the life span with stable associations present throughout childhood. Knowledge of underlying mechanisms may affect treatment and long-term outcomes of individuals with psychopathology.

High Risk for Psychiatric Disorders in Bipolar Offspring. A Four Years Prospective Study

Bipolar disorder (BD) has a large hereditary component. It is a disorder that begins in early adulthood, but about which it has been described a premorbid period preceding the onset of BD. During this herald expression psychiatric disorders and symptoms, such as depressive, manic, psychotic, anxious and others, may appear.

OBJECTIVE

To determine the psychopathological profile of a Bipolar Offspring (BO) group compared with the Community Control Offspring (CCO) group, and its evolution over time, including subthreshold symptoms and mental disorders.

METHODS

We conducted an observational mixed cohort study, with a prospective design. We included subjects from six to 30 years of age, from the region of Antioquia, Colombia. A total of 131 subjects from the risk group BO and 150 subjects from the CCO group were evaluated through validated psychiatric diagnostic interviews (K-SADS-PL and DIGS) at baseline and at 4 years follow up. All interviews were carried out by a staff blind to parent diagnoses. Follow-up assessment were complete in 72% of the offspring. Forty-two subjects were excluded as they surpassed the age of 30 years, and only 46 subjects were not followed (change of address or did not consent to participate).

RESULTS

Compared with the CCO group, the BO group had a higher frequency of affective disorder, psychotic disorder, externalizing disorders and use of the psychoactive substances during both assessments at time 1 and 2. The magnitude of the differences between the groups increased when they reach time 2. The BO group had a greater risk for presenting subthreshold symptoms and definitive psychiatric disorders, such as affective disorders, psychotic disorders and externalizing disorders. In addition, the BO group had a younger age of onset for psychoactive substances consumption.

CONCLUSION

During the follow-up period, the BO group had a higher risk of presenting mental disorders compared with the CCO group. The most relevant symptoms and disorders that could precede the onset of BD were depressive, bipolar not otherwise specified, psychotic and substance use.

Preliminary study of structural magnetic resonance imaging phenotypes related to genetic variation in Interleukin-1β rs16944 in adolescents with Bipolar Disorder

BACKGROUND

Bipolar disorder (BD), among the most heritable psychiatric conditions, is associated with increased pro-inflammatory blood markers and pro-inflammatory gene expression in post-mortem brain. We therefore examined the effects of pro-inflammatory single nucleotide polymorphism interleukin-1β (IL-1β) rs16944 on brain structure in adolescents with BD and healthy control (HC) adolescents.

METHODS

T₁-weighted 3-T magnetic resonance imaging data were acquired for 38 adolescents with BD and 32 HC adolescents (14-20 years). Using FreeSurfer, a priori regions of interest analyses, examining hippocampus, amygdala, dorsolateral prefrontal cortex (DLPFC), and caudal anterior cingulate cortex, were complemented by exploratory whole-brain vertex-wise analyses. General linear models assessed the association between IL-1β rs16944 and the ROIs, controlling for sex, age, and intracranial volume.

RESULTS

There was an IL-1β rs16944 polymorphism-by-diagnosis interaction effect on the DLPFC; T-carriers with BD had greater surface area compared to non-carriers with BD. Whereas, HC T-carriers had smaller DLPFC volume compared to HC non-carriers. In vertex-wise analyses, similar interactions were evident in a pars triangularis surface area cluster and a lateral occipital cortex volume cluster. Whole-brain analyses also yielded a main effect of IL-1β rs16944 polymorphism, whereby T-carriers had greater lateral occipital cortex surface area and volume.

CONCLUSIONS

The IL-1β rs16944 polymorphism is associated with neurostructural phenotypes in cognitive and visual regions that subserve functions, including facial recognition and response inhibition, which are known to be aberrant in BD. Future studies are warranted to evaluate whether the observed rs16944-related structural differences are relevant to neurocognitive function, functional neuroimaging phenotypes and IL-1β protein levels.

More assortative mating in US compared to European parents and spouses of patients with bipolar disorder: implications for psychiatric illness in the offspring

The effect of assortative mating on offspring is often not considered. Here, we present data on illness in the spouse and the parents of patients with bipolar disorder as they affect illness in the offspring. A history of psychiatric illness (depression, bipolar disorder, suicide attempt, alcohol abuse, drug abuse, and "other" illness) was elicited for the parents, spouse, and the offspring of 968 patients with bipolar disorder (540 of whom had children) who gave informed consent for participation in a treatment outcome network. Assortative mating for a mood disorder in the spouse and parents in those from the United States (US) was compared to those from the Netherlands and Germany and related to illnesses in the offspring. There was more illness and assortative mating for a mood disorder in both the spouse and patient's parents from the US compared to Europe. In the parents of the US patients, assortative mating for a mood disorder was associated with more depression, bipolar disorder, alcohol, and "other" illness in the offspring. Compared to the Europeans, there was more assortative mating for mood and other disorders in two generations of those from the US. This bilineal positivity for a parental mood disorder was related to more depression a second generation later in the patients' offspring. In clinical assessment of risk of illness in the offspring, the history of psychiatric illness in the spouse and patient's parents might provide additional information.

ADHD with Comorbid Bipolar Disorders: A Systematic Review of Neurobiological, Clinical and Pharmacological Aspects Across the Lifespan

BACKGROUND

Attention deficit hyperactivity (ADHD) disorder is a neurodevelopmental disorder characterized by inattention, hyperactivity, disruptive behaviour, and impulsivity. Despite considered typical of children for a long time, the persistence of ADHD symptoms in adulthood gained increasing interest during the last decades. Indeed, its diagnosis, albeit controversial, is rarely carried out even because ADHD is often comorbid with several other psychiatric diosrders, in particular with bipolar disorders (BDs), a condition that complicates the clinical picture, assessment and treatment.

AIMS

The aim of this paper was to systematically review the scientific literature on the neurobiological, clinical features and current pharmacological management of ADHD comorbid with BDs across the entire lifespan, with a major focus on the adulthood.

DISCUSSION

The pharmacology of ADHD-BD in adults is still empirical and influenced by the individual experience of the clinicians. Stimulants are endowed of a prompt efficacy and safety, whilst non-stimulants are useful when a substance abuse history is detected, although they require some weeks in order to be fully effective. In any case, an in-depth diagnostic and clinical evaluation of the single individual is mandatory.

CONCLUSION

The comorbidity of ADHD with BD is still a controversial matter, as it is the notion of adult ADHD as a distinct nosological category. Indeed, some findings highlighted the presence of common neurobiological mechanisms and overlapping clinical features, although disagreement does exist. In any case, while expecting to disentangle this crucial question, a correct management of this comorbidity is essential, which requires the co-administration of mood stabilizers. Further controlled clinical studies in large samples of adult ADHD-BD patients appear extremely urgent in order to better define possible therapeutic guidelines, as well as alternative approaches for this potentially invalidating condition.

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

OBJECTIVE

To examine development of bipolar spectrum disorders (BPSD) and other disorders in prospectively followed children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

In the Longitudinal Assessment of Manic Symptoms (LAMS) study, 531 of 685 children age 6-12 (most selected for scores > 12 on General Behavior Inventory 10-item Mania scale) had ADHD, 112 with BPSD, and 419 without. With annual assessments for 8 years, retention averaged 6.2 years. Chi-square analyses compared rate of new BPSD and other comorbidity between those with versus without baseline ADHD and between retained versus resolved ADHD diagnosis. Cox regression tested factors influencing speed of BPSD onset.

RESULTS

Of 419 with baseline ADHD but not BPSD, 52 (12.4%) developed BPSD, compared with 16 of 110 (14.5%) without either baseline diagnosis. Those who developed BPSD had more nonmood comorbidity over the follow-up than those who did not develop BPSD (p = .0001). Of 170 who still had ADHD at eight-year follow-up (and not baseline BPSD), 26 (15.3%) had developed BPSD, compared with 16 of 186 (8.6%) who had ADHD without BPSD at baseline but lost the ADHD diagnosis (χ²  = 3.82, p = .051). There was no statistical difference in whether ADHD persisted or not across new BPSD subtypes (χ²  = 1.62, p = .446). Of those who developed BPSD, speed of onset was not significantly related to baseline ADHD (p = .566), baseline anxiety (p = .121), baseline depression (p = .185), baseline disruptive behavior disorder (p = .184), age (B = -.11 p = .092), maternal mania (p = .389), or paternal mania (B = .73, p = .056). Those who started with both diagnoses had more severe symptoms/impairment than those with later developed BPSD and reported having ADHD first.

CONCLUSIONS

In a cohort selected for symptoms of mania at age 6-12, baseline ADHD was not a significant prospective risk factor for developing BPSD. However, persistence of ADHD may marginally mediate risk of BPSD, and early comorbidity of both diagnoses increases severity/impairment.

The impact of familial risk and early life adversity on emotion and reward processing networks in youth at-risk for bipolar disorder

A recently developed risk calculator for bipolar disorder (BD) accounts for clinical and parental psychopathology. Yet, it is understood that both familial predisposition and early life adversity contribute to the development of BD. How the interplay between these two factors influence emotion and reward processing networks in youth at risk for BD remains unclear. In this exploratory analysis, offspring of BD parents performed emotion and reward processing tasks while undergoing a fMRI scan. Risk calculator score was used to assess risk for developing BD in the next 5 years. Environmental risk was tabulated using the Stressful Life Events Schedule (SLES). Emotion and reward processing networks were investigated for genetic and/or environment interactions. Interaction effects were found between risk calculator scores, negative SLES score and activity in right amygdala and bilateral fusiform gyri during the emotion processing task, as well as activity in the fronto-, striatal, and parietal regions during the reward processing task. Our findings are preliminary; however, they support the unique and interactive contributions of both familial and environmental risk factors on emotion and reward processing within OBP. They also identify potential neural targets to guide development of interventions for youth at greatest risk for psychiatric disorders.

Clinical, cortical thickness and neural activity predictors of future affective lability in youth at risk for bipolar disorder: initial discovery and independent sample replication

We aimed to identify markers of future affective lability in youth at bipolar disorder risk from the Pittsburgh Bipolar Offspring Study (BIOS) (n = 41, age = 14, SD = 2.30), and validate these predictors in an independent sample from the Longitudinal Assessment of Manic Symptoms study (LAMS) (n = 55, age = 13.7, SD = 1.9). We included factors of mixed/mania, irritability, and anxiety/depression (29 months post MRI scan) in regularized regression models. Clinical and demographic variables, along with neural activity during reward and emotion processing and gray matter structure in all cortical regions at baseline, were used to predict future affective lability factor scores, using regularized regression. Future affective lability factor scores were predicted in both samples by unique combinations of baseline neural structure, function, and clinical characteristics. Lower bilateral parietal cortical thickness, greater left ventrolateral prefrontal cortex thickness, lower right transverse temporal cortex thickness, greater self-reported depression, mania severity, and age at scan predicted greater future mixed/mania factor score. Lower bilateral parietal cortical thickness, greater right entorhinal cortical thickness, greater right fusiform gyral activity during emotional face processing, diagnosis of major depressive disorder, and greater self-reported depression severity predicted greater irritability factor score. Greater self-reported depression severity predicted greater anxiety/depression factor score. Elucidating unique clinical and neural predictors of future-specific affective lability factors is a step toward identifying objective markers of bipolar disorder risk, to provide neural targets to better guide and monitor early interventions in bipolar disorder at-risk youth.

Clinical differences between patients with pediatric bipolar disorder with and without a parental history of bipolar disorder

Pediatric Bipolar Disorder (PBD) is a highly heritable condition responsible for 18% of all pediatric mental health hospitalizations. Despite the heritability of this disorder, few studies have assessed potential differences in the clinical manifestation of PBD among patients with a clear parental history of BD. Additionally, while recent studies suggest that attentional deficits are a potential endophenotypic marker of PBD, it is unclear whether heritability is a relevant contributor to these symptoms. In order to address this gap, the present study assessed 61 youth with PBD (6-17 years old), corresponding to 27 offspring of BD patients, and 31 PBD patients without a parental history of the disorder. All standardized assessments, including the K-SADS-PL-W were performed by trained child and adolescent psychiatrists. We performed a logistic multivariate model using the variables of ADHD, rapid cycling, and lifetime psychosis. Rates of ADHD comorbidity were significantly higher among PBD patients who had a parent with BD. Furthermore, PBD patients who had a parent with BD showed a trend toward significance of earlier symptom onset. PBD offspring did not show increased rates of suicide attempts, rapid cycling, or psychosis. Given these findings, it appears that PBD patients who have a parent with BD may represent a distinct endophenotype of the disorder. Future longitudinal and larger studies are required to confirm our findings.

Risk and coaggregation of major psychiatric disorders among first-degree relatives of patients with bipolar disorder: a nationwide population-based study

BACKGROUND

Bipolar disorder is a highly heritable mental illness that transmits intergeneratively. Previous studies supported that first-degree relatives (FDRs), such as parents, offspring, and siblings, of patients with bipolar disorder, had a higher risk of bipolar disorder. However, whether FDRs of bipolar patients have an increased risk of schizophrenia, major depressive disorder (MDD), autism spectrum disorder (ASD), and attention deficit hyperactivity disorder (ADHD) remains unclear.

METHODS

Among the entire population in Taiwan, 87 639 patients with bipolar disorder and 188 290 FDRs of patients with bipolar disorder were identified in our study. The relative risks (RRs) of major psychiatric disorders were assessed among FDRs of patients with bipolar disorder.

RESULTS

FDRs of patients with bipolar disorder were more likely to have a higher risk of major psychiatric disorders, including bipolar disorder (RR 6.12, 95% confidence interval (CI) 5.95-6.30), MDD (RR 2.89, 95% CI 2.82-2.96), schizophrenia (RR 2.64, 95% CI 2.55-2.73), ADHD (RR 2.21, 95% CI 2.13-2.30), and ASD (RR 2.10, 95% CI 1.92-2.29), than the total population did. These increased risks for major psychiatric disorders were consistent across different familial kinships, such as parents, offspring, siblings, and twins. A dose-dependent relationship was also found between risk of each major psychiatric disorder and numbers of bipolar patients.

CONCLUSIONS

Our study was the first study to support the familial coaggregation of bipolar disorder with other major psychiatric disorders, including schizophrenia, MDD, ADHD, and ASD, in a Taiwanese (non-Caucasian) population. Given the elevated risks of major psychiatric disorders, the public health government should pay more attention to the mental health of FDRs of patients with bipolar disorder.

Childhood factors associated with increased risk for mood episode recurrences in bipolar disorder-A systematic review

BACKGROUND

Bipolar Disorder (BD) is a recurrent illness associated with high morbidity and mortality. The frequency of mood episode recurrence in BD is highly heterogeneous and significantly impacts the person's psychosocial functioning and well-being. Understanding the factors associated with mood recurrences could inform the prognosis and treatment. The objective of this review is to summarize the literature on factors, present during childhood, that influence recurrence.

METHODOLOGY

A systematic review of PubMed (1946-2017) and PsycINFO (1884-2017) databases was conducted to identify candidate studies. Search terms included bipolar disorder, episodes, predictors, recurrences, and course. Study characteristics, risk for bias, and factors associated with recurrence were coded by two raters according to predetermined criteria.

RESULTS

Twenty child studies and 28 adult studies that retrospectively evaluated childhood variables associated with mood recurrences were included. Early age of onset, low socioeconomic status, comorbid disorders, inter-episode subsyndromal mood symptoms, BD-I/II subtypes, presence of stressors, and family history of BD were associated with higher number of recurrences.

LIMITATIONS

Risk factors and mood recurrences were assessed and defined in different ways, limiting generalizability.

CONCLUSION

Multiple factors are associated with increased risk of mood episode recurrence in BD. Interventions targeting modifiable factors could reduce the impact of BD. For example, treatment of comorbid disorders and subsyndromal mood symptoms, coupled with appropriate cognitive behavioral and family-focused therapies could ameliorate risk related to many clinical factors. When coupled with social services to address environmental factors, the number of episodes could be reduced and the course of BD significantly improved.

Risk of autistic spectrum disorder in offspring with parental mood disorders: A systematic review and meta-analysis

BACKGROUND

The association between mood disorders in parents and autism spectrum disorder (ASD) risk in offspring has been investigated in several studies, but the evidence is inconclusive. This systematic review and meta-analysis will explore whether an association exists between parental mood disorders and ASD risk in offspring.

METHODS

A literature search was performed using the electronic databases PubMed, EMBASE, PsycINFO, and Scopus. We also reviewed reference lists from retrieved articles. Meta-analysis was conducted, and combined effect values and their 95% confidence intervals were calculated. Study-specific risk ratios (RRs) were pooled using a random effect model. The risk of publication bias was assessed by funnel plot and Egger's regression asymmetry test.

RESULTS

Nine observational studies (two cohort and seven case-control studies) were included for analysis. Our meta-analysis found a greater risk of ASD in children exposed to parental affective, depressive, and bipolar disorders [(RRs 1.65 (95%CI 1.45-1.88); 1.37 (95%CI 1.04-1.81) and 1.87; 95%CI 1.69-2.07) respectively]. We also found increased ASD risk in children of mothers who experienced affective and depressive disorders [(RRs 1.67 (95%CI 1.34-2.09) and 1.62 (95%CI 1.32-1.99) respectively]. We found no increased risk of ASD in children exposed to paternal affective and depressive disorders. Subgroup and sensitivity analysis confirmed the robustness of our main analysis.

CONCLUSION

The evidence from the present study suggests parental affective, depressive and bipolar, as well as maternal affective and depressive disorders increased the risk of ASD in offspring. Exposure to affective and depressive disorders in fathers only was not linked with ASD risk in children.

Parsing cyclothymic disorder and other specified bipolar spectrum disorders in youth

OBJECTIVE

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Prevalence of psychopathology in bipolar high-risk offspring and siblings: a meta-analysis

This meta-analysis aimed to update existing data on the comparison of prevalence rates of psychopathology primarily among offspring with at least one parent with bipolar disorder (BD) and offspring of parents without psychiatric illness. Seventeen studies were derived from a systematic search of PsychInfo, Medline, Scopus and Embase. Inclusion criteria were use of a control offspring group, standardized diagnostic procedures and reporting of clear frequency data. Risk of psychopathology was estimated by aggregating frequency data from selected studies. Compared to control offspring, high-risk BD offspring are nine times more likely to have a bipolar-type disorder, almost two and a half times more likely to develop a non-BD affective disorder and over two times more likely to develop at least one anxiety disorder. High-risk offspring also showed a significant increased risk of other non-mood psychopathology such as attention deficit hyperactivity disorder (ADHD), any type of behavioral disorder and substance use disorder (SUDs). Risk of developing a broad range of affective and non-affective psychopathology is significantly higher in high-risk BD offspring. Identifying clinical presentations of this genetically high-risk cohort is important in establishing appropriate preventative treatment.

Clinical staging model in offspring of parents with bipolar disorder: a systematic review

OBJECTIVE

We sought to systematically review the literature on the psychiatric risk of offspring of parents with bipolar disorder (OPBD) using a developmental psychopathology framework. The review also sought to establish the utility of clinical stage modelling as a framework for identifying precursor disorders to later onset of bipolar disorder (BD) in OPBD.

METHODS

A systematic search was performed using EMBASE, PsychINFO and Medline. Reference lists of included studies and previous reviews were also searched. Studies were included if they reported diagnostic outcomes for child, adolescent and young adult offspring of parents diagnosed with BD.

RESULTS

Twenty-six studies were identified representing 21 individual cohorts. The review identified that OBPD present as a high-risk group for a range of mood and non-mood disorders in childhood, adolescence and young adulthood. The trajectory of risk was from non-mood disorders in childhood via non-bipolar mood disorders in early adolescence towards mania/hypomania in late adolescence and early adulthood. From a clinical staging perspective, childhood anxiety disorders were associated with later onset of BD. Recurrent substance use disorder was identified as a risk in OPBD during late adolescence and early adulthood. Quality ratings indicated that studies were methodologically robust.

CONCLUSIONS

Our review provides evidence for a developmental psychopathology trajectory of precursor risks to BD in OPBD. There is support for clinical stage modelling as a conceptual framework for understanding developmental risk in OPBD and as a tool for developing early and individualized intervention strategies.

Psychometric Properties and Factor Structures of the Korean Version of Children's Depression Rating Scale-Revised

OBJECTIVE

The Children's Depression Rating Scale-Revised (CDRS-R) is a valid instrument for the assessment of depressive symptoms in youth, but this measure is yet to be validated in Korea. Thus, the present study aimed to evaluate the validity of the Korean version of the CDRS-R and to determine its factor structures.

METHODS

This study included 66 youths between 12 and 17 years of age who participated as part of an ongoing study investigating biomarkers of the antidepressant response and suicidal events in depressed youth. At baseline, the participants were assessed using the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL), CDRS-R, Children's Depression Inventory (CDI), Beck Depression Inventory (BDI), Clinical Global Impressions-Severity (CGI-S), Children's Global Assessment Scale (CGAS), and Child Behavior Checklist (CBCL). Based on their diagnosis, each participant was assessed either five (major depressive disorder [MDD], n = 36) or two (non-MDD, n = 30) more times with the CDRS-R, CDI, BDI, CGI-S, and CGAS; thus, 306 assessments were included in the final analyses of the present study. Pearson's r and Cronbach's α values were used to determine validity and internal consistency, and exploratory factor analysis was performed to determine the factor structures of the Korean version of the CDRS-R.

RESULTS

The CDRS-R score was significantly correlated with scores on the K-SADS-PL depression subscale (r = 0.93, p < 0.01), CDI (r = 0.86, p < 0.01), BDI (r = 0.85, p < 0.01), CGI-S (r = 0.84, p < 0.01), and CGAS (r = -0.86, p < 0.01), indicating that this measure has strong criterion validity. In addition, the high correlation of the CDRS-R with the depression subscale of the CBCL (r = 0.67, p < 0.01) and lower correlations with the subscales of the CBCL that assess delinquent behavior, aggressive behavior, and externalizing problem support the discriminant validity of this instrument (r_s ≤ 0.50, p < 0.01). Internal consistency was high, as evidenced by a Cronbach's α of 0.91, and the exploratory factor analysis revealed that the Korean version of the CDRS-R comprised three factors as follows: subjective depressed mood, daily functional impairment, and observed depressive affect. These factors differed from those used in previous studies, which were performed with the English version of the CDRS-R.

CONCLUSIONS

This study of the Korean version of the CDRS-R provides initial promising data regarding its criterion validity, discriminant validity, internal consistency, and factor structures. These properties were significantly strong, which suggests that the Korean version of the CDRS-R is a valid and reliable instrument for the assessment of depressive symptoms in youth.

What can we learn from offspring studies in bipolar disorder?

We offer a contemporary review of studies of the offspring of parents with bipolar disorder and explore the clinical characteristics of these populations. We discuss how different methodological approaches may influence study findings and may explain some of the heterogeneity in the results reported. We also highlight some of the environmental risk factors that may increase the likelihood of transition from an ‘at-risk’ or high-risk state to bipolar disorder. Last, we briefly discuss the implications of study findings for early intervention strategies and comment on such issues as genetic counselling and primary and early secondary prevention programmes.

Personalized management of bipolar disorder

Bipolar disorder (BD) is one of the most serious psychiatric disorders. The rates of disability, the risk of suicide attempts and their high lethality, as well as frequent and severe psychiatric and medical comorbidities, put it among the major causes of mortality and disability worldwide. At the same time, many patients can do well when treated properly. In this review, we focus on those aspects of the clinical care that offer the potential of individualized approach, in the context of the recent technology driven advances in the comprehension of the neurobiological underpinnings of BD. We first review those clinical and biological factors that can help identifying individuals at high risk of developing BD. Among these are a family history of BD and/or completed suicide, prodromal symptoms (in childhood and/or adolescence) such as anxiety and mood lability, early onset, and poor response to antidepressants. Panels of genetic markers are also being studied to identify subjects at risk for BD. Further, neuroimaging studies have found an increased gray matter density in the right Inferior Frontal Gyrus (rIFG) as a possible risk marker of BD. We then examine clinical factors that influence the initiation, selection and possibly discontinuation of long-term treatment. Lastly, we discuss the risk of side effects in BD, and their relevance for treatment adherence and for treatment monitoring. In summary, we discuss how a personalized approach in BD can be implemented through the identification of specific clinical and molecular predictors. We show that the realization of a personalized management of BD is not only of a theoretical value, but has substantial clinical repercussions, resulting in a significant reduction of the long-term morbidity and mortality associated to BD.

A developmental approach to dimensional expression of psychopathology in child and adolescent offspring of parents with bipolar disorder

The aim of this is to describe psychopathology, functioning and symptom dimensions accounting for subthreshold manifestations and developmental status in child and adolescent offspring of parents with bipolar disorder ("high-risk offspring"). The study population comprised 90 high-risk offspring (HR-offspring) and 107 offspring of community control parents (CC-offspring). Direct clinical observations and parental and offspring reports based on selected standardized clinical scales were used to assess offspring threshold and subthreshold diagnoses, symptoms and functioning. All outcomes were compared between the whole HR-offspring and CC-offspring samples and then by developmental status. After controlling for potential confounders, HR-offspring showed significantly poorer adjustment for childhood (r = 0.18, p = 0.014) and adolescence (r = 0.21, p = 0.048) than CC-offspring, as well as more emotional problems (r = 0.24, p = 0.001) and higher depression scores (r = 0.16, p = 0.021). As for differences in lifetime categorical diagnoses (threshold and subthreshold) between HR-offspring and CC-offspring, the prevalence of disruptive disorders was higher in pre-pubertal HR-offspring (OR 12.78 [1.45-112.42]), while prevalence of mood disorders was higher in post-pubertal HR-offspring (OR 3.39 [1.14-10.06]). Post-pubertal HR-offspring presented more prodromal (r = 0.40, p = 0.001), negative (r = 0.38, p = 0.002), manic (r = 0.22, p = 0.035) and depressive (r = 0.23, p = 0.015) symptoms than pre-pubertal HR-offspring, as well as more peer relationship problems (r = 0.31, p = 0.004), poorer childhood adjustment (r = 0.22, p = 0.044) and worse current psychosocial functioning (r = 0.27, p = 0.04). Externalizing psychopathology is more prevalent in pre-pubertal HR-offspring, while depressive and prodromal symptoms leading to functional impairment are more prominent in post-pubertal HR-offspring. Developmental approaches and dimensional measures may be useful for identifying children at high risk of developing bipolar disorder and help guide specific preventive strategies.

Psychiatric Disorders and Quality of Life in the Offspring of Parents with Bipolar Disorder

OBJECTIVE

To determine current and lifetime psychopathology and assess quality of life (QoL) in offspring of a parent with bipolar disorder (BD).

METHODS

We investigated 43 offspring of bipolar parents (high-risk offspring [HRO]) (mean age 12.5 ± 3.1; range 6.7-17.9 years) and 43 comparison offspring matched for sex, age, and IQ of healthy parents. Lifetime and current presence of Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnoses were assessed using Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). We administered parent and self-report versions of General Behavior Inventory and the Screen for Child Anxiety-Related Emotional Disorders (SCARED). QoL was evaluated using the self-report questionnaire KIDSCREN-52.

RESULTS

Thirty-seven HRO (86%) and 18 controls (42%) met DSM-5 criteria for at least one lifetime psychiatric diagnosis (adjusted OR = 7.20; 95% CI 2.27-22.81). Compared to controls, HRO had higher lifetime frequency of any mood disorder (33% vs. 2%, p < 0.001), anxiety disorder (60% vs. 14%, p < 0.001), and attention-deficit/hyperactivity disorder (26% vs. 5%, p = 0.01). After adjustment for confounders, only mood (OR = 13.05; 95% CI 1.41-120.60) and anxiety (OR = 9.69; 95% CI 2.75-34.31) disorders remained significantly more frequent in the HRO group. In comparison with controls, HRO scored lower in the following domains: QoL, social support and relationship with peers (p = 0.003; Cohen's d = 0.91), parent relationships and home life (p = 0.008; d = 0.67), as well as self-perception (p = 0.04; d = 0.55).

CONCLUSIONS

In agreement with other studies, we found a higher rate of lifetime anxiety and mood disorders in children and adolescents at confirmed familial risk for BD. Reduction in QoL was already evident across a number of domains. Adult psychiatrists should incorporate into their assessment procedures targeted questions on the presence of psychopathology in offspring of their adult patients with severe mental disorders and child services should bridge with adult services providing accessible services to children of affected parents.

Assessment of a Person-Level Risk Calculator to Predict New-Onset Bipolar Spectrum Disorder in Youth at Familial Risk

IMPORTANCE

Early identification of individuals at high risk for the onset of bipolar spectrum disorder (BPSD) is key from both a clinical and research perspective. While previous work has identified the presence of a bipolar prodrome, the predictive implications for the individual have not been assessed, to date.

OBJECTIVE

To build a risk calculator to predict the 5-year onset of BPSD in youth at familial risk for BPSD.

DESIGN, SETTING, AND PARTICIPANTS

The Pittsburgh Bipolar Offspring Study is an ongoing community-based longitudinal cohort investigation of offspring of parents with bipolar I or II (and community controls), recruited between November 2001 and July 2007, with a median follow-up period of more than 9 years. Recruitment has ended, but follow-up is ongoing. The present analysis included offspring of parents with bipolar I or II (aged 6-17 years) who had not yet developed BPSD at baseline.

MAIN OUTCOMES AND MEASURES

This study tested the degree to which a time-to-event model, including measures of mood and anxiety, general psychosocial functioning, age at mood disorder onset in the bipolar parent, and age at each visit, predicted new-onset BPSD. To fully use longitudinal data, the study assessed each visit separately, clustering within individuals. Discrimination was measured using the time-dependent area under the curve (AUC), predicting 5-year risk; internal validation was performed using 1000 bootstrapped resamples. Calibration was assessed by comparing observed vs predicted probability of new-onset BPSD.

RESULTS

There were 412 at-risk offspring (202 [49.0%] female), with a mean (SD) visit age of 12.0 (3.5) years and a mean (SD) age at new-onset BPSD of 14.2 (4.5) years. Among them, 54 (13.1%) developed BPSD during follow-up (18 with BD I or II); these participants contributed a total of 1058 visits, 67 (6.3%) of which preceded new-onset BPSD within the next 5 years. Using internal validation to account for overfitting, the model provided good discrimination between converting vs nonconverting visits (AUC, 0.76; bootstrapped 95% CI, 0.71-0.82). Important univariate predictors of outcome (AUC range, 0.66-0.70) were dimensional measures of mania, depression, anxiety, and mood lability; psychosocial functioning; and parental age at mood disorder.

CONCLUSIONS AND RELEVANCE

This risk calculator provides a practical tool for assessing the probability that a youth at familial risk for BPSD will develop new-onset BPSD within the next 5 years. Such a tool may be used by clinicians to inform frequency of monitoring and treatment options and for research studies to better identify potential participants at ultra high risk of conversion.

Longitudinal changes in the antecedent and early manifest course of bipolar disorder-A narrative review of prospective studies

OBJECTIVE

Prospective study designs ideally allow patients to be followed from the first manifestations of the illness or even from an at-risk stage. It can thus provide data on the predictive value of changes in clinical symptomatology, cognition or further biological markers to broaden our understanding of the etiopathology and symptomatic trajectory of bipolar disorders. The scope of this narrative review is to summarize evidence from prospectively collected data on psychopathological and other clinical and biological changes in the early developmental course of bipolar disorders.

METHODS

The narrative review was based on a literature search conducted in February 2016 within the PubMed library for prospective study data of persons in antecedent and early manifest stages of manifest bipolar disorder published within the last 15 years.

RESULTS

A total of 19 prospective studies were included. Regarding psychopathological features; personality, temperament and character traits as well as changes in sleep and circadian rhythm, the evidence suggests that risk factors for the development of bipolar disorder can already be described and should be studied further to understand their interaction, mediation with other factors and timing in the developmental process of bipolar disorder. Apart from the positive family history, childhood anxiety, sleep problems, subthreshold (hypo)manic symptoms and certain character traits/emotionality should be identified and monitored already in clinical practice as their presence likely increases risk of bipolar disorder. Up to date no substantiated evidence was found from prospective studies addressing cognitive features, life events, immunological parameters and morphological central nervous system changes as potential risk factors for bipolar disorder.

CONCLUSION

For an improved understanding of episodic disorders, longitudinal data collection is essential. Since the etiology of bipolar disorders is complex, a number of potential risk factors have been proposed. Prospective studies addressing this spectrum and resilience factors are critical and will be best conducted within multi-site research networks or initiatives.

The Relationship Between Stressful Life Events and Axis I Diagnoses Among Adolescent Offspring of Probands With Bipolar and Non-Bipolar Psychiatric Disorders and Healthy Controls: The Pittsburgh Bipolar Offspring Study (BIOS)

BACKGROUND

Previous studies have explored the role of stressful life events in the development of mood disorders. We examined the frequency and nature of stressful life events as measured by the Stressful Life Events Schedule (SLES) among 3 groups of adolescent offspring of probands with bipolar (BD), with non-BD psychiatric disorders, and healthy controls. Furthermore, we examined the relationship between stressful life events and the presence of DSM-IV Axis I disorders in these offspring. Stressful life events were characterized as dependent, independent, or uncertain (neither dependent nor independent) and positive, negative, or neutral (neither positive nor negative).

METHODS

Offspring of probands with BD aged 13-18 years (n = 269), demographically matched offspring of probands with non-BD Axis I disorders (n = 88), and offspring of healthy controls (n = 81) from the Pittsburgh Bipolar Offspring Study were assessed from 2002 to 2007 with standardized instruments at intake. Probands completed the SLES for their offspring for life events within the prior year. Life events were evaluated with regard to current Axis I diagnoses in offspring after adjusting for confounds.

RESULTS

After adjusting for demographic and clinical between-group differences (in probands and offspring), offspring of probands with BD had greater independent (χ² = 11.96, P < .04) and neutral (χ² = 17.99, P < .003) life events compared with offspring of healthy controls and greater number of more severe stressful life events than offspring of healthy controls, but not offspring of probands with non-BD. Offspring of BD probands with comorbid substance use disorder reported more independent stressful life events compared to those without comorbid substance use disorder (P = .024). Greater frequency and severity of stressful life events were associated with current Axis I disorder in offspring of both probands with BD and probands with other Axis I disorders regardless of dependency or valence. Greater frequency and severity of stressful life events were associated with greater current Axis I disorder in all offspring.

CONCLUSIONS

Offspring of probands with BD have greater exposure to independent and neutral life events than offspring of healthy controls. Greater frequency and severity of stressful life events were associated with Axis I disorder in offspring of both BD and non-BD affected probands.

More childhood onset bipolar disorder in the United States than Canada or Europe: Implications for treatment and prevention

Evidence of a high or increasing incidence of childhood onset bipolar disorder in the United States (US) has been viewed skeptically. Here we review evidence that childhood onsets of bipolar disorder are more common in the US than in Europe, treatment delays are longer, and illness course is more adverse and difficult. Epidemiological data and studies of offspring at high risk also support these findings. In our cohort of outpatients with bipolar disorder, two of the major vulnerability factors for early onset - genetics and environmental adversity in childhood - were also greater in the US than in Europe. An increased familial loading for multiple psychiatric disorders was apparent in 4 generations of the family members of the patients from the US, and that familial burden was linked to early onset bipolar disorder. Since both early onset and treatment delay are risk factors for a poor outcome in adulthood, new clinical, research, and public health initiatives are needed to begin to address and ameliorate this ongoing and potentially devastating clinical situation.