Twelve-month outcome of adolescents with bipolar disorder following first hospitalization for a manic or mixed episode

Treatment development and feasibility study of family-focused treatment for adolescents with bipolar disorder and comorbid substance use disorders

BACKGROUND

Comorbid substance use disorders (SUD) are associated with increased illness severity and functional impairment among adolescents with bipolar disorder (BD). Previous psychosocial treatment studies have excluded adolescents with both BD and SUD. Studies suggest that integrated interventions are optimal for adults with BD and SUD.

METHODS

We modified family-focused treatment for adolescents with BD (FFT-A) in order to explicitly target comorbid SUD (FFT-SUD). Ten adolescents with BD who had both SUD and an exacerbation of manic, depressed, or mixed symptoms within the last 3 months were enrolled. FFT-SUD was offered as an adjunct to pharmacotherapy, with a target of 21 sessions over 12 months of treatment. The FFT- SUD manual was iteratively modified to integrate a concurrent focus on SUD.

RESULTS

Six subjects completed a mid-treatment 6-month assessment (after a mean of 16 sessions was completed). Of the 10 subjects, 3 dropped out early (after ≤1 session); in the case of each of these subjects, the participating parent had active SUD. No other subjects in the study had a parent with active SUD. Preliminary findings suggested significant reductions in manic symptoms and depressive symptoms and improved global functioning in the subjects who completed 6 months of treatment. Reduction in cannabis use was modest and did not reach significance. Limitations. Limitations included a small sample, open treatment, concurrent medications, and no control group.

CONCLUSIONS

These preliminary findings suggest that FFT-SUD is a feasible intervention, particularly for youth without parental SUD. FFT-SUD may be effective in treating mood symptoms, particularly depression, despite modest reductions in substance use. Integrating motivation enhancing strategies may augment the effect of this intervention on substance use. Additional strategies, such as targeting parental substance use, may prevent early attrition.

More pernicious course of bipolar disorder in the United States than in many European countries: implications for policy and treatment

BACKGROUND

There is some controversy but growing evidence that childhood onset bipolar disorder may be more prevalent and run a more difficult course in the United States than some European countries.

METHODS

We update and synthesize course of illness data from more than 960 outpatients with bipolar disorder (average age 40) from 4 sites in the U.S. and 3 sites in Netherlands and Germany. After giving informed consent, patients reported on parental history, childhood and lifetime stressors, comorbidities, and illness characteristics.

RESULTS

Almost all aspects of bipolar disorder were more adverse in patients from the US compared with Europe, including a significantly higher prevalence of: bipolar disorder in one parent and a mood disorder in both parents; childhood verbal, physical, or sexual abuse; stressors in the year prior to illness onset and the last episode; childhood onsets of bipolar illness; delay to first treatment; anxiety disorder, substance abuse, and medical comorbidity; mood episodes and rapid cycling; and nonresponse to prospective naturalistic treatment.

LIMITATIONS

Selection bias in the recruit of patients cannot be ruled out, but convergent data in the literature suggest that this does not account for the findings. Potential mechanisms for the early onset and more adverse course in the U.S. have not been adequately delineated and require further investigation.

CONCLUSIONS

The data suggest the need for earlier and more effective long-term treatment intervention in an attempt to ameliorate this adverse course and its associated heavy burden of psychiatric and medical morbidity.

Neuropsychological screening as a standard of care during discharge from psychiatric hospitalization: the preliminary psychometrics of the CNS Screen

Cost-prohibitive factors currently prevent a warranted integration of neuropsychological screenings into routine psychiatric evaluations, as a standard of care. To overcome this challenge, the current study examined the psychometric properties of a new computerized measure-the CNS Screen. One hundred and twenty six psychiatric inpatients completed the CNS Screen, the Montreal Cognitive Assessment (MoCA), and the Quick Inventory of Depressive Symptomatology-Self Rated (QIDS-SR₁₆) on the day of hospital discharge. Statistical analysis established convergent validity with a moderate correlation between the self-administered CNS Screen and the clinician-administered MoCA (r=0.64). Discriminant validity was implicated by a non-significant correlation with the QIDS-SR₁₆. Concurrent validity was supported by a moderate, negative correlation with patients' age (r=-0.62). In addition, consistent with previous findings, patients with psychotic disorders exhibited significantly poorer performance on the CNS Screen than patients with a mood disorder. Similarly, patients with a formal disability status scored significantly lower than other patients. The CNS Screen was well tolerated by all patients. With further development, this type of measure may provide a cost-effective approach to expanding neuropsychological screenings on inpatient psychiatric units.

A systematic narrative review of the literature: adherence to pharmacological and nonpharmacological treatments among adolescents with mental disorders

AIMS AND OBJECTIVES

To review current research into the adherence to mental health treatment by adolescents.

BACKGROUND

Nonadherence to medication among adolescents has been studied much more extensively than nonadherence to other forms of treatment. Monitoring adherence to all recommended services is essential when assessing the long-term effectiveness of different treatment programmes. Healthcare professionals who treat patients with mental illness must be able to accurately determine which of their patients are adhering to all prescribed treatments.

DESIGN

This is a systematic narrative literature review of the current literature.

METHODS

Using a narrative synthesis, the data from 15 relevant articles concerning adolescents in inpatient or outpatient mental health care were extracted and synthesised.

RESULTS

The reviewed papers are discussed in terms of the methods used to study treatment adherence, the working definition of adherence used in each case and the results obtained concerning adherence in adolescents. Thirty-four to sixty-seven per cent of adolescents treated are fully adherent to their medication and exhibit reasonably good follow-through for the recommended treatments. However, rates of noncompliance with medication are quite high, and significant numbers of adolescents choose to discontinue their medication.

CONCLUSIONS

This review synthesises current published data on adherence to mental health treatment among adolescents in order to provide practitioners and researchers with a better understanding of this important area. It is recommended that future investigations should focus on adherence in inpatient care, adherence to nonpharmacological treatments and the identification of factors that influence adherence.

RELEVANCE TO CLINICAL PRACTICE

The monitoring and understanding of adherence to recommended services is important. Therefore, these findings can be used by healthcare professionals who treat patients with mental illness to help them assess which of their patients are adhering to the prescribed treatments.

Parental history of substance use disorders (SUD) and SUD in offspring: a controlled family study of bipolar disorder

BACKGROUND AND OBJECTIVES

Adolescents with bipolar disorder (BPD) have been previously shown to be at very high risk for substance use disorders (SUD). We now examine the influence of a parental history of substance use disorders on SUD risk in offspring with and without BPD.

METHODS

We studied 190 parents ascertained through 104 adolescent BPD probands and 189 parents ascertained through 98 control probands using structured interviews. We compared the prevalence of SUD using logistic regression.

RESULTS

While adjusting for BPD in our combined sample, probands with a parental history of SUD were more likely to have an alcohol use disorder compared to probands without a parental history. Probands with a parental history of SUD were not more likely to have a drug use disorder or overall SUD compared to probands without a parental history. BPD in the offspring did not pose any additional risk between parental history of SUD and offspring SUD.

CONCLUSION

Alcohol use disorders were more common in the offspring of parents with a SUD history compared to parents without SUD and the risk was not influenced by offspring BPD.

SCIENTIFIC SIGNIFICANCE

Clarifying the mechanisms linking parental SUD to offspring SUD, particularly in children and adolescents with BPD, would help clinicians to educate and monitor high-risk families, which would facilitate strategies to mitigate risks associated with parental substance abuse.

Hypomania spectrum disorder in adolescence: a 15-year follow-up of non-mood morbidity in adulthood

BACKGROUND

We investigated whether adolescents with hypomania spectrum episodes have an excess risk of mental and physical morbidity in adulthood, as compared with adolescents exclusively reporting major depressive disorder (MDD) and controls without a history of adolescent mood disorders.

METHODS

A community sample of adolescents (N = 2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes (40 full-syndromal, 18 with brief episode, and 32 subsyndromal), while another 197 fulfilled the criteria for MDD without a history of a hypomania spectrum episode. A follow up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. The participation rate at the follow-up interview was 71% (64/90) for the hypomania spectrum group, and 65.9% (130/197) for the MDD group. Multiple imputation was used to handle missing data.

RESULTS

The outcomes of the hypomania spectrum group and the MDD group were similar regarding subsequent non-mood Axis I disorders in adulthood (present in 53 vs. 57%). A personality disorder was reported by 29% of the hypomania spectrum group and by 20% of the MDD group, but a statistically significant difference was reached only for obsessive-compulsive personality disorder (24 vs. 14%). In both groups, the risk of Axis I disorders and personality disorders in adulthood correlated with continuation of mood disorder. Prescription drugs and health service use in adulthood was similar in the two groups. Compared with adolescents without mood disorders, both groups had a higher subsequent risk of psychiatric morbidity, used more mental health care, and received more psychotropic drugs.

CONCLUSIONS

Although adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes, both groups are at increased risk for subsequent mental health problems. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course.

Effects of comorbid anxiety disorders on the longitudinal course of pediatric bipolar disorders

OBJECTIVE

To examine the longitudinal effects of comorbid anxiety disorders in youth with bipolar spectrum disorder (BP).

METHOD

As part of the Course and Outcome of Bipolar Youth study, 413 youth, who were 7 through 17 years or age and who met criteria for DSM-IV BP-I (n = 244), BP-II (n = 28), and operationally defined bipolar disorder not otherwise specified (BP-NOS) (n = 141) were included. Subjects were followed on average 5 years using the Longitudinal Interval Follow-up Evaluation. Effects of anxiety on the time to mood recovery and recurrence and percentage of time with syndromal and subsyndromal mood symptomatology during the follow-up period were analyzed.

RESULTS

At intake and during the follow-up, 62% of youth with BP met criteria for at least 1 anxiety disorder. About 50% of the BP youth with anxiety had ≥2 anxiety disorders. Compared to BP youth without anxiety, those with anxiety had significantly more depressive recurrences and significantly longer median time to recovery. The effects of anxiety on recovery disappeared when the severity of depression at intake was taken into account. After adjusting for confounding factors, BP youth with anxiety, particularly those with ≥2 anxiety disorders, spent significantly less follow-up time asymptomatic and more time with syndromal mixed/cycling and subsyndromal depressive symptomatology compared to those without anxiety.

CONCLUSIONS

Anxiety disorders are common and adversely affect the course of BP in youth, as characterized by more mood recurrences, longer time to recovery, less time euthymic, and more time in mixed/cycling and depressive episodes. Prompt recognition and the development of treatments for BP youth with anxiety are warranted.

Anxiety disorders and rapid cycling: data from a cohort of 8129 youths with bipolar disorder

Anxiety disorders (ADs) are common in youths with bipolar disorder (BD). We examine psychiatric comorbidity, hospitalization, and treatment in youths with versus without AD and rapid cycling (four or more cycles per year). Data from the Integrated Healthcare Information Services cohort were used and included 8129 youths (ages ≤18 years). Prevalence of AD, demographic, type of AD, hospitalization, and use of psychotropics were compared between rapid and nonrapid cycling. Overall, 51% of the youths met criteria for at least one comorbid AD; they were predominantly female and were between 12 and 17 years of age. The most common comorbid ADs were generalized ADs and separation ADs. In the patients with rapid cycling, 65.5% met criteria for comorbid AD. The BD youths with AD were more likely to have major depressive disorders and other comorbid ADs, to be given more psychotropics, and to be hospitalized for depression and medical conditions more often than were those without AD.

Predictors of first-onset substance use disorders during the prospective course of bipolar spectrum disorders in adolescents

OBJECTIVE

Substance use disorders (SUD) are common and problematic in bipolar disorder (BP). We prospectively examined predictors of first-onset SUD among adolescents with BP.

METHOD

Adolescents (12-17 years old; N = 167) in the Course and Outcome of Bipolar Youth (COBY) study fulfilling criteria for BP-I, BP-II, or operationalized BP not otherwise specified, without SUD at intake, were included. Baseline demographic, clinical, and family history variables, and clinical variables assessed during follow-up, were examined in relation to first-onset SUD. Participants were prospectively interviewed every 38.5 ± 22.2 weeks for an average of 4.25 ± 2.11 years.

RESULTS

First-onset SUD developed among 32% of subjects, after a mean of 2.7 ± 2.0 years from intake. Lifetime alcohol experimentation at intake most robustly predicted first-onset SUD. Lifetime oppositional defiant disorder and panic disorder, family history of SUD, low family cohesiveness, and absence of antidepressant treatment at intake were also associated with increased risk of SUD, whereas BP subtype was not. Risk of SUD increased with increasing number of these 6 predictors: 54.7% of subjects with 3 or more predictors developed SUD vs. 14.1% of those with fewer than 3 predictors (hazard ratio = 5.41 95% confidence interval = 2.7-11.0 p < .0001). Greater hypo/manic symptom severity in the preceding 12 weeks predicted greater likelihood of SUD onset. Lithium exposure in the preceding 12 weeks predicted lower likelihood of SUD.

CONCLUSIONS

This study identifies several predictors of first-onset SUD in the COBY sample that, if replicated, may suggest targets for preventive interventions for SUD among youth with BP. Treatment-related findings are inconclusive and must be interpreted tentatively, given the limitations of observational naturalistic treatment data. There is a substantial window of opportunity between BP and SUD onset during which preventive strategies may be used.

Bipolar disorder in children and adolescents

BACKGROUND

The existence of bipolar disorder (BP) in youth is controversial.

METHODS

The current evidence regarding the diagnosis of BP in youth was reviewed.

RESULTS

BP is a recurrent familial disorder that occurs in 1-3% of youth, particularly in adolescents. Except for subsyndromal BP, the prevalence of BP-I is similar across most countries. Due to the child's immaturity, the presence of comorbid disorders, and divergent interpretations of manic symptomatology it is difficult to diagnose BP in youth. Youth with subsyndromal mania and family history of BP, are at high risk to develop BP-I and BP-II. Both the full and subsyndromal syndromal BP are associated with significant psychosocial difficulties and increased risk for use of substances, suicidality, legal problems, and services utilization.

CONCLUSION

BP disorder exists in youth, but it is difficult to diagnose. The recurrent nature and psychosocial morbidity associated with this illness during critical developmental stages calls for comprehensive longitudinal evaluation and accurate recognition and treatment because delays in treatment are associated with poor outcome.

Difficulties in emotional regulation and substance use disorders: a controlled family study of bipolar adolescents

BACKGROUND

Self-regulatory mechanisms appear etiologically operant in the context of both substance use disorders (SUD) and bipolar disorder (BD), however, little is known about the role of deficits in emotional self-regulation (DESR) as it relates to SUD in context to mood dysregulation. To this end, we examined to what extent DESR was associated with SUD in a high-risk sample of adolescents with and without BD.

METHODS

203 families were assessed with a structured psychiatric interview. Using the Child Behavior Checklist (CBCL), a subject was considered to have DESR when he or she had an average elevation of 1 standard deviation (SD) above the norm on 3 clinical scale T scores (attention, aggression, and anxiety/depression; scores: 60 × 3 ≥ 180).

RESULTS

Among probands and siblings with CBCL data (N=303), subjects with DESR were more likely to have any SUD, alcohol use disorder, drug use disorder, and cigarette smoking compared to subjects with scores <180 (all p values <0.001), even when correcting for BD. We found no significant differences in the risk of any SUD and cigarette smoking between those with 1SD and 2SD above the mean (all p values >0.05). Subjects with cigarette smoking and SUD had more DESR compared to those without these disorders.

CONCLUSIONS

Adolescents with DESR are more likely to smoke cigarettes and have SUD. More work is needed to explore DESR in longitudinal samples.

Do alcohol use disorders destabilize the course of bipolar disorder?

OBJECTIVES

To determine whether long-term data implicate a negative effect of alcohol-use disorders (AUDs) on time to remission, risk of mood episode recurrence, and risk of mood switch/cycling in patients with bipolar disorder (BD). The short-term temporal sequence between alcohol use and onset of mood episodes was also examined.

METHODS

A MEDLINE literature search was conducted for measurement-based reports of alcohol and course of bipolar disorder.

RESULTS

Twenty-three original data publications were identified. Three out of 5 studies addressing the impact of AUDs on recovery from a mood episode demonstrated that alcohol did not prolong index mood episodes of any type. Six out of 11 reports evaluating the relationship between alcohol and the long term risk of mood episode recurrences suggested that high levels of alcohol intake increase the risk of a mood recurrence. Five out of 7 studies evaluating the short-term temporal sequence of AUDs and development of mood episodes among BD patients found that increased alcohol use preceded the development of new mood episodes. Four out of 5 studies examining the association between alcohol and rapid cycling indicated that AUDs were associated with higher rates of rapid-cycling.

LIMITATIONS

We limited our review to studies that were large enough to perform statistical testing, which may have led us to overlook informative smaller studies.

CONCLUSIONS

Although alcohol does not seem to affect time to mood episode remission, alcohol use destabilizes the course of illness over the long run as evidenced by associations with more rapid cycling and mood episode recurrence.

Family functioning, social impairment, and symptoms among adolescents with bipolar disorder

OBJECTIVE

Impaired social functioning is common among youth with bipolar disorder (BD), emerges in multiple settings, and persists over time. However, little is known about factors associated with poor peer and family functioning in the early-onset form of BD. Using a sample of adolescents with BD I or II, we examined which symptoms of BD, including nonspecific symptoms such as inattention, aggression, and anxiety/depression, were associated with family functioning (adaptability, cohesion, and conflict) and peer relationship quality.

METHOD

Adolescents (N = 115; 46% male) with BD I and II and their parents were evaluated before participation in a multi-site randomized controlled trial. Adolescents had experienced an episode of depression, mania, or hypomania within the previous 3 months and were not in full remission. Adolescents' problem behaviors were assessed using the parent-rated Child Behavior Checklist (CBCL). Family functioning was assessed via child- and parent-report questionnaires.

RESULTS

Depressive symptoms were associated with lower child-ratings of family functioning. Contrary to hypotheses, moderate mania was associated with better parent-reported family conflict, adaptability, and cohesion. Aggression was associated with poorer family functioning across reporters and measures, even when controlling for the effects of depression, mania, and inattention. None of these symptom clusters were associated with peer functioning.

CONCLUSIONS

Aggression was the strongest correlate of family functioning in pediatric BD in this cross-sectional study. Findings speak to the potential value of addressing aggression and family dysfunction in the treatment of youth with BD. Clinical trial registration information-Effectiveness of Family-Focused Treatment Plus Pharmacotherapy for Bipolar Disorder in Adolescents; http://clinicaltrials.gov/; NCT00332098.

Treatment moderators and predictors of outcome in the Treatment of Early Age Mania (TEAM) study

OBJECTIVE

Both the diagnosis and treatment of bipolar disorder in youth remain the subject of debate. In the Treatment of Early Age Mania (TEAM) study, risperidone was more effective than lithium or divalproex in children diagnosed with bipolar mania and highly comorbid with attention-deficit/hyperactivity disorder (ADHD). We searched for treatment moderators and predictors of outcome.

METHOD

TEAM was a multi-site, 8-week, randomized clinical trial of risperidone, lithium, or divalproex in 279 medication-naïve patients, aged 6 through 15 years, with a DSM-IV diagnosis of bipolar disorder currently in manic or mixed phase. Outcome measures included binary end-of-treatment responder status and change in the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Mania Rating Scale (KMRS). Baseline demographics and clinical characteristics were tested as modifiers of treatment effect and as overall predictors of outcome.

RESULTS

Moderator effects were detected for site, ADHD, and obesity. Across sites, the response ratio (RR) for risperidone versus lithium ranged from 1.2 (95% confidence interval [CI] = 0.8-1.7) to 8.3 (95% CI = 1.1-60.8), and for risperidone versus divalproex from 1.3 (95% CI = 0.8-2.2) to 10.5 (95% CI = 1.4-77.7). The RR for risperidone versus lithium was 2.1 for patients with ADHD, but 1.0 for those without ADHD, and 2.3 (95% CI = 1.6-3.3) for nonobese patients, but 1.1 (95% CI = 0.6-2.0) for obese ones. Older age and less severe ADHD symptoms were associated with greater improvement on the KMRS.

CONCLUSIONS

Risperidone was more effective than lithium or divalproex across the demographics and clinical characteristics of the sample, but the magnitude of its effect was influenced by site-related characteristics and presence of ADHD. Clinical trial registration information--Treatment of Early Age Mania; http://clinicaltrials.gov/; NCT00057681.

Anxiety in children with mood disorders: a treatment help or hindrance?

This study examined the role of comorbid anxiety in treatment outcome for children with mood disorders (N = 165; age 8-11) participating in Multi-Family Psychoeducational Psychotherapy (MF-PEP). Assessments occurred at baseline, 6, 12, and 18 months for two randomly assigned groups: immediate treatment and 1-year wait-list. Most children (69%) had comorbid anxiety disorders. Baseline comorbid anxiety, as reported on the Children's Interview for Psychiatric Syndromes (ChIPS), was associated with higher Children's Depression Rating Scale- Revised (CDRS-R) scores but not Young Mania Rating Scale (YMRS) scores. Higher levels of anxiety symptoms were associated with lower Children's Global Assessment Scale (C-GAS) scores. Participation in MF-PEP did not significantly reduce anxiety symptoms (p = 0.62). However, presence of comorbid anxiety did not impede reduction in depressive (CDRS-R, p = 0.74) or manic (YMRS scores, p = 0.94) symptoms following MF-PEP. More baseline anxiety symptoms were associated with greater improvement in C-GAS scores post-treatment (p = 0.02). Implications are discussed.

Pattern recognition and functional neuroimaging help to discriminate healthy adolescents at risk for mood disorders from low risk adolescents

Introduction

There are no known biological measures that accurately predict future development of psychiatric disorders in individual at-risk adolescents. We investigated whether machine learning and fMRI could help to: 1. differentiate healthy adolescents genetically at-risk for bipolar disorder and other Axis I psychiatric disorders from healthy adolescents at low risk of developing these disorders; 2. identify those healthy genetically at-risk adolescents who were most likely to develop future Axis I disorders.

Methods

16 healthy offspring genetically at risk for bipolar disorder and other Axis I disorders by virtue of having a parent with bipolar disorder and 16 healthy, age- and gender-matched low-risk offspring of healthy parents with no history of psychiatric disorders (12–17 year-olds) performed two emotional face gender-labeling tasks (happy/neutral; fearful/neutral) during fMRI. We used Gaussian Process Classifiers (GPC), a machine learning approach that assigns a predictive probability of group membership to an individual person, to differentiate groups and to identify those at-risk adolescents most likely to develop future Axis I disorders.

Results

Using GPC, activity to neutral faces presented during the happy experiment accurately and significantly differentiated groups, achieving 75% accuracy (sensitivity = 75%, specificity = 75%). Furthermore, predictive probabilities were significantly higher for those at-risk adolescents who subsequently developed an Axis I disorder than for those at-risk adolescents remaining healthy at follow-up.

Conclusions

We show that a combination of two promising techniques, machine learning and neuroimaging, not only discriminates healthy low-risk from healthy adolescents genetically at-risk for Axis I disorders, but may ultimately help to predict which at-risk adolescents subsequently develop these disorders.

Cigarette smoking and its relationship to mood disorder symptoms and co-occurring alcohol and cannabis use disorders following first hospitalization for bipolar disorder

OBJECTIVES

Cigarette smoking is highly prevalent among individuals with bipolar disorder (BD) and may adversely affect symptoms of the disorder, as well as the co-occurrence of other substance use disorders. However, anecdotal reports suggesting that smoking cessation caused a worsening of mood in smokers with BD have raised concerns about quitting. In the present study, we prospectively evaluated the course of BD, alcohol use disorders, and cannabis use disorders in relation to smoking and examined the relationship between smoking abstinence and changes in mood.

METHODS

Participants (N = 161) were adolescents (n=80) and adults (n = 81) with bipolar I disorder who were hospitalized for their initial mixed or manic episode. Participants were followed up to eight years post-hospitalization (median follow-up = 122 weeks) as part of a naturalistic, observational study of the longitudinal course of BD and substance use.

RESULTS

The course of BD symptoms in the 12 months following index hospitalization did not differ by smoking status in either the adolescent or the adult subsample. Among adolescents, smoking was associated with an increased risk of having a cannabis or alcohol use disorder, almost all of which were new-onset disorders, in the year following first hospitalization. Neither adolescents nor adults who were abstinent from smoking for at least two months experienced significant increases in depressive or manic symptoms.

CONCLUSIONS

Although cigarette smoking did not predict a worse course of BD, smoking was associated with an increased risk of developing alcohol and cannabis use disorders in adolescents with BD. Importantly, these data provide no evidence to suggest that abstinence from smoking is associated with worsening symptoms of depression or mania in the short term.

Social cognition and global functioning in bipolar disorder

The purpose of this study was to assess the role of social cognition, together with other relevant clinical variables and measures of general cognition, in the global functioning of euthymic bipolar patients. Thirty-nine euthymic outpatients fulfilling DSM-IV-TR criteria for bipolar disorder type I or II were recruited and were divided in two groups: high (n = 19) and low (n = 20) global functioning. Both groups' performance was compared in verbal and nonverbal social cognition (Faux pas test and Facial Emotion Recognition test), sustained attention and executive function. The low-functioning group showed a significant impairment in both verbal and nonverbal measurements of social cognition compared with the high-functioning group. Globally, both bipolar groups showed a significant impairment in facial emotion recognition compared with a similar sample of healthy volunteers. Social cognition may play a significant role in the clinical-functional gap of bipolar patients.

Subthreshold symptoms in bipolar disorder: impact on neurocognition, quality of life and disability

OBJECTIVE

To provide empirical evidence of the effect of subthreshold symptomatology (both depressive and manic) on psychosocial functioning, neurocognition and quality of life in bipolar disorder.

METHODS

A total of 133 participants were enrolled for this study (bipolar patients, n=103; healthy controls, n=30). Patients were divided into two groups according to their levels of subthreshold symptomatology: the subsyndromic group was constituted by those patients with upper levels of subthreshold symptomatology (HDRS≥4 and YMRS≥3) and the asymptomatic group represented the patients with lower scores (HDRS≤3 and YMRS≤2). All participants were administered a comprehensive neuropsychological battery. Moreover the patients answered the SF-36 (Quality of Life, QoL) and were interviewed with the WHODAS-2 (Psychosocial functioning and disability). One-way ANOVA were used in order to compare the differences between the three groups.

RESULTS

The analyses revealed that both patients groups, albeit free of acute symptoms of mania or depression, differed in terms of functioning and disability assessed with the WHODAS-2. Specifically, the total global score of disability was higher for the subsyndromic group indicating more impairment (p=0.008). The same pattern of impairment was found for three of its domains: "understanding and communicating" (p=0.013); "self-care" (p=0.035) and "getting along with others" (p=0.024). The subsyndromic group also scored lower when compared to their counterparts in the Mental Component of QoL of the SF-36 (p=0.045). Finally, in the neuropsychological performance verbal learning and memory was found to be impaired regardless the levels of subthreshold symptomatology, suggesting that this variable is a robust indicator of neuropsychological impairment in BD patients.

CONCLUSIONS

This report presents empirical data suggesting a moderate impact of subthreshold symptoms on functioning/disability and QoL and a discrete impact on neuropsychological impairment.

Factors associated with the persistence and onset of new anxiety disorders in youth with bipolar spectrum disorders

OBJECTIVE

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder, but, to our knowledge, no studies examined the course of anxiety disorders in youth and adults with bipolar disorder.

METHOD

As part of the Course and Outcome of Bipolar Youth study, 413 youth, ages 7 to 17 years who met criteria for Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) bipolar I disorder (n = 244), bipolar II disorder (n = 28), and operationally defined bipolar disorder not otherwise specified (n = 141) were recruited primarily from outpatient clinics. Subjects were followed on average for 5 years using the Longitudinal Interval Follow-Up Evaluation. We examined factors associated with the persistence (> 50% of the follow-up time) and onset of new anxiety disorders in youth with bipolar disorder.

RESULTS

Of the 170 youth who had anxiety at intake, 80.6% had an anxiety disorder at any time during the follow-up. Most of the anxiety disorders during the follow-up were of the same type as those present at intake. About 50% of the youth had persistent anxiety, particularly generalized anxiety disorder (GAD). Persistence was associated with multiple anxiety disorders, less follow-up time in euthymia, less conduct disorder, and less treatment with antimanic and antidepressant medications (all P values ≤ .05). Twenty-five percent of the sample who did not have an anxiety disorder at intake developed new anxiety disorders during follow-up, most commonly GAD. The onset of new anxiety disorders was significantly associated with being female, lower socioeconomic status, presence of attention-deficit/hyperactivity disorder and substance use disorder, and more follow-up time with manic or hypomanic symptoms (all P values ≤ .05)

CONCLUSIONS

Anxiety disorders in youth with bipolar disorder tend to persist, and new-onset anxiety disorders developed in a substantial proportion of the sample. Early identification of factors associated with the persistence and onset of new anxiety disorders may enable the development of strategies for treatment and prevention.

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

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

Prospective predictors of mood episodes in bipolar disorder

BACKGROUND

: Bipolar disorder (BD) is associated with alterations in mood, personality, cognition and event-related potential (ERP) measures. The relationship between these multidimensional measures of state and subsequent course of the illness is not well understood. Therefore, this study aimed to prospectively identify factors that predicted the course of mood episodes.

METHODS

: Sixty-five participants with BD were administered the auditory P300 oddball task, clinical assessment instruments and cognitive tests at baseline, and were subsequently administered the SCID interview once a month by telephone for 12 months.

RESULTS

: Hierarchical regression analyses indicated that the Montgomery-Asberg Depression Rating Scale (MADRS) predicted the number of months spent in a depressed state (p<.001) and in a mixed state (p=.001), while both the MADRS (p<.001) and time to complete Trails A (p=.033) predicted total number of months in a mood episode (across all mood states). Among euthymic patients at entry, Cox regression analyses indicated that higher ratings on both the MADRS (p=.017) and Hypomanic Personality Scale (HPS; p<.001) were associated with both increased likelihood of a mood episode and less time until the onset of a mood episode.

LIMITATIONS

: The sample size is relatively small, not all participants completed 12 months, and follow-up assessments were conducted via telephone.

CONCLUSIONS

: Our results suggest that affective and cognitive measures, and personality factors, especially the MADRS and HPS, serve as important predictors of the course of mood episodes or relapse in BD patients. These prospective markers of acute mood states may be used to guide treatment decisions.

Factors associated with the course of symptoms in bipolar disorder during a 1-year follow-up: depression vs. sub-threshold mixed state

BACKGROUND

Mixed mood states, even in their sub-threshold forms, may significantly affect the course and outcome of bipolar disorder (BD).

AIM

To compare two samples of BD patients presenting a major depressive episode and a sub-threshold mixed state in terms of global functioning, clinical outcome, social adjustment and quality of life during a 1-year follow-up.

METHODS

The sample was composed by 90 subjects (Group 1, D) clinically diagnosed with a major depressive episode and 41 patients (Group 2, Mx) for a sub-threshold mixed state. All patients were administered with a pharmacological treatment and evaluated for depressive, anxious and manic symptoms by common rating scales. Further evaluations included a global assessment of severity and functioning, social adjustment and quality of life. All evaluations were performed at baseline and after 1, 3, 6 and 12 months of treatment.

RESULTS

The two groups were no different for baseline as well as improvement in global severity and functioning. Though clearly different for symptoms severity, the amount of change of depressive and anxiety symptoms was also no different. Manic symptoms showed instead a trend to persist over time in group 2, whereas a slight increase of manic symptoms was observed in group 1, especially after 6 months of treatment. Moreover, in group 1, some manic symptoms were also detected at the Young Mania Rating Scale (n = 24, 26.6%). Finally, improvement in quality of life and social adjustment was similar in the two groups, though a small trend toward a faster improvement in social adjustment in group 1.

CONCLUSIONS

Sub-threshold mixed states have a substantial impact on global functioning, social adjustment and subjective well-being, similarly to that of acute phases, or at least major depression. In particular, mixed features, even in their sub-threshold forms, tend to be persistent over time. Finally, manic symptoms may be still often underestimated in depressive episodes, even in patients for BD.

Bipolar Disorder Differences between Genders: Special Considerations for Women

The objective of this article is to review clinical differences between men and women with bipolar disorder. The secondary objective is to analyze the differences in adherence to medication between genders. Men usually present with manic episodes and have comorbid drug abuse, while women usually present with major depressive episode, the onset is often later, comorbidity of physical pathology is common and adherence to medication is greater than in men. In women who have an earlier onset of the illness and are single, the risk of nonadherence is higher than in other groups of women. There are two time periods that are very important in women: pregnancy and postpartum. Both are critical periods and a relapse or recurrence of symptoms at either stage can have serious consequences for the woman and/or her baby. In addition, the effect of medication on the fetus is unclear. In conclusion, there is a clear need for more studies on gender differences in bipolar disorder and how to improve adherence to treatment. Moreover, a better understanding of how to treat women with bipolar disorder during pregnancy and lactation will undoubtedly lead to improved outcomes for both the mother and her child.

Progression of amygdala volumetric abnormalities in adolescents after their first manic episode

OBJECTIVE

Although previous neuroimaging studies suggest that adolescents with bipolar disorder exhibit smaller amygdala volumes compared with healthy adolescents, whether these abnormalities are present at illness onset or instead develop over time remains unclear. The aim of this study was to conduct a prospective longitudinal investigation comparing amygdala neurodevelopment among adolescents after their first manic episode, adolescents with attention-deficit/hyperactivity disorder (ADHD), and healthy adolescents.

METHOD

A total of 30 adolescents hospitalized for their first manic/mixed episode associated with bipolar disorder, 29 adolescents with ADHD, and 24 demographically matched healthy teens underwent magnetic resonance imaging scanning at index assessment and approximately 12 months later. Adolescents with bipolar disorder were prospectively evaluated using diagnostic interviews and with symptom rating scales.

RESULTS

Mixed models examining the group × time effect for both left (p = .005) and right (p = .002) amygdala volumes were statistically significant. Change in left (p = .01) and right (p = .0008) amygdala volumes from baseline to 12 months were significantly different among groups. Specifically, left amygdala volumes increased over time in healthy adolescents (p = .008) and adolescents with ADHD (p = .0009), but not in adolescents with bipolar disorder (p = .3). Right amygdala volume increased over time in adolescents with ADHD (p < .001), but not in healthy adolescents nor in adolescents with bipolar disorder (p = .1 and p = .3, respectively). In adolescents with bipolar disorder, baseline total amygdala volume was significantly greater in those who subsequently achieved symptomatic recovery as compared with those who did not achieve recovery (p = .02).

CONCLUSIONS

Adolescents with mania do not exhibit normal increases in amygdala volume that occur during healthy adolescent neurodevelopment.

Are anxiety disorders associated with a more severe form of bipolar disorder in adolescents?

BACKGROUND

Anxiety disorders are common among children and adolescents with bipolar disorder. Among adults, anxiety disorder comorbidity is associated with a more severe form of bipolar disorder and a poorer outcome. There is limited data on the effect of comorbid anxiety disorder on bipolar disorder among children and adolescents.

AIM

To study the prevalence of anxiety disorders among adolescents with remitted bipolar disorder and examine their association with the course and severity of illness, global functioning, and quality of life.

MATERIALS AND METHODS

We evaluated 46 adolescents with DSM IV bipolar disorder (I and II) who were in remission, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children. We measured quality of life using the Pediatric Quality of Life Inventory and global functioning using the Children's Global Assessment Scale, and then compared these parameters between adolescents with and without current anxiety disorders. We also compared the two groups on other indicators of severity such as number of episodes, suicidal ideation, presence of psychotic symptoms, and response to treatment.

RESULTS

Among the 46 subjects, the prevalence of current and lifetime anxiety disorders were 28% (n=13) and 41% (n=19), respectively. Compared with others, adolescents with anxiety had more lifetime suicidal ideation, more number of episodes, lower physical, psychosocial, and total subjective quality of life, and lower global functioning.

CONCLUSIONS

Among adolescents with bipolar disorder, anxiety disorders are associated with a poorer course, lower quality of life, and global functioning. In these subjects, anxiety disorders should be promptly recognized and treated.

Pediatric bipolar disorder in a Spanish sample: results after 2.6years of follow-up

INTRODUCTION

Bipolar disorder (BD) often starts in childhood or adolescence. There is considerable scepticism outside the United States over the validity, stability and prevalence of BD in children and adolescents. Persistence of course lends support to the validity of a diagnosis.

OBJECTIVES

To describe the longitudinal course of pediatric BD in a Spanish sample over a median follow-up period of 2.6years and to examine risk factors associated with outcome.

METHODS

We retrospectively reviewed the medical records of all children and adolescents (N=38) with DSM-IV-TR BD-I, II and NOS evaluated in the Child and Adolescent Psychiatry Unit, University of Navarra (Pamplona, Spain) from 1999 to 2005. We used the NIMH Lifetime Mood Chart and the Clinical Global Impression-Severity Scale to assess clinical course.

RESULTS

79% (N=30) were boys and 21% (N=8) were girls; 44.7% (N=17) had BD-I, 5.3% (N=2) BD-II, and 50% (N=19) BD-NOS. Median (inter-quartile range: IQR: Q25; Q75) age at diagnosis was 13.9 (10.64; 15.84). Median follow-up period was 2.6years (0.91; 3.66). Mean percentage of time in an episode was 46.17% (23.36; 75.26), and it was longer in younger children (p<0.05). 2.6% had rapid cycling. At the end of follow-up, only 47% achieved remission or recovery. Younger children showed a worse treatment response (p<0.05). We found higher rates of hospitalization in children with ADHD (21%) (p<0.05).

CONCLUSION

Children with BD had a chronic course with little interepisodic recovery. BD can be diagnosed in children using DSM-IV-TR criteria. An early age of onset and ADHD comorbidity are risk factors for worse prognosis.

Brain functional domains inform therapeutic interventions in attention-deficit/hyperactivity disorder and pediatric bipolar disorder

A deeper understanding of how the relationships between impulsivity, reward systems and executive function deficits may be similar or different in attention-deficit/hyperactivity disorder (ADHD) and pediatric bipolar disorder (PBD) is fundamental for better defining phenotypy in these two developmental illnesses, and moving towards improved treatment and intervention. We focus our article on recent neurocognitive and neuroimaging data examining the behavioral and neural aspects of poor behavior regulation, response inhibition and reward systems in ADHD and PBD. In light of recent research evidence, we propose that the common behavioral manifestations of impulsivity in ADHD and PBD may indeed originate from different neural mechanisms mediated by altered reward systems. In order to define and differentiate these mechanisms, unlike previous approaches, our theoretical model examines the interface of the dorsal frontostriatal circuit, involved in behavior regulation, and the ventral frontostriatal circuit, which is involved in reward-related and affect processes. Preliminary evidence suggests that the neural systems involved in impulsivity, reward systems and executive function engage differently in the two illnesses. In PBD, 'emotional impulsivity' is predominantly 'bottom-up' and emotionally/motivationally driven, and stems from ventral frontostriatal circuitry dysfunction. By contrast, in ADHD 'cognitive impulsivity' is predominantly 'top-down' and more 'cognitively driven', and stems from dorsal frontostriatal dysfunction. We discuss this evidence in view of clinically relevant questions and implications for illness-based intervention. We conclude that the reward-related mechanisms underlying the interactions between executive function, behavior regulation and impulsivity in PBD and ADHD may be differentially compromised, and in accordance differently shape the clinical symptoms of impulsivity and goal-directed behavior.

Open-label uridine for treatment of depressed adolescents with bipolar disorder

This report is an open-label case series of seven depressed adolescents with bipolar disorder treated with uridine for 6 weeks. Treatment response was measured with the Children's Depression Rating Scale-Revised and the Clinical Global Impressions scale. Uridine was associated with decreased depressive symptoms, and was well tolerated by study participants. Further systematic studies of uridine are warranted.

Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths

In recent years, increasing numbers of children have been diagnosed with bipolar disorder. In some cases, children with unstable mood clearly meet current diagnostic criteria for bipolar disorder, and in others, the diagnosis is unclear. Severe mood dysregulation is a syndrome defined to capture the symptomatology of children whose diagnostic status with respect to bipolar disorder is uncertain, that is, those who have severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation. An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood. Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups. No specific treatment for severe mood dysregulation currently exists, but verification of its identity as a syndrome distinct from bipolar disorder by further research should include treatment trials.

Measurement of psychiatric treatment adherence

OBJECTIVE

Nonadherence to medications for mental disorders substantially limits treatment effectiveness and results in higher rates of relapse, hospitalization, and disability. Accurate measurement of medication adherence is important not only in adherence research but also in clinical trials in which medications are being evaluated and in clinical practice where failure to detect nonadherence results in premature medication changes, unnecessary polypharmacy, and greater likelihoods of functional deteriorations and hospitalizations. This is a review of psychiatric treatment adherence methods and measures arising from a meeting on "Methodological Challenges in Psychiatric Treatment Adherence Research" held on September 27-28, 2007, in Bethesda, MD, and organized by the National Institute of Mental Health (NIMH).

METHODS

This paper reviews the range of modalities currently available for assessing adherence behavior including pill counts, pharmacy records, technology-assisted monitoring, biological assays, and a range of self-report and interviewer-rated scales. Measures of adherence attitudes are also reviewed.

RESULTS

Each of the adherence measures described are imperfect estimates of actual medication ingestion, but each provides informative estimates of adherence or the attitudinal factors associated with adherence. Measure selection depends on a range of factors including the patient sample, the context in which the measure is being used, and the clinical outcomes expected from various levels of nonadherence. The use of multiple measures of adherence is encouraged to balance the limitations of individual measures.

CONCLUSION

While adherence assessment has become increasingly sophisticated in recent years, there remains a need for refinement and expansion on currently available methods and measures.

Olanzapine approved for the acute treatment of schizophrenia or manic/mixed episodes associated with bipolar I disorder in adolescent patients

BACKGROUND

Severe and persistent mental illnesses in children and adolescents, such as early- onset schizophrenia spectrum (EOSS) disorders and pediatric bipolar disorder (pedBP), are increasingly recognized. Few treatments have demonstrated efficacy in rigorous clinical trials. Enduring response to current medications appears limited. Recently, olanzapine was approved for the treatment of adolescents with schizophrenia or acute manic/mixed episodes in pedBP.

METHODS

PubMed searches were conducted for olanzapine combined with pharmacology, schizophrenia, or bipolar disorder. Searches related to schizophrenia and bipolar disorder were limited to children and adolescents. The bibliographies of the retrieved articles were hand-checked for additional relevant studies. The epidemiology, phenomenology, and treatment of EOSS and pedBP, and olanzapine's pharmacology are reviewed. Studies of olanzapine treatment in youth with EOSS and pedBP are examined.

RESULTS

Olanzapine is efficacious for EOSS and pedBP. However, olanzapine is not more efficacious than risperidone, molindone, or haloperidol in EOSS and is less efficacious than clozapine in treatment-resistant EOSS. No comparative trials have been done in pedBP. Olanzapine is associated with weight gain, dyslipidemia, and transaminase elevations in youth. Extrapyramidal symptoms, neuroleptic malignant syndrome, and blood dyscrasias have also been reported but appear rare.

CONCLUSIONS

The authors conclude that olanzapine should be considered a second-line agent in EOSS and pedBP due to its risks for significant weight gain and lipid dysregulation. Awareness of the consistent weight and metabolic changes observed in olanzapine-treated youth focused attention on the potential long-term risks of atypical antipsychotics in youth.

Long-term effectiveness of aripiprazole in adolescents and young adults with bipolar disorder: A naturalistic study

Abstract Objective. The purpose of this study was to investigate the long-term effectiveness of aripiprazole in Taiwanese samples of adolescents and young adults with bipolar disorders. Methods. This investigation comprises a 24-week, observational, prospective study. A total of 28 patients with bipolar I disorder, diagnosed using the Mini International Neuropsychiatric Interview, were administered aripiprazole. Effectiveness was assessed by the change from the baseline in Clinical Global Impression Scale (CGI), Brief Psychiatric Rating Scale (BPRS) and The World Health Organization Quality of Life questionnaire (WHOQOL). Results. The sample comprised 19 males and nine females with a mean (SD) age of 18.5 (3.3) years. The diagnosis was bipolar I disorder with manic (n = 8), depressive (n = 6) and mixed (n = 14) episodes. Eighteen patients (64.3%) discontinued aripiprazole prematurely. The CGI severity, BPRS total score improved significantly from the baseline to the endpoint. Conclusion. Aripiprazole led to clinically meaningful improvement of global symptoms in adolescents and young adults with bipolar disorder. However, discontinuation of medication within 6 months was high. Whether aripiparzole benefits patients with manic episodes more than those with depressive or mixed episodes warrants further investigation.

Comorbid anxiety in children and adolescents with bipolar spectrum disorders: prevalence and clinical correlates

OBJECTIVE

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder. We aimed to examine the prevalence and correlates of comorbid anxiety disorders among youth with bipolar disorder.

METHOD

As part of the Course and Outcome of Bipolar Youth study, 446 youth, ages 7 to 17 years, who met DSM-IV criteria for bipolar I disorder (n = 260) or bipolar II disorder (n = 32) or met operationalized criteria for bipolar disorder not otherwise specified (n = 154) were included. Subjects were evaluated for current and lifetime Axis I psychiatric disorders at intake using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime version, and standardized instruments were used to assess functioning and family history.

RESULTS

Forty-four percent (n = 194) of the sample met DSM-IV criteria for at least 1 lifetime anxiety disorder, most commonly separation anxiety (24%) and generalized anxiety disorders (16%). Nearly 20% met criteria for 2 or more anxiety disorders. Overall, anxiety disorders predated the onset of bipolar disorder. Subjects with bipolar II disorder were more likely than subjects with bipolar I disorder or bipolar disorder not otherwise specified to have a comorbid anxiety disorder. After adjusting for confounding factors, youth with bipolar disorder with anxiety were more likely to have bipolar II disorder; longer duration of mood symptoms; more severe ratings of depression; and family history of depression, hopelessness, and somatic complaints during their worst lifetime depressive episode than those without anxiety.

CONCLUSIONS

Comorbid anxiety disorders are common in youth with bipolar disorder, and they most often predate bipolar disorder onset. Bipolar II disorder, a family history of depression, and more severe lifetime depressive episodes distinguish youth with bipolar disorder with comorbid anxiety disorders from those without. Careful consideration should be given to the assessment of comorbid anxiety in youth with bipolar disorder.

The association of weight gain with mood symptoms and functional outcomes following a first manic episode: prospective 12-month data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM)

OBJECTIVES

Up to 75% of patients with bipolar I disorder (BD-I) are overweight or obese. Obesity is associated with an increased liability for mood episodes in patients with established BD-I, but data from early in the illness are lacking. Obesity in the general population is also consistently associated with functional impairment, but the relationship between weight gain and functional outcomes in BD-I has received little attention.

METHODS

We measured rates of clinically significant weight gain (CSWG), defined as gaining ≥ 7% of baseline weight, over 12 months in 46 patients with BD-I who recently recovered from their first manic episode. We compared patients with and without CSWG for (i) the amount of time spent with mood symptoms, assessed using standard clinical rating scales and National Institute of Mental Health Life Charts, and (ii) functioning at 12 months, measured using the Multidimensional Scale of Independent Functioning (MSIF).

RESULTS

A total of 41% of patients (n = 19) experienced CSWG by 12 months. We did not detect an association between CSWG and the number of days with mood symptoms. Patients with CSWG had significantly poorer 12-month global functioning than those without CSWG [MSIF score = 2.26 (SD = 1.24) versus 1.74 (0.98); p = 0.011]. Functional impairment was independent of recent or current mood symptoms, which were entered as covariates in our analyses.

CONCLUSIONS

Weight gain may be an overlooked, but potentially modifiable, cause of functional impairment in BD-I. Clinicians should consider the possibility of weight gain when making the earliest treatment decisions in BD-I.

Achieving adolescent adherence to treatment of major depression

When treatments are ordered for adolescent major depression, or for other adolescent medical illnesses, adherence and clinical outcomes are likely to be unsatisfactory, unless 4 basic principles of the medical treatment of adolescent illness are implemented. These comprise providing effective patient and parent/caregiver education, establishing effective patient and caregiver therapeutic alliances, providing effective treatment, and managing other factors associated with treatment adherence as indicated. The goals of treatment are to achieve the earliest possible response and remission. Failure to treat adolescent major depression successfully has potentially serious consequences, including worsened adherence, long-term morbidity, and suicide attempt. Accordingly, prescribed treatment must be aggressively managed. Doses of an antidepressant medication should be increased as rapidly as can be tolerated, preferably every 1-2 weeks, until full remission is achieved or such dosing is limited by the emergence of unacceptable adverse effects. A full range of medication treatment options must be employed if necessary. Treatment adherence, occurrence of problematic adverse effects, clinical progress, and safety must be systematically monitored. Adolescents with major depression must be assessed for risk of harm to self or others. When this risk appears significant, likelihood of successful outcomes will be enhanced by use of treatment plans that comprehensively address factors associated with treatment nonadherence. Abbreviated and comprehensive plans for the treatment of potentially fatal adolescent illnesses are outlined in this review.

[Cannabis and mood]

OBJECTIVE

Evaluate the relationship between acute and chronic use of cannabis and mood changes.

METHOD

Articles were selected by electronic search in PubMed. Chapters in books and reference lists of selected articles were also reviewed. As the research did not involve humans, there was no evaluation by a Research Ethics Committee.

RESULTS

High rates of comorbidity between use/abuse/dependence of cannabis and affective disorders in longitudinal studies and in clinical samples were observed. Longitudinal studies indicate that, in long-term, the higher use of cannabis is associated with an increased risk of developing bipolar disorder, and probably, major depression in subjects initially without affective disorder, but was not found increased risk of cannabis use among those initially only with mania or depression. Another important observation is that substance abuse in bipolar patients may be associated with a number of negative characteristics, such as difficulty in recovering the affective symptoms, more hospitalizations, poor compliance with treatment, increased risk of suicide, aggression and a poor response to lithium. Psychosocial and pharmacological treatments are indicated for the management of comorbidity between cannabis and affective disorders.

CONCLUSION

The relationship between cannabis use and mood changes are observed both in the epidemiological research and in the clinical settings.

Pharmacotherapy of bipolar disorder in children and adolescents: recent progress

Child and adolescent bipolar disorder (BPD) is a serious psychiatric disorder that often causes significant impairment in functioning. Pharmacological intervention is the cornerstone of treatment for bipolar youth, although psychotherapeutic interventions may be beneficial as adjunctive treatment. Medications used for the treatment of BPD in adults are still commonly used for bipolar children and adolescents. With the recent US FDA indication of risperidone, aripiprazole, quetiapine and olanzapine for the treatment of bipolar youth, the atypical antipsychotics are rapidly becoming a first-line treatment option. However, these agents are associated with adverse effects such as increased appetite, weight gain and type II diabetes mellitus. Although several evidence-based medications are now available for the treatment of BPD in younger populations, additional studies to evaluate the short- and long-term efficacy and potential for adverse events of these and other medications are needed.

Predicting the course and outcome of bipolar disorder: a review

Despite of advances in pharmacological and non-pharmacological treatments, bipolar disorder often entails multiple relapses and impaired psychological functioning. The extent to which modern treatments have influenced the natural course of a mental disorder is uncertain. Prediction of the course and outcome of bipolar disorders continues to be challenging, despite the multiple research efforts worldwide. Due to a lack of laboratory diagnostic tests and biomarkers, psychiatric interview and examination provide the basis for outcome prediction. While considered to have more favorable prognosis than schizophrenia, it is not uncommon for bipolar disorder to include persisting alterations of psychosocial functioning. Although long-term symptomatic remission does not guarantee functional recovery, it may have a favorable impact on long-term overall prognosis. The high degree of treatment resistance in patients with bipolar disorder highlights the need to develop better identification of outcome predictors, prognosis and treatment intervention, designed to reverse or prevent this illness burden. This review summarizes the main factors involved in predicting the course and outcome of bipolar disorder.

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.

Pediatric bipolar disorder: evidence for prodromal states and early markers

BACKGROUND

Childhood bipolar disorder remains a controversial but increasingly diagnosed disorder that is associated with significant impairment, chronic course and treatment resistance. Therefore, the search for prodromes or early markers of risk for later childhood bipolar disorder may be of great importance for prevention and/or early identification.

METHODS

Literature searches were conducted to identify reviews, case reports and empirical papers addressing the issue of prodromes of childhood bipolar disorder.

RESULTS

A total of 54 articles were found that related to bipolar prodromes, risk factors for later childhood bipolar disorder, childhood risk for adult bipolar disorder, mania manifestations in early childhood, and neuropsychological and biological markers of childhood bipolar disorder. A review of articles suggest (a) childhood bipolar prodromes may be detectable prior to the onset of the disorder, (b) prodromal symptoms may display episodicity during childhood, (c) there is evidence of possible endophenotypic markers such as deficits in executive function, sustained attention, and emotion labeling, (d) there is a potential association with functional, structural, and biochemical alterations evident in brain structures involved in mood regulation, (e) a link between childhood bipolar disorder with early tempermental markers, such as emotional regulation and behavioral disinhibition and (f) there is some early but promising evidence of effective psychotherapeutic preventions.

CONCLUSIONS

There has been very limited investigation of early prodromes of childhood bipolar disorder. Based on the promising findings of prodromes as well as high-risk states and possible endophenotypic markers, more controlled and targeted investigations into the early markers of bipolar disorder appear warranted and potentially fruitful. Until such longitudinal studies with appropriate controls are conducted, specific markers for bipolar prodromes will remain elusive, although evidence suggests they are manifest in at least some subgroups. The finding of promising psychotherapeutic prevention programs underscores the need to find specific and sensitive markers of bipolar prodromes in childhood.

Antipsychotic and mood stabilizer efficacy and tolerability in pediatric and adult patients with bipolar I mania: a comparative analysis of acute, randomized, placebo-controlled trials

OBJECTIVE

To compare antipsychotic and mood stabilizer (MS) efficacy and tolerability in youth and adults with bipolar mania.

METHODS

Medline/PubMed search for studies including: (i) youth (< 18 years) or adults (> or = 18 years); (ii) bipolar I disorder; (iii) double-blind, randomized, placebo-controlled trial (DB-RPCT); (iv) < or = 12 weeks of treatment; and (v) calculable effect sizes (ES) and/or numbers needed to treat/harm (NNT/NNH) +/- 95% confidence intervals (CI). Non-overlapping 95% CIs determined significant group differences.

RESULTS

We identified nine DB-RPCTs in youth (n = 1,609), 5 evaluating second-generation antipsychotics (SGAs) (n = 1,140) and 4 evaluating MSs (n = 469). We also identified 23 DB-RPCTs in adults (n = 6,501), 14 including SGAs (n = 3,297), 5 using haloperidol as an active comparator (n = 580), and 11 including MSs (n = 2,581). Young Mania Rating Scale scores improved significantly more with SGAs than MSs in youth (ES = 0.65, CI: 0.53-0.78 versus 0.24, CI: 0.06-0.41) and adults (ES = 0.48, CI: 0.41-0.55 versus 0.24, CI: 0.17-0.31). After excluding topiramate studies, SGAs had larger ES than MSs only in youth (ES = 0.65, CI: 0.53-0.78 versus 0.20, CI: 0.02-0.39), but not adults (ES = 0.48, CI: 0.41-0.55 versus 0.46, CI: 0.37-0.55). However, in adults SGAs had significantly larger ES regarding Clinical Global Impressions scores than MSs, even without topiramate (ES = 0.75, CI: 0.68-0.82 versus 0.24, CI: 0.07-0.41). Rates of response, remission, and discontinuation due to any reason compared to placebo were similar between medication and age groups, except for more favorable NNTs for remission with SGAs than MSs in adults after excluding topiramate. SGAs caused more weight gain than MSs in youth (ES = 0.53, CI: 0.41-0.66 versus 0.10, CI: -0.12-0.33), but not in adults (ES = 0.13, CI: 0.05-0.22 versus 0.00, CI: -0.08-0.08). However, results were heterogeneous and not significant in either age group after excluding topiramate. Nevertheless, SGA-related weight gain was significantly greater in youth than adults. In youth, SGA-related somnolence was greater than with MSs (NNH = 4.7, CI: 3.9-6.0 versus 9.5, CI: 6.3-23.5), and more likely than in adults (NNH = 7.1, CI: 6.1-8.8). Conversely, youth experienced less akathisia with SGAs than adults (NNH = 20.4, CI: 14.1-36.5 versus 10.2, CI: 8.1-13.7), likely due to lower doses/slower titration.

CONCLUSIONS

In treating mania, potentially greater short-term efficacy compared to placebo with SGAs versus MS needs to be balanced against increased adverse events, especially in youth.

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

OBJECTIVE

The authors evaluated lifetime prevalence and specificity of DSM-IV psychiatric disorders and severity of depressive and manic symptoms at intake in preschool offspring of parents with bipolar I and II disorders.

METHOD

A total of 121 offspring ages 2-5 years from 83 parents with bipolar disorder and 102 offspring of 65 demographically matched comparison parents (29 with non-bipolar psychiatric disorders and 36 without any lifetime psychopathology) were recruited for the study. Parents with bipolar disorder were recruited through advertisements and adult outpatient clinics, and comparison parents were ascertained at random from the community. Participants were evaluated with standardized instruments. All staff were blind to parental diagnoses.

RESULTS

After adjustment for within-family correlations and both biological parents' non-bipolar psychopathology, offspring of parents with bipolar disorder, particularly those older than age 4, showed an eightfold greater lifetime prevalence of attention deficit hyperactivity disorder (ADHD) and significantly higher rates of having two or more psychiatric disorders compared to the offspring of the comparison parents. While only three offspring of parents with bipolar disorder had mood disorders, offspring of parents with bipolar disorder, especially those with ADHD and oppositional defiant disorder, had significantly more severe current manic and depressive symptoms than comparison offspring.

CONCLUSIONS

Preschool offspring of parents with bipolar disorder have an elevated risk for ADHD and have greater levels of subthreshold manic and depressive symptoms than children of comparison parents. Longitudinal follow-up is warranted to evaluate whether these children are at high risk for developing mood and other psychiatric disorders.