Prior stimulant treatment in adolescents with bipolar disorder: association with age at onset

Shared and nonshared symptoms in youth-onset psychosis and ADHD

OBJECTIVE

We compared ratings of behavior and attention problems between youth-onset psychosis and ADHD, two disorders in which attentional impairments play a key role, and examined the effect of psychostimulant use on age of onset in psychosis.

METHOD

Parent and teacher ratings of behavioral problems and ADHD symptoms were collected using the Achenbach CBCL, TRF, and SNAP-IV Teacher Rating Scales on 42 participants with psychosis, 36 with ADHD and 57 controls (ages 8-19).

RESULTS AND CONCLUSIONS

Results suggested that academic, externalizing, and attention problems reflect symptoms shared between the disorders, whereas internalizing, social and thought problems reflect factors that differ between disorders. Furthermore, participants with psychosis who had been prescribed psychostimulants had a younger age of onset of psychotic symptoms than those who had not. This difference could reflect dissimilarities in symptom severity symptom between subgroups or potentially harmful effects of psychostimulants in individuals predisposed to develop psychosis.

The early natural history of bipolar disorder: what we have learned from longitudinal high-risk research

Longitudinal high-risk research has provided convergent evidence that major mood and psychotic disorders often develop from nonspecific antecedents in predisposed people over time and development. For example, bipolar disorder (BD) appears to evolve from nonspecific childhood antecedents, including anxiety and sleep problems, followed by adjustment and minor mood disturbances through early adolescence, culminating in major mood episodes in later adolescence and early adulthood. Therefore, the current cross-sectional symptom-based diagnostic approach requires rethinking: it considers neither the familial risk nor the longitudinal clinical course, with the consequence that the early stages of illness are not recognized as belonging to the end-stage disorder. Emerging evidence of identifiable clinical stages in the development of BD has tremendous potential for early identification, development of stage-specific treatments, and advancing our understanding of the pathophysiology associated with illness onset and progression. The clinical staging model also has direct implications for the optimal organization of clinical services for high-risk youth. Specifically, specialty psychiatric programs are needed that break down traditional institutional barriers to provide surveillance and timely comprehensive psychiatric assessment during the entire risk period, from childhood through to early adulthood. In this regard, the development of specialty psychiatric programs aiming to identify youth in the early stages of evolving psychosis are substantially ahead of services for youth in the early stages of evolving major mood disorders.

Adult ADHD and its comorbidities, with a focus on bipolar disorder

Attention deficit hyperactivity disorder (ADHD) is a syndrome that most often presents in childhood. However, the condition is also relatively common in adults, with prevalence rates reaching 5% in the general population, with more than half the children affected by ADHD retaining the condition during their adult years. While the disorder in children is most often described as a disorder involving hyperactivity and impulsiveness, ADHD presents with very different characteristics in adulthood, notably with less externalizing symptoms and with a higher rate of psychiatric comorbidities, including major depressive disorder, bipolar disorder (BD), anxiety disorders and substance abuse. This review will focus on the evidence relating to bipolar disorder BD and its potential link with ADHD, looking at epidemiological, familial and neuroimaging studies. The comorbid presentation of people suffering with ADHD and BD (ADHD/BD) is associated with a more severe disease course, more severe mood disorder symptoms, and lower functional scores. Importantly, the co-segregation of these two conditions makes ADHD diagnosis challenging because its symptoms are often mistakenly assumed to be part of BD. As a result, patients with comorbid ADHD/BD are under-diagnosed and under-treated. Optimal diagnosis, understanding and treatment of the comorbid condition are important, as ADHD/BD has been associated with significant functional impairment and suboptimal treatment responses when compared to ADHD or BD populations alone.

Bipolar disorder and comorbid attention deficit hyperactivity disorder. A distinct clinical phenotype? Clinical characteristics and temperamental traits

OBJECTIVES

It has been suggested that bipolar disorder (BD) with comorbid ADHD represents a distinct clinical phenotype of BD. There are no data regarding potential heterogeneity between BD subjects with a diagnosis of ADHD in childhood whose ADHD remitted in adulthood (cADHD-BD) vs. BD patients with persistent ADHD diagnosis in adulthood (aADHD-BD). This heterogeneity may constitute a confounder in investigations of the nature of the co-occurrence between BD and ADHD. The aim of this paper is to compare BD patients without ADHD, to those with aADHD-BD, and those with cADHD-BD on clinical and temperamental characteristics, hypothesizing that maladaptive temperament will be increased in BD subjects with a stable diagnosis of ADHD in adulthood compared to those whose ADHD remitted. We further hypothesize that maladaptive temperament will be associated with the severity of both illnesses.

METHODS

A total of 100 outpatients (aged 18-30 years) with BD in remission were included. The assessment of ADHD was made according to a procedure aimed to reduce potential recall biases. Subjects had to have a parent available and had never been treated with stimulants. Temperamental traits were assessed with the California Child Q-sort (CCQ) and the Early Adolescent Temperament Questionnaire (EATQ).

RESULTS

Rate of co-occurrence of ADHD-BD was 18% lifetime and 10% current diagnosis. Patients with ADHD-BD (aADHD-BD+cADHD-BD) reported a significantly earlier onset of mood disorder, higher number of previous mood episodes, and significantly higher impulsivity than BD patients without ADHD. aADHD-BD showed a significantly earlier BD onset, higher number of previous mood episodes, higher impulsivity, decreased Reactive Control and higher Negative Emotionality temperamental scores than cADHD patients.

CONCLUSION

Findings suggest that patients with aADHD-BD present a clinical phenotype distinct from that of patients with BD without ADHD or with a childhood ADHD diagnosis that remitted with the age. This appealing hypothesis of a BD-distinct phenotype that can be detected early due to its associated maladaptive temperamental traits requires further investigation in larger samples, supported by neuropsychological, genetic and imaging data.

Post-traumatic stress symptoms and trauma exposure in youth with first episode bipolar disorder

AIMS

To examine the prevalence of trauma exposure as well as the rates and effects of post-traumatic stress disorder (PTSD) in adolescents with bipolar disorder following a first manic episode.

METHODS

Adolescents (12-18 years) with DSM-IV bipolar I disorder and experiencing their first manic or mixed episode were recruited. Participants underwent structured diagnostic interviews, completed the Trauma Symptom Checklist for Children (TSCC), and were prospectively evaluated using diagnostic, symptomatic and functional assessments over the course of 12 months.

RESULTS

Seventy-six adolescents (14.9 +/- 1.7 years) completed the TSCC and 66% (50 individuals) reported exposure to traumatic events. Two (3%) subjects met DSM-IV criteria for PTSD, 11 (14%) had post-traumatic stress t-scores > or = 65, the threshold for clinically significant symptoms. Subjects with and without post-traumatic stress t-scores > or = 65 did not differ in demographic characteristics. When compared by t-score, TSCC subscores of the first episode bipolar adolescents were similar to normative data. Regression models incorporating TSCC subcomponents, did not predict syndromic recovery or recurrence or symptomatic recovery.

CONCLUSIONS

Rates of PTSD were lower in this sample of bipolar adolescents at the time of their first hospitalization compared with rates in samples of bipolar adults. These differences coupled with the low incidence of PTSD and trauma symptoms in this young sample suggests that bipolar disorder may be a risk factor for the development of PTSD later in the course of illness or following recurrent affective episodes.

Pharmacological and non-drug treatment of child bipolar I disorder during prospective eight-year follow-up

OBJECTIVES

The Phenomenology and Course of Pediatric Bipolar Disorders study, a National Institute of Mental Health-funded study of child bipolar I disorder (BP-I) begun in 1995, is a prospective follow-up study that included collecting pharmacological and non-drug treatment data.

METHODS

There were 115 first-episode subjects who fit full DSM-IV criteria for BP-I, mixed or manic phase, with severity scores in the clinically impaired range, ascertained by consecutive new case ascertainment. Subjects were assessed with the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS), given separately to parents about their children and to children about themselves. All treatment was provided by the subjects' own community practitioners, exactly as if they had not been in the research study. Thus, families were only seen for research assessments, and research staff were not at all involved in their treatment. Data on type, dose, and duration of pharmacological and non-drug treatment were collected. During follow-up, 93.9% (n = 108) were assessed at each of the nine assessment times.

RESULTS

During the eight years, only 62.6% received any antimanic medication (antipsychotic, anticonvulsant, lithium) at any time. Percents who received non-antimanic medication included 77.4% medication for attention-deficit hyperactivity disorder and 64.3% antidepressants. A total of 67.8% of subjects were taking two or more concurrent medication classes. Subjects ascertained from psychiatric versus pediatric sites received antimanics significantly more frequently (p = 0.006). Earlier recovery during eight-year follow-up was predicted by greater percent of weeks on lithium (p = 0.017).

CONCLUSIONS

Given these findings, and the poor prognosis from prospective follow-up of this sample reported elsewhere, there is a need for further research that informs the development of effective treatment strategies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Occupational outcome in adult ADHD: impact of symptom profile, comorbid psychiatric problems, and treatment: a cross-sectional study of 414 clinically diagnosed adult ADHD patients

OBJECTIVE

To determine the effects of symptom profile, comorbid psychiatric problems, and treatment on occupational outcome in adult ADHD patients.

METHOD

Adult ADHD patients (N = 414) responded to questionnaires rating past and present symptoms of ADHD, comorbid conditions, treatment history, and work status.

RESULTS

Of the patients, 24% reported being in work, compared to 79% in a population-based control group (N = 359). Combined subtype of ADHD, substance abuse, and a reported history of depression or anxiety were correlated with being out of work. Current and past medical treatment of ADHD was correlated with being in work. Logistic regression analyses showed that stimulant therapy during childhood was the strongest predictor for being in work as adults (odds ratio = 3.2, p = .014).

CONCLUSION

Early recognition and treatment of ADHD is a strong predictor of being in work as an adult, independently of comorbidity, substance abuse, and current treatment.

Early-onset bipolar spectrum disorders: diagnostic issues

Since the mid 1990s, early-onset bipolar spectrum disorders (BPSDs) have received increased attention in both the popular press and scholarly press. Rates of diagnosis of BPSD in children and adolescents have increased in inpatient, outpatient, and primary care settings. BPSDs remain difficult to diagnose, particularly in youth. The current diagnostic system makes few modifications to accommodate children and adolescents. Researchers in this area have developed specific BPSD definitions that affect the generalizability of their findings to all youth with BPSD. Despite knowledge gains from the research, BPSDs are still difficult to diagnose because clinicians must: (1) consider the impact of the child's developmental level on symptom presentation (e.g., normative behavior prevalence, environmental limitations on youth behavior, pubertal status, irritability, symptom duration); (2) weigh associated impairment and course of illness (e.g., neurocognitive functioning, failing to meet full DSM criteria, future impairment); and (3) make decisions about appropriate assessment (differentiating BPSD from medical illnesses, medications, drug use, or other psychiatric diagnoses that might better account for symptoms; comorbid disorders; informant characteristics and assessment measures to use). Research findings concerning these challenges and relevant recommendations are offered. Areas for further research to guide clinicians' assessment of children with early-onset BPSD are highlighted.

Differential brain activation during response inhibition in bipolar and attention-deficit hyperactivity disorders

AIM

To identify differential patterns of brain activation between adolescents with bipolar disorder and adolescents with attention-deficit hyperactivity disorder (ADHD) to better understand the neurophysiology of both disorders. We hypothesized that subjects with ADHD would show altered activation in brain regions involved in executive and sustained attention. In contrast, we hypothesized that bipolar subjects would show altered brain activation in regions responsible for emotionally homeostasis, including the striatum and amygdala.

METHODS

Functional magnetic resonance imaging was performed during a continuous performance task with a response inhibition component in 11 adolescents with bipolar disorder during a manic episode, 10 adolescents with ADHD, and 13 healthy adolescents.

RESULTS

There were no differences in behavioural performance among the three groups. Compared with bipolar subjects, subjects with ADHD showed increased activation in the superior temporal lobe during successful response inhibition. Although bipolar subjects did not show activation differences in the striatum or amygdala compared with ADHD subjects, increased left parahippocampal activation in the bipolar group was associated with increased manic symptoms.

CONCLUSIONS

The patterns of brain activation observed in the current study support divergent patterns of neurophysiological dysfunction in individuals with bipolar disorder as compared with those with ADHD. Therefore, the impulsive behaviour seen in both disorders may be the consequence of dysfunction in different brain regions, and further research may help identify neurobiological markers that are specific to each condition.

Diffusion tensor imaging study of white matter fiber tracts in pediatric bipolar disorder and attention-deficit/hyperactivity disorder

BACKGROUND

To investigate microstructure of white matter fiber tracts in pediatric bipolar disorder (PBD) and attention-deficit/hyperactivity disorder (ADHD).

METHODS

A diffusion tensor imaging (DTI) study was conducted at 3 Tesla on age- and IQ-matched children and adolescents with PBD (n = 13), ADHD (n = 13), and healthy control subjects (HC) (n = 15). Three DTI parameters, fractional anisotropy (FA), apparent diffusion coefficient (ADC), and regional fiber coherence index (r-FCI), were examined in eight fiber tracts: anterior corona radiata (ACR), anterior limb of the internal capsule (ALIC), superior region of the internal capsule (SRI), posterior limb of the internal capsule (PLIC), superior longitudinal fasciculus (SLF), inferior longitudinal fasciculus (ILF), cingulum (CG), and splenium (SP).

RESULTS

Significantly lower FA was observed in ACR in both PBD and ADHD relative to HC. In addition, FA and r-FCI values were significantly lower in ADHD relative to PBD and HC in both the ALIC and the SRI. Further, ADC was significantly greater in ADHD relative to both the PBD and HC in ACR, ALIC, PLIC, SRI, CG, ILF, and SLF.

CONCLUSIONS

Decreased FA in ACR implies an impaired fiber density or reduced myelination in both PBD and ADHD in this prefrontal tract. These abnormalities, together with the reduced fiber coherence, extended to corticobulbar tracts in ADHD. Increased ADC across multiple white matter tracts in ADHD indicates extensive cellular abnormalities with less diffusion restriction in ADHD relative to PBD.

Pharmacologic treatment of pediatric bipolar disorder

Bipolar disorder (BPD) is being diagnosed with increasing frequency in the pediatric population as the phenomenology of this disorder is becoming more clearly delineated. Early diagnosis and treatment of pediatric BPD is important to minimize psychosocial disability and improve prognosis. Traditional mood stabilizers and atypical antipsychotic agents are frequently used to treat BPD in youth, and there are emerging data to support their use in this population. This article provides a review of the literature on appropriate pharmacologic treatment strategies for BPD in children and adolescents. The complex treatment issues of comorbid BPD and attention deficit/hyperactivity disorder also are addressed.

Attention deficit-hyperactivity disorder and early-onset bipolar disorder: two facets of one entity?

Early-onset bipolar disorder (BD) and attention-deficithyperactivity disorder (ADHD) have recently been the subject of highly controversial debate, due to theories regarding underlying pathophysiological processes and a clinical overlap of symptoms. Epidemiological data, clinical aspect, neuroimaging, neurochemical, and genetic studies suggest that there may be a possible relationship between biological factors and clinical characteristic in the development of symptoms. However, longitudinal data supporting the hypothesis of a diagnostic shift from BD to ADHD symptoms and vice versa are currently not available. These would be essential to enable further investigations into whether these two disorders possibly represent two different aspects of an underlying common psychopathophysioiogical entity.

Neural bases of emotional processing in pediatric bipolar disorder

Pediatric bipolar disorder (PBD) presents with severe affect dysregulation characterized by elated mood, irritability and depressive symptoms, often in the form of a mixed episode. Early recognition of the external clinical features and the underlying emotional processing circuitry will help us understand the neurobiological underpinnings of this disorder and offer innovative ideas for early intervention.

METHODS

A 5-year review was conducted in structural and functional imaging studies in PBD that are potentially relevant to the emotional processing in PBD.

RESULTS

The ventral frontolimbic circuitry and the dorsal frontostriatal circuitry appear to be involved in affect regulation, with the ventral circuitry being more directly involved in emotion processing. The associated and interlinked circuits include the facial emotion-processing circuit and the association circuit between the occipital and the limbic regions responsible for automatic processing of emotions.

CONCLUSION

While we are at a preliminary stage in understanding the neural circuitry behind emotional processing, there appears to be a top-down regulation of affect with prefrontal systems modulating subcortical structures such as the amygdala and the ventral striatum. Structural and connectivity studies support the functional studies findings, providing a cogent model for understanding emotion-processing circuits involving corticosubcortical neural systems. Functional studies with PBD patients are beginning to demonstrate the dysfunction in the affective and cognitive circuits that work in concert.

The efficacy and tolerability of methylphenidate and behavior modification in children with attention-deficit/hyperactivity disorder and severe mood dysregulation

OBJECTIVES

This study examines the tolerability and efficacy of methylphenidate (MPH) and behavior modification therapy (BMOD) in children with attention-deficity/hyperactivity disorder (ADHD) and severe mood dysregulation (SMD).

METHODS

Children (ages 5-12) from a summer program for ADHD were screened for SMD and additional manic-like symptoms using structured assessments and direct clinical interview with the Young Mania Rating Scale (YMRS). The SMD group was comprised of 33 subjects with SMD and elevated YMRS scores (mean = 23.7). They underwent weekly mood assessments plus the daily ADHD measures that are part of the program. The comparison group (n = 68) was comprised of the rest of the program participants. Using a crossover design, all subjects in both groups were treated with three varying intensities of BMOD (no, low, high) each lasting 3 weeks, with MPH dose (placebo, 0.15 mg/kg t.i.d., 0.3mg/kg t.i.d., and 0.6 mg/kg t.i.d.) varying daily within each behavioral treatment.

RESULTS

Groups had comparable ADHD symptoms at baseline, with the SMD group manifesting more oppositional defiant disorder/conduct disorder (ODD/CD) symptoms (p < 0.001). Both groups showed robust improvement in externalizing symptoms (p < 0.001). There was no evidence of differential treatment efficacy or tolerability. Treatment produced a 34% reduction in YMRS ratings in SMD subjects (p - 0.001). However, they still exhibited elevated YMRS ratings, more ODD/CD symptoms (p < 0.001), and were more likely to remain significantly impaired at home than non-SMD subjects (p < 0.05).

CONCLUSIONS

MPH and BMOD are tolerable and effective treatments for children with ADHD and SMD, but additional treatments may be needed to optimize their functioning.

Attention-deficit hyperactivity disorder (ADHD): does new research support old concepts?

OBJECTIVE

To examine the evidence for and against the classification of attention-deficit hyperactivity disorder (ADHD) as a valid disease entity, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV ), criteria.

DATA SOURCES

Sources included but were not limited to published literature on ADHD accessed via PubMed (http://www.ncbi.nlm.nih.gov/PubMed/).

STUDY SELECTION

Peer-reviewed research, review articles, consensus statements, "white papers," and proceedings of professional meetings were used.

DATA EXTRACTION

Focused on evidence base and scientific validity of conclusions.

DATA SYNTHESIS

Evidence for a genetic or neuroanatomic cause of ADHD is insufficient. Experimental work shows that executive function deficits do not explain ADHD. The psychometric properties of widely used ADHD rating scales do not meet standards expected for disease identification.

CONCLUSIONS

ADHD is unlikely to exist as an identifiable disease. Inattention, hyperactivity, and impulsivity are symptoms of many underlying treatable medical, emotional, and psychosocial conditions affecting children.

Does pharmacotherapy for attention-deficit/hyperactivity disorder predict risk of later major depression?

OBJECTIVE

This study's goal was to determine among youths with attention-deficit/hyperactivity disorder (ADHD) how the history of ADHD pharmacotherapy influenced the risk of developing major depressive disorder (MDD), compared to other commonly reported predictors.

METHOD

Diagnostic and treatment history data were analyzed retrospectively in 75 youths 11-18 years old with definite or probable ADHD, enrolled in an observational study at a tertiary mental health clinic. Subjects with histories of MDD (H/o MDD) (n = 36) were compared to others who had never been depressed (Never-Depressed) (n = 39) regarding histories of ADHD pharmacotherapy, psychopathology and other potential covariates of MDD risk.

RESULTS

H/o MDD subjects reported longer delays before initiating ADHD pharmacotherapy, were more often female, reported having experienced more traumatic event types, and had higher rates of early anxiety and externalizing disorders. With all covariates allowed to enter a backward stepwise Cox regression of survival time till first episodes of MDD, only two variables remained in the model. The time-dependent variable, ADHD pharmacotherapy, prolonged survival times (p = .012), while having experienced more traumatic event types shortened them (p = .001).

CONCLUSIONS

This study provides preliminary evidence that pharmacotherapy for ADHD may have a protective effect in ADHD youths, reducing the risk of later MDD.

Pediatric Bipolar Disorder

In the past decade, interest in and research on pediatric bipolar disorder (BD) has increased substantially. Prevalence rates of the disorder have doubled in outpatient settings, while twice as many research articles on pediatric BD were published in the past five years as in the prior decade. This review focuses on recent developments in the study of pediatric BD. We examine current research on the diagnostic boundaries of BD in youths, in particular the issues of episodicity and irritability, and provide assessment guidelines. We review data elucidating the pathophysiology of pediatric BD, with a focus on how these results may inform diagnosis. Finally, we discuss treatment approaches for pediatric BD, particularly psychotherapeutic interventions. Throughout the review, we pay particular attention to youths with severe chronic irritability, hyperarousal, and hyperreactivity, who reflect the population in whom the diagnosis of BD is most debated.

Frontiers between attention deficit hyperactivity disorder and bipolar disorder

The co-occurrence of attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received much recent attention in the literature. The authors review the literature examining associations between ADHD and bipolar disorder in children, and data concerning severe irritability in youth with ADHD. This article focuses on (1) population-based studies examining ADHD and bipolar disorder or ADHD and co-occurring irritability, (2) the co-occurrence and prospective relationships of ADHD and bipolar disorder in clinical samples, (3) phenomenology and assessment of bipolar disorder and ADHD, (4) treatment of comorbid ADHD and bipolar disorder, (5) family and genetic studies of ADHD and bipolar disorder, and (6) pathophysiologic comparisons between children with ADHD and irritability and bipolar disorder. We draw on the research to make clinical recommendations and highlight important directions for future research.

Initiation of stimulant and antidepressant medication and clinical presentation in juvenile bipolar I disorder

OBJECTIVES

The primary purpose of this study was to examine the extent to which the initiation of stimulant and antidepressant medication was associated with the subsequent onset of juvenile bipolar I disorder (BP I). Another aim was to investigate differences in clinical presentation between youths prescribed stimulant or antidepressant medication before and after the onset of juvenile BP I disorder.

METHODS

Youths between the ages of 5 and 17 years meeting full, unmodified DSM-IV diagnostic symptom criteria for BP were included in this study. Data regarding the age of onset of BP I, psychiatric comorbidities, and current symptoms of mania and depression were obtained. Medication history was recorded as part of the assessment interview with parents and youths.

RESULTS

Of the 245 youths with BP I, 65% (n = 160) were treated with stimulant medication; 32% (56/173) were treated after the onset of BP I, and 19% (32/173) were treated before the onset of BP I. Forty-six percent (113/245) were treated with antidepressant medication; 33% (67/206) were treated after the onset of BP I, and 3% (7/206) were treated before the onset of BP I. Patients who were treated with stimulants after the onset of BP I were significantly more likely to be younger (p < 0.0001). Patients who were treated with antidepressants before the onset of BP I were significantly more likely to be older and to have lower levels of mania on the Young Mania Rating Scale at assessment (p < 0.01).

CONCLUSIONS

Data from this retrospective case series do not support the association between initial stimulant or antidepressant use and the onset of BP I or presenting symptoms of depression or manic symptoms.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The early manifestations of bipolar disorder: a longitudinal prospective study of the offspring of bipolar parents

OBJECTIVE

A major aim of this longitudinal high-risk study is to identify reliable early indicators of emerging bipolar disorder (BD) among offspring from well-characterized parents.

METHODS

High-risk offspring were recruited from families in which one parent had BD diagnosed on the basis of the Schedule for Affective Disorders and Schizophrenia - Lifetime version (SADS-L) interviews and DSM-IV diagnostic criteria and the other parent was well. Bipolar parents were further subdivided on the basis of response or non-response to long-term lithium. A comparison group of offspring was recruited from well parents diagnosed on the basis of either SADS-L interviews or the family history method. All consenting offspring from high-risk and control families were assessed longitudinally with the Schedule for Affective Disorders and Schizophrenia for School-aged Children - Present and Lifetime version (KSADS-PL) interviews and DSM-IV diagnoses were made on a blind consensus review. The offspring were reassessed on average annually, as well as at any time symptoms developed.

RESULTS

Antecedent conditions to BD in both high-risk groups included sleep and anxiety disorders, while attention-deficit hyperactivity disorder and pre-psychotic conditions were antecedents among the offspring of lithium non-responders only. Among those offspring developing BD, the index mood episode was almost always depressive.

CONCLUSIONS

Despite a specific genetic risk, BD began with non-specific psychopathology and/or depressive disorders in a majority of offspring. Therefore, diagnosis based only on cross-sectional assessment of symptoms appears to be insufficient for the accurate early detection of emerging BD. Other parameters such as family history and associated antecedents should be taken into account.

Concurrent ADHD and bipolar disorder

Attention-deficit/hyperactivity disorder (ADHD) frequently is present concurrently with bipolar disorder (BPD) in youth. This concurrence appears to be more common in younger children. The degree to which ADHD is present in adults with BPD has not been well studied. The psychiatric and behavioral symptoms associated with ADHD and BPD have significant overlap. The core symptoms of BPD are relatively independent and respond to different pharmacologic and behavioral strategies. Although much symptomatic overlap exists between ADHD and BPD, these conditions can be reliably differentiated from each other and require independent treatments that frequently need to be sequenced.

Differentiating bipolar disorder in Turkish prepubertal children with attention-deficit hyperactivity disorder

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) in children are frequently comorbid conditions. Because the coexistence of ADHD and mania seriously complicates the course of the condition and the treatment of children, diagnosing or missing this comorbidity has important clinical implications. There are very few systematic studies on the subject in the literature and BPD in children is not recognized or studied in most countries other than the USA. We aimed to differentiate Turkish prepubertal children with ADHD from those with comorbid ADHD and BPD and compare their clinical characteristics.

METHODS

A total of 147 treatment- and drug-naïve children, aged 7 to 13 years, who had been consecutively referred to the ADHD clinic, were evaluated using the Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime version (K-SADS-PL). Parents completed the Child Behavior Checklist (CBCL) 4-18 and the Parent-Young Mania Rating Scale (P-YMRS) prior to the clinical interview.

RESULTS

Twelve children (8.2%) had comorbid bipolar disorder (ADHD + BPD). The ADHD + BPD group had significantly higher rates of depressive disorders, oppositional defiant disorder, panic disorder and a family history of bipolar disorder compared with the ADHD group. The ADHD + BPD group had significantly more problems on the CBCL scale (anxiety/depression, social problems, thought problems, aggression, externalization, and total score) and on the P-YMRS (all items except for insight) compared with the ADHD group.

CONCLUSIONS

We conclude that ADHD + BPD in Turkish children represents a clinical picture different to that of ADHD alone, in which the clinical characteristics resemble those of children reported in the literature. Further long-term follow-up studies are needed in larger clinical and community samples.

Response and remission in adolescent mania: signal detection analyses of the young mania rating scale

OBJECTIVE

The purpose of this study was to determine optimal criteria for defining response and remission in adolescents with acute mania.

METHOD

Data were analyzed from three treatment studies of adolescents with acute mania (N = 99). Trained raters completed the Young Mania Rating Scale (YMRS), and clinicians completed the Clinical Global Impressions Scale for Bipolar Disorder (CGI-BP) independent of YMRS ratings. For response, the percentages of reduction in YMRS scores from baseline to endpoint were compared with CGI-BP Mania Improvement scores. For remission, endpoint YMRS scores were compared with CGI-BP Mania Severity scores. Signal detection analyses were conducted to evaluate the efficiency of selected cutoffs associated with response and remission.

RESULTS

A > or =55% reduction in YMRS scores from baseline to endpoint was the optimal cutoff defining response. An absolute endpoint YMRS score < or =12 was the optimal cutoff defining remission.

CONCLUSIONS

The results of this signal detection analysis in adolescent mania suggest that current commonly used cutoffs to define response (> or =50% reduction) and remission (< or =12) may be appropriate with regard to efficiency. Studies with methods specifically tailored to evaluate and compare these rating scales and larger patient samples from multiple sites are needed to confirm these preliminary findings.

Voxel-based study of structural changes in first-episode patients with bipolar disorder

BACKGROUND

Although morphometric studies of bipolar disorder (BD) suggest that neurofunctional abnormalities reflect underlying structural changes, it remains unclear whether abnormalities are present at illness onset or reflect disease progression. Previous voxel-based morphometry (VBM) findings suggest that ventrolateral prefrontal cortex (VLPFC) changes develop over time, whereas morphologic abnormalities elsewhere in the anterior limbic network (ALN) are present early in BD. In this study, we used VBM to explore structural brain changes in first-episode bipolar patients.

METHODS

First-episode bipolar (n = 33) and healthy (n = 33) subjects underwent magnetic resonance imaging. Images were normalized and compared on a voxel-by-voxel basis.

RESULTS

Bipolar subjects showed no change in VLPFC density or volume. We observed increased volume in left thalamus and fusiform and cerebellum bilaterally; increased gray matter density in anterior cingulate and posterior parietal structures; and increased gray matter volume and density in middle/superior temporal and posterior cingulate gyri. No areas of decreased volume or density were observed.

CONCLUSIONS

These data indicate that structural changes are absent from VLPFC early in the course of BD. Morphologic abnormalities are present in other portions of the ALN and in structures previously observed to mediate neurofunctional changes in BD, suggesting that dysfunctional neuronal proliferation or pruning may occur in bipolar patients.

Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology

Attention-deficit/hyperactivity disorder (ADHD) is an established diagnosis in children, associated with a large body of evidence on the benefits of treatment. Adolescents with ADHD are now leaving children's services often with no readily identifiable adult service to support them, which presents problems as local pharmacy regulations often preclude the prescription of stimulant drugs by general practitioners (GPs). In addition, adults with ADHD symptoms are now starting to present to primary care and psychiatry services requesting assessment and treatment. For these reasons, the British Association for Psychopharmacology (BAP) thought it timely to hold a consensus conference to review the body of evidence on childhood ADHD and the growing literature on ADHD in older age groups. Much of this initial guidance on managing ADHD in adolescents in transition and in adults is based on expert opinion derived from childhood evidence. We hope that, by the time these guidelines are updated, much evidence will be available to address the many directions for future research that are detailed here.

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

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

Clinical characteristics of bipolar disorder in very young children

BACKGROUND

Clinical information about bipolar disorder (BPD) in preschool-age (3-7 years old) children is extremely limited. This study examined clinical presentations, applicability of the DSM-IV diagnostic criteria, comorbidity, recovery and relapse rates, as well as some treatment strategies used in the management of BPD in preschoolers.

METHODS

The charts of 26 outpatient children, ages 3-7, refereed to a child psychiatry outpatient clinic with mood and behavioral symptoms, were retrospectively reviewed.

RESULTS

The majority of the patients were referred with the tentative diagnosis of ADHD but the most common diagnoses made by child and adolescent psychiatrists at the time of initial evaluation were BPD NOS (61.5%), followed by BPD I (26.9%), and mood disorder NOS (23.1%). Thirty-eight percent of the patients had one or more comorbid diagnoses. The most common presenting symptoms were irritability (84.6%) and aggression (88.5%). The most widely prescribed class of medications after diagnosis in the clinic was atypical antipsychotics and mood stabilizers. Twenty-six percent of the patients were treated with a combination of atypical antipsychotics and mood stabilizers.

LIMITATIONS

Retrospective design; small sample size; lack of a comparison group.

CONCLUSIONS

The course of BPD with onset in preschool years is complicated with high recovery and relapse rates. The questions of development of age-appropriate diagnostic criteria, long-term prognosis and treatment strategies used in this population require further intensive investigation.

Co-occurrence of bipolar and attention-deficit hyperactivity disorders in children

OBJECTIVES

Pediatric bipolar disorder (BPD) and attention-deficit hyperactivity disorder (ADHD) co-occur more frequently than expected by chance. In this review, we examine 4 potential explanations for the high rate of this common co-occurrence: (i) BPD symptom expression leads to overdiagnosis of ADHD in BPD youth; (ii) ADHD is a prodromal or early manifestation of pediatric-onset BPD; (iii) ADHD and associated factors (e.g., psychostimulants) lead to the onset of pediatric BPD; and (iv) ADHD and BPD share an underlying biological etiology (i.e., a common familial or genetic risk or underlying neurophysiology).

METHODS

Peer-reviewed publications of studies of children and adolescents with comorbid BPD and ADHD were reviewed.

RESULTS

There is a bidirectional overlap between BPD and ADHD in youth, with high rates of ADHD present in children with BPD (up to 85%), and elevated rates of BPD in children with ADHD (up to 22%). Phenomenologic, genetic, family, neuroimaging, and treatment studies revealed that BPD and ADHD have both common and distinct characteristics. While there are data to support all 4 explanations postulated in this paper, the literature most strongly suggests that ADHD symptoms represent a prodromal or early manifestation of pediatric-onset BPD in certain at-risk individuals. Bipolar disorder with comorbid ADHD may thus represent a developmentally specific phenotype of early-onset BPD.

CONCLUSIONS

The etiology of comorbid BPD and ADHD is likely multifactorial. Additional longitudinal and biological studies are warranted to clarify the relationships between BPD and ADHD since they may have important diagnostic and treatment implications.

Lithium treatment effects on Myo-inositol in adolescents with bipolar depression

BACKGROUND

The neurochemical effects of lithium in adolescents with bipolar disorder largely are unknown. This study used proton magnetic resonance spectroscopy (1H MRS) to identify the in vivo effects of lithium on myo-inositol (mI) concentrations in adolescent bipolar depression.

METHODS

Twenty-eight adolescents (12-18 years old) with bipolar I disorder, current episode depressed, received open-label lithium 30 mg/kg, adjusted to achieve serum levels of 1.0-1.2 mEq/L. The mI concentrations in the medial as well as the left and right lateral prefrontal cortices were measured at baseline, day 7, and day 42 of treatment. Changes in mI concentrations over time were analyzed.

RESULTS

Significant main effects of time were observed for mI concentrations in the medial (p = .03) and right lateral (p = .05) prefrontal cortices. Baseline concentrations of mI were not significantly different from day 7 or day 42 concentrations. However, mI concentrations on day 42 were significantly higher than those on day 7 (p = .02) in both regions.

CONCLUSIONS

This study demonstrates that prefrontal mI concentrations do not significantly change from baseline after acute and chronic lithium treatment in adolescents with bipolar depression. Further investigation of the effect of lithium on mI is warranted to better understand possible mechanisms by which lithium exerts antidepressant activity.

Controlled study of switching from attention-deficit/hyperactivity disorder to a prepubertal and early adolescent bipolar I disorder phenotype during 6-year prospective follow-up: Rate, risk, and predictors

Rate, risk, and predictors of switching from attention-deficit/hyperactivity disorder (ADHD) to a prepubertal and early adolescent bipolar I disorder phenotype (PEA-BP-I) were examined in a blindly rated, controlled, prospective 6-year follow-up that included assessments at 2-year intervals. Subjects were outpatients obtained by consecutive new case ascertainment. There were 81 subjects who were 9.7 +/- 2.0 years. Subjects had DSM-IV ADHD (hyperactive or combined subtypes); a Children's Global Assessment Scale (CGAS) score of < or =60, consistent with moderate-severe impairment; and no BP or major depressive disorder (MDD) diagnoses. PEA-BP-I was defined as DSM-IV BP I (manic or mixed phase), with cardinal symptoms (elation and/or grandiosity), to avoid diagnosing mania by symptoms that overlapped with those of ADHD, and by a CGAS score of < or =60. Morbid risk of switching to PEA-BP-I was 28.5%. Significant predictors of switching in a multivariate Cox model were more severe baseline CGAS, paternal recurrent MDD, and less stimulant use. BP I in first-degree relatives, antidepressants, psychosocial measures, and life events were not predictive.

Rational approaches to the neurobiologic study of youth at risk for bipolar disorder and suicide

OBJECTIVES

The aims of this paper are to provide an overview of neuroimaging findings specific to bipolar disorder and suicide, and to consider rational approaches to the design of future in vivo studies in youth at risk.

METHODS

Neuroimaging and related neurobiological literature pertaining to bipolar disorder and suicide in adult and pediatric samples was reviewed in a non-quantitative manner.

RESULTS

Specific structural and functional brain findings in bipolar disorder are described, where possible in the context of relevant current neurobiological theories of etiology. Diagnostic and prognostic implications are discussed.

CONCLUSIONS

The simultaneous use of complementary neurobiological approaches may be a powerful way of identifying and validating factors reliably associated with bipolar disorder and suicide. A profile of neurobiological markers with which to screen for bipolar disorder and suicide risk may provide for earlier and more accurate diagnosis, perhaps even in the pre- or subsyndromal stages in high-risk youth.

Mixed amphetamine salts extended release: a clinical review of its use in the treatment of attention-deficit hyperactivity disorder

Mixed amphetamine salts extended release (MAS-XR) has been demonstrated in pediatric, adolescent and adult studies to be a well tolerated and effective treatment for attention-deficit hyperactivity disorder (ADHD). MAS-XR utilizes a double-pulse delivery system to replicate the pharmacokinetic properties of equal doses of immediate-release MAS administered 4 h apart. Doses of 20 mg MAS-XR produce significant reductions of core symptoms of ADHD over a 12-h period. Adverse effects observed in controlled studies include anorexia, weight loss, dry mouth, insomnia and abdominal pain, and rates of adverse effects are comparable to other stimulant agents approved for ADHD. At this time, there are no data to suggest that sudden death due to cardiovascular complications occurs more frequently in patients treated with MAS-XR than in the general population, but careful consideration of the risks and benefits of MAS-XR is warranted in patients with pre-existing structural heart disease and adult patients with a history of hypertension.

Attention-deficit hyperactivity disorder -- bipolar comorbidity in children and adolescents

OBJECTIVE

A substantial portion of juvenile bipolar disorder (BD) has a comorbid attention-deficit hyperactivity disorder (ADHD). The aim of our study was to analyze the cross-sectional and longitudinal implications of such comorbidity in children and adolescents with BD.

METHODS

Ninety-eight refereed patients (mean age 13.7 +/- 3.0 years) with a diagnosis of BD by the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime version (K-SADS-PL) were followed for 6 months.

RESULTS

Thirty-seven BD patients (37.8%) presented a lifetime diagnosis of comorbid ADHD. The mean age of onset of ADHD was 3.7 +/- 1.1 years, and the mean age of onset of BD was 10.0 +/- 3.2 years. Bipolar subjects with comorbid ADHD were predominantly male, younger, and had an earlier onset of BD (8.1 +/- 2.8 versus 11.1 +/- 2.9 years). Bipolar-ADHD patients presented more frequently a chronic rather than an episodic course of BD, with an irritable rather than an elated mood. They showed higher rates of oppositional defiant disorder/conduct disorder, lower rates of panic disorder, and less frequently received antidepressant medications. Finally, ADHD comorbidity was associated with a greater psychosocial impairment.

CONCLUSIONS

ADHD comorbidity is frequent in juvenile BD and can influence age of onset, phenomenology, comorbidity, and course of BD. A timely diagnosis should improve our efforts regarding the outcome of these subjects.

Preliminary study of relationships among measures of depressive symptoms in adolescents with bipolar disorder

PURPOSE

The aim of this study was to explore relationships between the Children's Depression Rating Scale-Revised (CDRS-R) and Hamilton Rating Scale for Depression (HAM-D) in adolescent bipolar disorder. We hypothesized that CDRS-R and HAM-D scores would be significantly correlated and both scales would be sensitive to change resulting from treatment.

METHODS

Data from a randomized, double-blind, placebo-controlled study of quetiapine with divalproex versus divalproex alone (n = 30) and an open-label study of lithium (n = 27) were used. Assessments using the CDRS-R and HAM-D were completed separately without any dependence on ratings from the alternate rating scale or specific order. All raters for symptom rating scales were blinded to the study for which they were completing a patient assessment and the intent to conduct these post hoc analyses and were different from those who performed diagnostic interviews. Relationships between these measures were assessed using the Pearson correlation coefficient, and receiver operator characteristic curves evaluated the ability of CDRS-R and HAM-D scores to predict the level of global improvement.

RESULTS

The mean (+/- standard deviation) age of subjects was 15.0 +/- 1.6 years. Baseline CDRS-R and HAM-D scores were moderately correlated (r = 0.63; p < 0.001), while week 6 scores showed stronger correlation (r = 0.88; p < 0.001). Both measures showed significant main effects for time on treatment (CDRS-R: F(3.4,191.2) = 39.4, p < 0.001; HAM-D: F(3.9,217.9) = 38.5, p < 0.001). A CDRS-R score of 30.5 and HAM-D score of 7.5 represent the highest sensitivity and specificity in classifying responders and nonresponders. A 42.2% and 60.6% reduction in baseline CDRS-R and HAM-D scores, respectively, provided the highest sensitivity and specificity.

CONCLUSIONS

Our preliminary results demonstrated that CDRS-R and HAM-D scores were significantly correlated, suggesting that either measure may be used to assess depressive symptoms in studies of adolescent bipolar disorder. Limitations to this study included a relatively small pooled sample, variation in clinician judgment, and study design not specific for the comparison of rating scales. Studies with methods specific to evaluate and compare these rating scales and larger patient samples from multiple treatment sites are needed to confirm these findings.

A one-year open-label trial of risperidone augmentation in lithium nonresponder youth with preschool-onset bipolar disorder

OBJECTIVE

The aim of this study was to assess the safety and efficacy of risperidone augmentation of lithium in preschool-onset bipolar disorder (BD) among youth who insufficiently respond to lithium monotherapy.

METHOD

Thirty-eight subjects between the ages of 4 and 17 years (mean age = 11.37 +/- 3.8 years) with onset of BD in preschool years (manic or mixed episode) entered this 12-month trial. All subjects received lithium monotherapy. Patients who failed to adequately respond to lithium monotherapy after 8 weeks and those who relapsed after an initial response were given risperidone augmentation for up to 11 months. The Young Mania Rating Scale (YMRS) was the primary outcome measure. Response was defined as a > or =50% decrease from baseline. Additional data were collected on diagnostic comorbidity, family history, number of hospitalizations, perinatal risk factors, history of physical or sexual abuse, Child Depression Rating Scale-Revised (CDRS-R), Clinical Global Impression (CGI) scale for BD (CGI-BP), Children's Global Assessment Scale (C-GAS), and adverse medication effects.

RESULTS

Of the 38 subjects treated with lithium monotherapy, 17 responded, whereas 21 required augmentation with risperidone. Response rate in the youths treated with lithium + risperidone was 85.7% (n = 18/21). Significant predictors of inadequate response to lithium monotherapy requiring augmentation were: (1) attention-deficit/hyperactivity disorder (ADHD), (2) severity at baseline, (3) history of sexual or physical abuse, and (4) preschool age. Combination treatment of lithium and risperidone was found to be safe and well tolerated.

CONCLUSIONS

A substantial proportion of youth with a history of preschool-onset BD treated with lithium were either nonresponders or partial responders. Subsequent augmentation of lithium with risperidone in these cases was well tolerated and efficacious. Potential predictors of lithium nonresponse identified in this study may guide the choice of medications earlier in the treatment process.

Open-label lithium for the treatment of adolescents with bipolar depression

OBJECTIVES

To investigate the effectiveness and tolerability of lithium for the treatment of acute depression in adolescents with bipolar disorder. We hypothesized that patients receiving open-label treatment with lithium during a 6-week period would experience a statistically and clinically significant decrease in depressive symptoms and tolerate lithium treatment fairly well.

METHOD

Twenty-seven adolescents (12-18 years old) with an episode of depression associated with bipolar disorder type I received open-label lithium 30 mg/kg (twice-daily dosing), which was adjusted to achieve a therapeutic serum level (1.0-1.2 mEq/L). Effectiveness measures included the Children's Depression Rating Scale-Revised (CDRS-R) and Clinical Global Impressions Scale for Bipolar Disorder (CGI-BP). Adverse events were assessed weekly.

RESULTS

Mean CDRS-R scores significantly decreased from baseline to endpoint (mean [SD] change = -25.5 (20.4); p < .001), resulting in a large effect size of 1.7. Response and remission rates (defined by a > or = 50% reduction in CDRS-R score from baseline to endpoint, and a CDRS-R score < or = 28 and a CGI-BP Improvement score of 1 or 2, respectively) were 48% and 30%. Side effects, which were generally mild to moderate in severity, included headache (74%), nausea/vomiting (67%), stomachache (30%), and abdominal cramps (19%).

CONCLUSIONS

The findings of this study indicate that lithium may be effective and is relatively well tolerated for the treatment of an acute episode of depression in adolescents with bipolar disorder. Controlled studies of lithium in adolescent bipolar depression are needed.

Phenomenology associated with age at onset in patients with bipolar disorder at their first psychiatric hospitalization

OBJECTIVE

To compare the clinical presentation of patients with early-onset (age <18 years) and typical-onset (age 20-30 years) bipolar disorder at the time of first hospitalization.

METHODS

Patients, aged 12-45 years at their first psychiatric hospitalization, with a DSM-IV diagnosis of bipolar disorder, manic or mixed, were evaluated on measures of manic, depressive, and positive psychotic symptoms. Differences in symptom profiles between early- and typical-onset groups were examined.

RESULTS

One hundred three early-onset and 58 typical-onset patients were compared. Mixed episodes were more common in the early-onset group, while psychotic features and current substance use were more common in the typical-onset group. There was no significant difference in manic symptom severity ratings between early- and typical-onset groups (F = 1.8, df = 11, 144, p = 0.06). However, these groups differed in depressive (F = 4.2, df = 16, 139, p < 0.001) and positive psychotic (F = 2.8, df = 16, 139, p = 0.001) symptom profiles. Typical-onset bipolar patients reported more severe weight loss and formal thought disorder compared with early-onset patients.

CONCLUSIONS

Depressive and positive psychotic symptoms may differ in association with age at onset among patients with bipolar disorder. Additional studies are necessary to determine whether homogeneous phenotypes of bipolar disorder can be delineated based upon age at onset.

Ethnic differences in symptom presentation of youths with bipolar disorder

OBJECTIVE

To compare symptom profiles of African-American and white adolescents with a diagnosis of bipolar disorder.

METHOD

Adolescents, aged 12-18 years at their first psychiatric hospitalization, with a DSM-IV diagnosis of bipolar disorder, manic or mixed, were evaluated on measures of manic, depressive, and positive symptoms of psychosis. Ethnic differences in symptom profiles were examined using multivariate analysis of covariance, and specific symptoms contributing to the difference were analyzed.

RESULTS

Ethnic differences existed in manic and positive symptom profiles, but not depressive symptoms. Compared with the white cohort, African-American youths were diagnosed more frequently as having psychotic features, and had higher ratings for auditory hallucinations.

CONCLUSIONS

Similar to adults, symptom expression in adolescent bipolar disorder may differ between ethnic groups. Future studies are needed to replicate these findings and explore possible explanations.

Comorbid ADHD is associated with altered patterns of neuronal activation in adolescents with bipolar disorder performing a simple attention task

OBJECTIVES

Bipolar disorder is increasingly recognized as a significant source of psychiatric morbidity in children and adolescents. Younger bipolar patients symptomatically differ from adults, and frequently present with comorbid disorders, particularly attention-deficit hyperactivity disorder (ADHD). The neurophysiological relationship between these two disorders, however, remains unclear. In this study we utilized functional magnetic resonance imaging (fMRI) to compare activation patterns during performance of a simple attention task between bipolar adolescents with and without ADHD.

METHODS

Eleven bipolar adolescents with comorbid ADHD and 15 bipolar adolescents without comorbidity were recruited to participate in fMRI scans. A single-digit continuous performance task alternated with a control task in a block-design paradigm. between-group comparisons were made using voxel-by-voxel analysis. Follow-up correlations were made between performance and activation.

RESULTS

Group performance did not significantly differ in percentage correct (p = 0.36) or discriminability (p = 0.11). ADHD comorbidity was associated with less activation in the ventrolateral prefrontal cortex (Brodmann 10) and anterior cingulate, and greater activation in posterior parietal cortex and middle temporal gyrus. Comorbid ADHD was associated with substantial differences in patterns of correlation between performance and voxel-by-voxel activation.

CONCLUSIONS

Our findings suggest that comorbid ADHD in bipolar adolescents is associated with activation of alternative pathways during performance of a simple attention task. The pattern of differences suggests that bipolar adolescents with comorbid ADHD demonstrate decreased activation of prefrontal regions, compared with bipolar adolescents without ADHD, and preferentially recruit portions of posterior parietal and temporal cortex.

Atomoxetine for the treatment of attention-deficit/hyperactivity disorder in children and adolescents with bipolar disorders

Children and adolescents with bipolar disorder (BD) have a high incidence of comorbid attention-deficit/hyperactivity disorder (ADHD). In this paper, we report a consecutive case series on 7 patients with pediatric BD and ADHD who were treated with atomoxetine-and all but one were also treated in conjunction with mood stabilizers. All patients were outpatients at the Stanford Pediatric Bipolar Disorders Clinic. Information on patients was collected in a retrospective chart review. All but 1 patient demonstrated significant improvement in symptoms of ADHD. No patients had episodes of hypomania or mania during the treatment period. Adverse effects of atomoxetine treatment included sedation, nausea, and decreased appetite. These cases suggest that atomoxetine may be a safe and effective treatment for ADHD in conjunction with mood stabilizers in children with BD.