Adverse life events and pediatric bipolar disorder in a community mental health setting

Prospective, comparative, pilot study of maintenance treatment in comorbid bipolar disorders with post-traumatic stress disorder

There is limited real-world evidence that evaluates the impact of monotherapy vs. combination therapy as a maintenance treatment in comorbid post-traumatic stress disorder (PTSD) in bipolar disorder (BD). Our aim was to compare lithium vs. lithium plus quetiapine in maintenance treatment in a sample of comorbid BD with PTSD. An exploratory, comparative pilot study over a 28-week period in 34 comorbid BD with PTSD patients was performed to compare monotherapy (n = 18) vs. combination therapy (n = 16) during maintenance treatment. The primary outcome was the time to event of recurrence of any mood episode. The secondary outcomes were regarding change from the baseline to endpoint in the Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). A Cox regression, Kaplan-Meir survival, and mixed-effects model for repeated measures analyses were performed. Lithium plus quetiapine reduces the risk of recurrence of any mood episode. There are significant differences between baseline and endpoint for YMRS, MADRS, and CGI-BP scales in the sample. In this pilot, exploratory analysis, combination therapy during maintenance treatment for comorbid BD with PTSD may be effective in preventing recurrences of any type of mood episode.

Childhood Trauma and Self-harm in Youths with Bipolar Disorders

BACKGROUND

Bipolar disorders (BD) in youth are associated with a high risk of self-harm behaviors. Childhood trauma (CT) is a relevant environmental stressor that is related to both BD diagnosis and self-harm in adulthood. It is not yet established whether CT may impact self-harm risk in youth. Therefore, the aim of this study was to investigate the distribution patterns of CT in youth BD with and without self-harm.

METHODS

We assessed 273 participants (aged 13-25 years), 96 youths with BD according to DSM-5 criteria and 177 healthy controls (HC). History of CT was obtained using the Childhood Trauma Questionnaire (CTQ). The association between CT and self-harm was tested using multivariate statistical models.

RESULTS

Over 45% of participants with BD reported lifetime self-harm. The BD Self-harm group reported more emotional abuse, emotional neglect, sexual abuse, and physical abuse than HC. The BD No-Self-harm group reported more emotional abuse than HC. The BD Self-harm group reported more emotional abuse and neglect than the BD No-Self-harm group. The BD Self-harm group also reported separated parents, hospitalizations, smoking, use of antiepileptics, antipsychotics and lithium. Emotional abuse was an independent predictor of self-harm in youths with BD.

CONCLUSION

Findings support the importance of assessing CT, in particular emotional abuse, in youth with BD at risk for self-harm.

Childhood trauma and bipolar affective disorder: Is there a linkage?

Bipolar affective disorder (BPAD) is a major psychiatric illness impairing the quality of life. The etiology of BPAD is influenced by different factors possibly related to gene-environment interactions. Approximately 30% to 50% of individuals with BPAD have experienced some traumatic event in childhood. Serious adverse experiences that children may suffer early in life are often described as childhood trauma (CT). It includes physical, emotional, and sexual abuse and physical and emotional neglect. CT is linked with an elevated risk of developing BPAD. Childhood adversities play a role in modulating the early onset of illness, increased number of depressive episodes, increased suicide attempts, and other clinical severity of BPAD. Hospital-based studies comprising heterogeneous populations had researched the specific role of each trauma subtype as a predisposing factor for BPAD. Identifying and addressing CT through early intervention methods may prevent the future development of chronic disorders like BPAD. This review article is an attempt to explore and highlight the existing literature regarding the association of different subtypes of CT with BPAD.

Hard-to-treat or hard-to-catch? Clinical features and therapeutic outcomes of help-seeking foster care youths with mood disorders

Introduction

The high level of emotional problems in youths placed in foster care contrasts with the limited use of evidence-based treatments. This study aims to better characterize the clinical features and therapeutic outcomes of foster care youths with mood disorders.

Methods

A secondary analysis of data collected in the context of a French-Canadian clinical research network on pediatric mood disorders in four sites was conducted to compare three groups of patients with depressive or bipolar disorder: those without exposure to child welfare intervention (WCWI, n = 181), those who received non-placement psychosocial intervention (NPI, n = 62), and those in placement interventions (PI, n = 41).

Results

We observed a very high rate of academic problems in patients in the groups NPI/PI compared to those in the WCWI group. Patients in the PI group had more disruptive behavioral disorders (OR = 6.87, 95% CI [3.25-14.52]), trauma-related disorders (OR = 3.78, 95% CI [1.6-8.94]), and any neurodevelopmental disorders (OR = 2.73, 95% CI [1.36-5.49]) compared to the other groups (NPI/WCWI). Among inpatients, the Clinical Global Impression-Improvement scale and the change in the Children Global Assessment Scale during the hospital stay did not differ across the three groups. We observed a higher prescription rate of antipsychotics in the PI group compared to the NPI/WCWI groups, but no significant difference for antidepressants and mood stabilizers.

Discussion

These findings support the view that, when provided with dedicated support, fostered inpatient youths can improve in a range comparable to other inpatients. Undetected neurodevelopmental disorders and academic problems are likely important contributors of the burden of mood disorders in these youths.

Trauma history in veterans with bipolar disorder and its impact on suicidality

OBJECTIVES

Veterans are at increased risk for exposure to trauma, developing serious mental illnesses, and death by suicide. History of trauma correlates with worsening outcomes in patients with bipolar disorder. This study investigated associations between trauma exposure (type and timing) and suicide attempt in Veterans with bipolar disorder.

METHODS

One hundred six Veterans with a diagnosis of bipolar disorder and 815 Veterans with no psychiatric history (age rage = 20-72 years old) completed a clinical questionnaire, the Beck Scale for Suicide Ideation, and the Traumatic Live Events Questionnaire. Multinomial logistic regressions investigated correlations between diagnosis, time of trauma (before, during, or after the military), trauma type (attack, illness, accident, child violence, child sexual abuse, and adult sexual abuse), and suicide attempt.

RESULTS

Seventy-five Veterans with bipolar disorder had comorbid PTSD. Controlling for PTSD, Veterans with bipolar disorder had a higher prevalence of trauma including physical assault [odds ratio (OR) = 2.85; 95% confidence interval (CI) = 1.39-5.86] and child sexual trauma (OR = 2.89; CI = 1.38-6.05). Veterans with bipolar disorder who endorsed previous suicide attempts (n = 42) had significantly higher levels of exposure to childhood trauma (OR = 5.69; CI = 1.84-17.62).

CONCLUSIONS

Results support incorporating history of previous trauma exposure when assessing Veterans at risk for bipolar disorder. Especially, trauma characterized as attack and childhood sexual abuse. Particular attention should be given to Veterans with bipolar disorder and exposure to trauma during childhood, which may be associated with increased risk of suicidality.

Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review

OBJECTIVE

To examine and synthesise the literature on adverse childhood experience (ACE) screening in clinical and healthcare settings servicing children (0-11) and young people (12-25).

DESIGN

A systematic review of literature was undertaken.

DATA SOURCE

PsycInfo, Web of Science, Embase, PubMed and CINAHL were searched through June 2021. Additional searches were also undertaken.

ELIGIBILITY CRITERIA

English language studies were included if they reported results of an ACE tool being used in a clinical or healthcare setting, participants were aged between 0 and 25 years and the ACE tool was completed by children/young people or by parents/caregivers/clinicians on behalf of the child/young person. Studies assessing clinicians' views on ACE screening in children/young people attending health settings were also included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed for risk of bias using the Mixed Methods Appraisal Tool. Results were synthesised qualitatively.

RESULTS

Initial searches identified 5231 articles, of which 36 were included in the final review. Findings showed that the most commonly used tool for assessing ACE was the ACE questionnaire; administering ACE tools was found to be feasible and acceptable; there were limited studies looking at the utility, feasibility and acceptability of assessing for ACE in First Nations people; and while four studies provided information on actions taken following ACE screening, no follow-up data were collected to determine whether participants accessed services and/or the impact of accessing services.

CONCLUSION

As the evidence stands, widespread ACE screening is not recommended for routine clinical use. More research is needed on how and what specific ACE to screen for and the impact of screening on well-being.

PROSPERO REGISTRATION NUMBER

University of York Centre for Reviews and Dissemination (CRD42021260420).

Impact of adverse childhood experiences on the symptom severity of different mental disorders: a cross-diagnostic study

Background

Adverse childhood experiences have a significant impact on different mental disorders.

Objective

To compare differences in adverse childhood experiences among those with different mental disorders and their relationships in a cross-disorder manner.

Methods

The study included 1513 individuals aged ≥18 years : 339 patients with substance use disorders, 125 patients with schizophrenia, 342 patients with depression, 136 patients with bipolar disorder, 431 patients with obsessive-compulsive disorder (OCD), and 140 healthy controls. The Early Trauma Inventory Self Report-Short Form was used to investigate childhood traumatic experiences, and the Addiction Severity Index, Positive and Negative Syndrome Scale, Hamilton Depression Scale, Young Mania Rating Scale, and Yale-Brown Obsessive-Compulsive Scale were used to assess mental disorder severity. Correlation and multivariate logistic regression were analysed between adverse childhood experiences and clinical features.

Results

Levels of adverse childhood experiences were significantly different among different mental disorders. Moreover, 25.8% of patients with substance use disorders reported childhood trauma, which was significantly higher than found in the other four psychiatric disorder groups. Emotional abuse scores were positively correlated with disease severity: the higher the total trauma score, the more severe the mental disorder.

Conclusions

Adverse childhood experiences are a common phenomenon in those with mental disorders, and the level of trauma affects mental disorder severity. Emotional abuse is closely related to many mental disorders. The incidence or severity of mental disorders can be reduced in the future by reducing the incidence of adverse childhood experiences or by timely intervention in childhood trauma.

Risk factors preceding new onset abuse among youth with bipolar disorder: A longitudinal prospective analysis

BACKGROUND

Childhood abuse negatively impacts the course of Bipolar Disorder (BD). Yet, no study has examined risk factors associated with prospectively evaluated physical/sexual abuse, specifically, those preceding first abuse among BD youth. We investigate past/intake/follow-up factors preceding first physical/sexual abuse among BD youth.

METHODS

Childhood-onset BD participants (n = 279 youth, mean age at intake = 12, mean length of follow-up = 12 years) enrolled in the Course and Outcome of Bipolar Youth (COBY) study. Demographic, clinical and family history variables were assessed every 7 months on average using Longitudinal Interval Follow-up Evaluation and Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL). Abuse was evaluated at intake using the K-SADS-PL, over follow-up with a Traumatic Events Screen. Family psychopathology was assessed using Family History Screen/Structured Clinical Interview for Diagnostic Statistical Manual-IV.

RESULTS

Fifteen-percent of youth reported new-onset abuse during follow-up (62% physical, 26% sexual; 12% both). Intake predictors included more severe depressive symptoms (HR = 1.29), low socioeconomic-status (SES) in families with substance abuse (HR = 0.84) (physical abuse), and female sex (HR = 2.41) (sexual abuse). Follow-up predictors preceding physical abuse included: older age (HR = 1.42), disruptive disorders (HR = 1.39), and the interaction between low SES and family substance abuse (HR = 0.86). For sexual abuse, female sex (HR = 4.33) and a non-biologically related father presence in the household (HR = 2.76). Good relationships with friends (prospectively evaluated) protected against physical/sexual abuse (HR = 0.72/0.70, respectively).

LIMITATIONS

Prospective data was gathered longitudinally but assessed retrospectively at every follow-up; perpetrator information and abuse severity were not available.

CONCLUSIONS

Identifying factors temporally preceding new onset physical/sexual abuse may hold promise for identifying high-risk youth with BD.

The influence of childhood trauma on the treatment outcomes of pharmacological and/or psychological interventions for adolescents and adults with bipolar disorder: A systematic review and meta-analysis

OBJECTIVE

The influence of childhood trauma on the treatment outcomes of pharmacological and/or psychological interventions for adolescents and adults with bipolar disorder was systematically reviewed.

METHODS

Randomised and non-randomised studies of interventions for bipolar disorder that included an assessment of childhood trauma were eligible. MEDLINE Complete, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched. Two independent reviewers completed the screening and extraction process. Two independent reviewers assessed the risk of bias in the included studies using the Cochrane Collaboration's Risk of Bias tool and the Newcastle-Ottawa Scale. Alongside a narrative synthesis, random-effects meta-analyses were performed.

RESULTS

Twelve studies (1175 participants) were included. The narrative review highlighted differential treatment outcomes among individuals with a history of childhood trauma. The meta-analyses suggested that childhood trauma was unrelated to treatment response (five studies, 426 participants; odds ratio 0.58, 95% CI 0.27-1.25, p = .164) but may be associated with greater improvement in global functioning (three studies, 210 participants; Hedge's g 0.65, 95% CI 0.04-1.26, p = .037).

LIMITATIONS

The impact of childhood trauma on the effectiveness of specific pharmacological/psychological interventions could not be explored due to the small body of research identified.

CONCLUSION

The overall quality of the extant evidence is low, which precludes definitive comment on the role of childhood trauma in the treatment of bipolar disorder. Additional research that uses large and representative samples is required to ascertain whether a history of childhood trauma affects the treatment outcomes of interventions for individuals with bipolar disorder.

Looking for the Good Timing: Predictors of Length of Stay and Therapeutic Outcomes in Adolescent Inpatients with Severe or Treatment-Refractory Mood Disorders

Objectives: While hospitalization is an essential aspect of the therapeutic strategy for adolescents with severe or treatment-refractory mood disorders, little is known about the outcome predictors during inpatient treatment. Methods: A retrospective chart review was conducted in a university tertiary referral hospital to determine the factors associated with the length of stay, symptom improvement (based on the Clinical Global Impression-Improvement [CGI-I] scale), and the change in the overall level of functioning during the stay (based on the Children-Global Assessment Scale [CGAS]). Over 2 years, 106 adolescents were diagnosed with mood disorders (mean age = 15.0 ± 0.16; 43% girls), with a particular high rate of associated adverse psychosocial factors, and an average length of stay longer than most psychiatric hospital settings (mean = 100.7 ± 9.57 days). Results: Multivariate analysis concluded that longer duration of current episode and worse functioning at admission (CGAS score) were independent predictors for length of stay. Greater functional improvement (CGAS score change from admission to discharge) was best predicted by the diagnosis of bipolar disorder, lower functioning, and greater illness severity on admission. Symptom improvement (CGI-I) did not have any independent predictors. Conclusion: This finding supports the value of measuring symptoms duration in predicting the hospitalization outcomes of adolescents with severe or treatment-refractory mood disorders, in view of addressing maintenance factors at an early stage. Bipolar symptoms should be sought not only at admission but also regularly during the stay.

The Effect of Traumatic Events on the Longitudinal Course and Outcomes of Youth with Bipolar Disorder

BACKGROUND

Exposure to severe Traumatic Events (TEs) has been associated with poor course and outcomes among individuals with Bipolar Disorder (BD). However, there is limited research on TEs among youth with BD, and few studies are longitudinal. This study prospectively followed a large sample of BD youth, examining the associations of lifetime TEs with their mood and functioning.

METHODS

BD participants (n=375; mean age=17; range 8-25y) were assessed, on average, every 7 months for a median 8.7 years. Psychopathology and lifetime trauma history were prospectively evaluated using the Longitudinal Interval Follow-Up Evaluation, and a traumatic events screening.

RESULTS

Accounting for covariates, participants with one or more lifetime TEs (84%) showed earlier BD onset, poorer psychosocial functioning, worse mood symptoms, and more suicidal ideation, comorbidities, and family psychopathology than those without TEs. TEs during recovery periods increased recurrence risk (p<0.02). More TEs were associated with poorer mood course, particularly among victims of violence/abuse (p<0.02). Abused participants (34% physical; 17% sexual) showed earlier onset of substance use disorders, more suicidality and comorbidities compared to those without abuse. Comparisons of mood course before and after abuse occurred, and with participants without abuse, showed worsening mood symptoms after, specifically hypo/mania (p<0.03).

LIMITATIONS

Prospective data was gathered longitudinally but assessed retrospectively at every follow-up; given approximate dates causality cannot be inferred; TEs severity was not assessed.

CONCLUSIONS

Severe TEs, particularly abuse, were associated with poorer course and outcomes among BD youth. Prompt screening of trauma and early intervention may be warranted to minimize TEs impact.

Emotional memory in bipolar disorder: Impact of multiple episodes and childhood trauma

BACKGROUND

Emotional memory is a critical amygdala-dependent cognitive function characterized by enhanced memory for emotional events coupled with retrograde amnesia. Our study aims to assess the influence of bipolar disorder (BD), trauma, and the number of mood episodes on emotional memory.

METHODS

53 subjects (33 euthymic patients with BD and 20 healthy controls) answered a clinical assessment, childhood trauma questionnaire (CTQ), and an emotional memory test composed of lists of nouns, including neutral words, one emotional (E), one preceding (E-1) and one following word (E + 1). We assessed for the influence of type, position, diagnosis, trauma, and number of mood episodes in word recall using generalized estimating equations.

RESULTS

Controlling for neutral words, BD had a higher recall for E-1 (p = 0.038) and a trend for a higher recall of E (p = 0.055). There was no difference between patients with and without trauma. Patients with BD who suffered multiple mood episodes had a higher recall of E compared to patients with fewer episodes (p = 0.016).

LIMITATIONS

Cross-sectional design and small sample size.

CONCLUSION

Our results indicate dysfunction in emotional memory in patients with BD, particularly after multiple mood episodes. While we expected an impaired emotional memory, patients with BD showed an increased recall for emotional stimuli and events preceding them. Childhood trauma does not seem to interfere with emotional memory changes in patients with BD. Emotional memory enhancement seems to be a promising marker of progression in BD.

Affective temperaments play an important role in the relationship between child abuse and the diagnosis of bipolar disorder

In previous studies, various components such as environmental and genetic factors have been shown to contribute to the development of bipolar disorder (BD). This study investigated how multiple factors, including child abuse, adult life events, and affective temperaments, are interrelated and how they affect the diagnosis of BD. A total of 170 healthy controls and 75 BD patients completed the following self-administered questionnaires: the Patient Health Questionnaire-9 evaluating the severity of depressive symptoms; the Child Abuse and Trauma Scale (CATS) evaluating child abuse; the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego autoquestionnaire (TEMPS-A) evaluating affective temperaments; and the Life Experiences Survey (LES) evaluating negative and positive adult life events. The data were subjected to univariate analysis, multivariable analysis, and structural equation modeling. The structural equation modeling showed that the diagnosis of BD was indirectly predicted by the neglect and sexual abuse scores of the CATS through four affective temperaments (depressive, cyclothymic, irritable, and anxious) of the TEMPS-A and directly predicted by these four affective temperaments. This study suggested that affective temperament plays an important role as a mediator in the influence of child abuse on BD diagnosis.

Adverse Childhood Experiences Among Inpatient Youths with Severe and Early-Onset Psychiatric Disorders: Prevalence and Clinical Correlates

This study aimed to determine the prevalence and the clinical correlates of Adverse Childhood Experiences (ACEs) among 158 inpatient youths with two types of severe psychiatric disorders. ACEs were retrospectively collected with the ACEs scale and the List of Threatening Experiences Questionnaire in 77 patients hospitalized for a catatonic syndrome (average age 15.2 years) and 81 for a manic or mixed episode (average age 15.7 years). ACEs were frequent in youths suffering from bipolar disorder type I (BD-I) (58 %) and from catatonia (57 %), with around one quarter exposed to severe abuse (i.e., physical/sexual/emotional abuse or physical/emotional neglect). Youths with BD-I were more likely to be exposed to family violence compared to those with catatonia. Youths who had been exposed to ACEs did not exhibit a more severe presentation or a poorer response to treatment compared to others, either in the bipolar group or in the catatonic group.

Leveling and abuse among patients with bipolar disorder at psychiatric outpatient departments in Ethiopia

INTRODUCTION

The World Health Organization (WHO) clearly states the importance of psychological well-being in the definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". However, in the community, the lives of people with bipolar disorders are often harsh and abusive. Till now, the rate and related information concerning verbal or physical abuse among patients with bipolar disorder at psychiatric outpatient clinics have not been well addressed in Ethiopian settings.

METHODS

Data were collected by interviewing 411 systematically selected participants at outpatient department of Amanuel Mental Specialized Hospital. For analysis, logistic regression and adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used, and P  < 0.05 was considered statistically significant.

RESULTS

The prevalence of abuse (verbal/physical) was 37.7%. Having two or more episodes [AOR 1.70, 95% CI (1.06, 2.74)], a history of aggression [AOR 3.06, 95% CI (1.63, 5.75)] and comorbid illness [AOR 2.21, 95% CI (1.25, 3.90)] were significantly associated.

CONCLUSION

The prevalence of reported abuse is high among patients with bipolar disorder, and it is important to remember the rights of patients during treatment.

Childhood adverse life events and parental psychopathology as risk factors for bipolar disorder

Childhood adverse events are risk factors for later bipolar disorder. We quantified the risks for a later diagnosis of bipolar disorder after exposure to adverse life events in children with and without parental psychopathology. This register-based population cohort study included all persons born in Denmark from 1980 to 1998 (980 554 persons). Adversities before age 15 years were: familial disruption; parental somatic illness; any parental psychopathology; parental labour market exclusion; parental imprisonment; placement in out-of-home care; and parental natural and unnatural death. We calculated risk estimates of each of these eight life events as single exposure and risk estimates for exposure to multiple life events. Main outcome variable was a diagnosis of bipolar disorder after the age of 15 years, analysed with Cox proportional hazard regression. Single exposure to most of the investigated adversities were associated with increased risk for bipolar disorder, exceptions were parental somatic illness and parental natural death. By far the strongest risk factor for bipolar disorder in our study was any mental disorder in the parent (hazard ratio 3.53; 95% confidence interval 2.73-4.53) and the additional effects of life events on bipolar risk were limited. An effect of early adverse life events on bipolar risk later in life was mainly observed in children without parental psychopathology. Our findings do not exclude early-life events as possible risk factors, but challenge the concept of adversities as important independent determinants of bipolar disorder in genetically vulnerable individuals.

Integrating Early Intervention for Borderline Personality Disorder and Mood Disorders

Borderline personality disorder (BPD) has been demonstrated to be a reliable and valid construct in young people (adolescents and young adults). Both borderline- and mood-related psychopathology become clinically apparent from puberty through to young adulthood, frequently co-occur, can reinforce one another, and can be difficult to differentiate clinically. This Gordian knot of overlapping clinical features, common risk factors, and precursors to both BPD and mood disorders complicates clinical assessment, prevention, and treatment. Regardless of whether an individual crosses an arbitrary diagnostic threshold, a considerable proportion of young people with borderline- and mood-related psychopathology will develop significant and persistent functional, vocational, and interpersonal impairment and disability during this critical risk and developmental period. There is a clear need for early intervention, but spurious diagnostic certainty risks stigma, misapplication of diagnostic labels, inappropriate treatment, and unfavorable outcomes. This article aims to integrate early intervention for BPD and mood disorders in the clinical context of developmental and phenomenological change and evolution. "Clinical staging," similar to disease staging in general medicine, is presented as a pragmatic, heuristic, and trans-diagnostic framework to guide prevention and intervention. It acknowledges that the early stages of these disorders cannot be disentangled sufficiently to allow for disorder-specific preventive measures and early interventions. Clinical staging defines an individual's location along the continuum of the evolving temporal course of a disorder. Such staging aids differentiation of early or milder clinical phenomena from those that accompany illness progression and chronicity, and suggests the application of appropriate and proportionate intervention strategies.

Childhood maltreatment and unfavourable clinical outcomes in bipolar disorder: a systematic review and meta-analysis

BACKGROUND

Bipolar disorder affects up to one in 25 individuals and identification of early risk indicators of negative outcomes could facilitate early detection of patients with greatest clinical needs and risk. We aimed to investigate the association between childhood maltreatment and key negative outcomes in patients with bipolar disorder.

METHODS

For this systematic review and meta-analysis we searched MEDLINE, PsycINFO, and Embase to identify articles published before Jan 1, 2015, examining the association of maltreatment (physical, sexual, or emotional abuse, neglect, or family conflict) before age 18 years with clinical features and course of illness in bipolar disorder. Data were extracted from published reports and any missing information was requested from investigators. We did 12 independent random-effects meta-analyses to quantify the associations between childhood maltreatment and course of illness or clinical features.

FINDINGS

We initially identified 527 records and after unsuitable studies were removed, our search yielded 148 publications of which 30 were used in the meta-analysis. Patients with bipolar disorder and history of childhood maltreatment had greater mania severity (six studies, 780 participants; odds ratio [OR] 2·02, 95% CI 1·21-3·39, p=0·008), greater depression severity (eight studies, 1007 participants; 1·57, 1·25-1·99, p=0·0001), greater psychosis severity (seven studies, 1494 participants; 1·49, 1·10-2·04, p=0·011), higher risk of comorbidity with post-traumatic stress disorder (eight studies, 2494 participants; 3·60, 2·45-5·30, p<0·0001), anxiety disorders (seven studies, 5091 participants; 1·90, 1·39-2·61, p<0·0001), substance misuse disorders (11 studies, 5469 participants; 1·84, 1·41-2·39, p<0·0001), alcohol misuse disorder (eight studies, 5040 participants; 1·44, 1·13-1·83, p=0·003), earlier age of bipolar disorder onset (14 studies, 5733 participants; 1·85, 1·43-2·40, p<0·0001), higher risk of rapid cycling (eight studies, 3010 participants; 1·89, 1·45-2·48, p<0·0001), greater number of manic episodes (seven studies, 3909 participants; 1·26, 1·09-1·47, p=0·003), greater number of depressive episodes (eight studies, 4025 participants; 1·38, 1·07-1·79, p=0·013), and higher risk of suicide attempt (13 studies, 3422 participants; 2·25, 1·88-2·70, p<0·0001) compared with those with bipolar disorder without childhood maltreatment. Overall, these associations were not explained by publication bias, undue effects of individual studies, or variation in study quality.

INTERPRETATION

Childhood maltreatment predicts unfavourable clinical features and course of illness in patients with bipolar disorder.

FUNDING

None.

Childhood maltreatment and comorbid anxiety in people with bipolar disorder

BACKGROUND

Comorbid anxiety disorders and a history of childhood maltreatment are important determinants of outcome in bipolar disorder, but the relationship between these two factors is unclear.

METHODS

In 174 outpatients with bipolar disorder, we assessed history of childhood maltreatment with the Childhood Trauma Questionnaire (CTQ) and lifetime diagnosis of anxiety disorders with the M.I.N.I. International Neuropsychiatric Interview. We used ordinary logistic regressions to test associations between childhood maltreatment and the number of comorbid anxiety disorders, controlling for age, sex and the type of bipolar disorder.

RESULTS

Ninety (51.7%) participants had no anxiety disorder, 50 (28.7%) had one anxiety disorder and 34 (19.5%) had two or more anxiety disorders. Childhood maltreatment, indexed by a higher CTQ total score, was associated with more lifetime anxiety disorders (OR=1.5; 95% CI=1.01 to 2.14; p=0.04). Of the CTQ subscales, emotional abuse (OR=1.68; 95% CI=1.13 to 2.49; p=0.01) and physical abuse (OR=1.43; 95% CI=1.02 to 2.01; p=0.04) were associated with anxiety disorders. Of the anxiety disorders, panic disorder was most strongly associated with childhood maltreatment (OR=2.27; 95% CI=1.28 to 4.02; p=0.01).

LIMITATIONS

The study is limited by a moderate sample size and the retrospective assessment of childhood maltreatment.

CONCLUSIONS

Exposure to maltreatment in childhood is associated with comorbid anxiety disorders among individuals living with bipolar disorder. Bipolar disorder with comorbid anxiety may constitute a separate aetiological type with a greater contribution of early environment.

Physical and sexual abuse and early-onset bipolar disorder in youths receiving outpatient services: frequent, but not specific

The objective of this study was to determine if physical and sexual abuse showed relationships to early-onset bipolar spectrum disorders (BPSD) consistent with findings from adult retrospective data. Participants (N = 829, M = 10.9 years old ± 3.4 SD, 60% male, 69% African American, and 18% with BPSD), primarily from a low socio-economic status, presented to an urban community mental health center and a university research center. Physical abuse was reported in 21%, sexual abuse in 20%, and both physical and sexual abuse in 11% of youths with BPSD. For youths without BPSD, physical abuse was reported in 16%, sexual abuse in 15%, and both physical and sexual abuse in 5% of youths. Among youth with BPSD, physical abuse was significantly associated with a worse global family environment, more severe depressive and manic symptoms, a greater number of sub-threshold manic/hypomanic symptoms, a greater likelihood of suicidality, a greater likelihood of being diagnosed with PTSD, and more self-reports of alcohol or drug use. Among youth with BPSD, sexual abuse was significantly associated with a worse global family environment, more severe manic symptoms, a greater number of sub-threshold manic/hypomanic symptoms, greater mood swings, more frequent episodes, more reports of past hospitalizations, and a greater number of current and past comorbid Axis I diagnoses. These findings suggest that if physical and/or sexual abuse is reported, clinicians should note that abuse appears to be related to increased severity of symptoms, substance use, greater co-morbidity, suicidality, and a worse family environment.

Predictors and Moderators of Clinical Outcomes in Adolescents with Severe Mental Disorders After an Assertive Community Treatment

Previous studies have shown that stressful life events (SLEs), gender, social functioning and pretreatment severity are some of the predictors and/or moderators of treatment outcome in psychiatric care. The current study explored the effect of these predictors and moderators on the treatment outcome related to assertive community treatment (ACT) proposed to young people with severe mental disorders. 98 patients were assessed for externalizing and emotional difficulties, at admission and then at discharge of an ACT. Analyses revealed significant improvements in terms of symptomatology. In particular, regression analyses showed that pretreatment severity is a significant predictor of the outcome on emotional symptoms and is moderated by SLE on the outcome on externalizing symptoms. Furthermore, higher social functioning proved to predict better outcome on externalizing symptoms. Our results further evidence that these factors can explain inter-individual differences in outcome related to ACT. The theoretical and clinical implications of these results are discussed.

Contributions of the social environment to first-onset and recurrent mania

In treated cohorts, individuals with bipolar disorder are more likely to report childhood adversities and recent stressors than individuals without bipolar disorder; similarly, in registry-based studies, childhood adversities are more common among individuals who later become hospitalized for bipolar disorder. Because these types of studies rely on treatment-seeking samples or hospital diagnoses, they leave unresolved the question of whether or not social experiences are involved in the etiology of bipolar disorder. We investigated the role of childhood adversities and adulthood stressors in liability for bipolar disorder using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=33 375). We analyzed risk for initial-onset and recurrent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manic episodes during the study's 3-year follow-up period. Childhood physical abuse and sexual maltreatment were associated with significantly higher risks of both first-onset mania (odds ratio (OR) for abuse: 2.23; 95% confidence interval (CI)=1.71, 2.91; OR for maltreatment: 2.10; CI=1.55, 2.83) and recurrent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR for maltreatment: 1.60; CI=1.00, 2.55). In addition, past-year stressors in the domains of interpersonal instability and financial hardship were associated with a significantly higher risk of incident and recurrent mania. Exposure to childhood adversity potentiated the effects of recent stressors on adult mania. Our findings demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways.

Can pediatric bipolar-I disorder be diagnosed in the context of posttraumatic stress disorder? A familial risk analysis

Despite ongoing concerns that traumatized children with severe symptoms of emotional dysregulation may be inappropriately receiving a diagnosis of pediatric bipolar-I (BP-I) disorder, this issue has not been adequately examined in the literature. Because both pediatric BP-I disorder and posttraumatic stress disorder (PTSD) are familial disorders, if children with both BP-I and PTSD were to be truly affected with BP-I disorder, their relatives would be at high risk for BP-I disorder. To this end, we compared patterns of familial aggregation of BP-I disorder in BP-I children with and without PTSD with age and sex matched controls. Participants were 236 youths with BP-I disorder and 136 controls of both sexes along with their siblings. Participants completed a large battery of measures designed to assess psychiatric disorders, psychosocial, educational, and cognitive parameters. Familial risk analysis revealed that relatives of BP-I probands with and without PTSD had similar elevated rates of BP-I disorder that significantly differed from those of relatives of controls. Pediatric BP-I disorder is similarly highly familial in probands with and without PTSD indicating that their co-occurrence is not due to diagnostic error.

The impact of child sexual abuse on the course of bipolar disorder: a systematic review

OBJECTIVES

The aim of this review was to elucidate the impact of child sexual abuse on all clinical phenomena that occur after the onset of bipolar disorder, including associated clinical features that are not part of the diagnostic criteria for the disorder.

METHODS

Five databases were searched and supplemented with a hand search of reference lists from retrieved papers. Study quality was assessed using a validated quality assessment tool. Blind assessments of study eligibility and quality were conducted by two independent researchers to reduce bias, minimize errors, and enhance the reliability of findings. Disagreements were resolved by consensus.

RESULTS

Eighteen studies that included a total of 2996 adults and youths with bipolar disorder and met the minimum quality criteria necessary to ensure objectivity and not invalidate results were analyzed. Across studies, child sexual abuse was strongly (and perhaps directly) associated with posttraumatic stress disorder; whereas it was less strongly (and perhaps indirectly) related to suicide attempts, alcohol and/or drug abuse or dependence, psychotic symptoms, and an early age of illness onset. In regard to the association between child sexual abuse and other clinical variables concerning the course of bipolar disorder, evidence was scant or conflicting.

CONCLUSIONS

Child sexual abuse is associated (either directly or indirectly) with some clinical phenomena that represent a more severe form of bipolar disorder. Although such a traumatic experience may directly affect the development of posttraumatic stress disorder, the effects of early sexual abuse on later suicidal behavior, substance abuse, and psychotic symptoms may operate through the mediating influences of certain psychopathological or neurobiological variables.

Prevalence of child sexual abuse among adults and youths with bipolar disorder: a systematic review

To estimate the prevalence and social and demographic correlates of child sexual abuse among people with bipolar disorder, the findings of all the pertinent studies were qualitatively and semi-quantitatively analyzed. Five databases were searched. Blind assessments of study eligibility and quality were conducted by two independent researchers. Twenty studies, meeting minimum quality standards and including 3407 adults and youths with bipolar disorder across 10 countries and 3 continents, were examined. The prevalence of child sexual abuse was 24% (23% without outliers); however, such prevalence rate might be underestimated, because many studies restricted definitions to the most severe forms of abuse. Child sexual abuse was a common experience for both males and females, while it was more frequent for adults than for youths. Compared to healthy individuals, patients with bipolar disorder reported higher rates of child sexual abuse; compared to populations with other mental disorders, participants with bipolar disorder reported similar or lower rates of such abuse. Individuals with bipolar disorder are at risk of having a history of child sexual abuse, although such risk seems to be neither more specific to nor stronger for these individuals, compared to people with other psychiatric disorders.

Childhood maltreatment and clinical outcomes of bipolar disorder

OBJECTIVE

Adverse life events, especially early trauma, play a major role in the course and expression of bipolar disorder (BD). The aim of this article is to present a systematic review about the impact of childhood trauma on the clinical course of BD.

METHOD

A computer-aided search was performed in Medline, ISI database, EMBASE, PsychInfo, Centre for Reviews and Dissemination, and Databases of Thomson Reuters at April 2011, supplemented by works identified from the reference lists of the first selected papers. Two investigators systematically and independently examined all articles, selecting those according inclusion and exclusion criteria.

RESULTS

Four hundred fifteen articles were identified, of which 19 remained in the review after exclusion criteria were applied. In general, childhood maltreatment predicted worsening clinical course of BD. After assessing the quality of the data and of the measurements, childhood maltreatment can be strongly associated to early onset of disorder, suicidality, and substance abuse disorder in patients with BD.

CONCLUSION

Data suggest that childhood abuse and neglect are risk factors associated with worsening clinical course of BD. The conclusions should be interpreted with caution because all the studies included are cross-sectional and the majority are showing inconsistencies regarding childhood trauma as independent variable and how it is assessed.

Some reflections on the use of psychiatric diagnosis in the looked after or "in care" child population

The current classification system, DSM-IV, inadequately captures the range and type of psychopathology seen in the "in care" population of children. A combination of pre-natal influences, early interpersonal trauma involving the primary caregiving relationship, disturbed and disrupted attachment relationships and other significant losses and adverse environmental effects produce a complex constellation of symptoms and a pervasive impact on development that is difficult to categorize. The challenges facing DSM-V are illustrated, highlighting unresolved topics such as quasi-autism, reactive attachment disorder and complex trauma.

Risk factors predicting onset and persistence of subthreshold expression of bipolar psychopathology among youth from the community

OBJECTIVE

To examine factors increasing the risk for onset and persistence of subthreshold mania and depression.

METHOD

In a prospective cohort community study, the association between risk factors [a family history of mood disorders, trauma, substance use, attention-deficit/hyperactivity disorder (ADHD) and temperamental/personality traits] and onset of manic/depressive symptoms was determined in 705 adolescents. The interaction between baseline risk factors and baseline symptoms in predicting 8-year follow-up symptoms was used to model the impact of risk factors on persistence.

RESULTS

Onset of manic symptoms was associated with cannabis use and novelty seeking (NS), but NS predicted a transitory course. Onset of depressive symptoms was associated with a family history of depression. ADHD and harm avoidance (HA) were associated with persistence of depressive symptoms, while trauma and a family history of depression predicted a transitory course.

CONCLUSION

Different risk factors may operate during onset and persistence of subthreshold mania and depression. The differential associations found for mania and depression dimensions suggest partly different underlying mechanisms.

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.

Controversies concerning the diagnosis and treatment of bipolar disorder in children

This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the present, ending with current efforts to distinguish between a small number of children whose behaviors closely fit DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disorder with Dysphoria.Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSM's diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compromised. And because BP has a strong genetic component, the label can distract attention from the family or social context.Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much on the child's context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed consent, they must be forthcoming with families about the relevant uncertainties and complexities.

Evidence for genetic association of RORB with bipolar disorder

BACKGROUND

Bipolar disorder, particularly in children, is characterized by rapid cycling and switching, making circadian clock genes plausible molecular underpinnings for bipolar disorder. We previously reported work establishing mice lacking the clock gene D-box binding protein (DBP) as a stress-reactive genetic animal model of bipolar disorder. Microarray studies revealed that expression of two closely related clock genes, RAR-related orphan receptors alpha (RORA) and beta (RORB), was altered in these mice. These retinoid-related receptors are involved in a number of pathways including neurogenesis, stress response, and modulation of circadian rhythms. Here we report association studies between bipolar disorder and single-nucleotide polymorphisms (SNPs) in RORA and RORB.

METHODS

We genotyped 355 RORA and RORB SNPs in a pediatric cohort consisting of a family-based sample of 153 trios and an independent, non-overlapping case-control sample of 152 cases and 140 controls. Bipolar disorder in children and adolescents is characterized by increased stress reactivity and frequent episodes of shorter duration; thus our cohort provides a potentially enriched sample for identifying genes involved in cycling and switching.

RESULTS

We report that four intronic RORB SNPs showed positive associations with the pediatric bipolar phenotype that survived Bonferroni correction for multiple comparisons in the case-control sample. Three RORB haplotype blocks implicating an additional 11 SNPs were also associated with the disease in the case-control sample. However, these significant associations were not replicated in the sample of trios. There was no evidence for association between pediatric bipolar disorder and any RORA SNPs or haplotype blocks after multiple-test correction. In addition, we found no strong evidence for association between the age-at-onset of bipolar disorder with any RORA or RORB SNPs.

CONCLUSION

Our findings suggest that clock genes in general and RORB in particular may be important candidates for further investigation in the search for the molecular basis of bipolar disorder.

Negative life events in children and adolescents with bipolar disorder

OBJECTIVE

To study the relationship between negative life events and demographic and clinical variables in youth with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified (NOS), as well as to compare the rates of life events in youth with bipolar disorder, depressive and/or anxiety disorders (DEP-ANX), and healthy controls.

METHOD

Subjects included 446 youth, aged 7 to 17 years, meeting DSM-IV criteria for bipolar I, bipolar II, or an operationalized definition of bipolar disorder NOS, and were enrolled in the Course and Outcome of Bipolar Illness in Youth study. Subjects completed the Life Events Checklist. Sixty-five DEP-ANX and 65 healthy youth were obtained from previous studies using similar methodology. The study was conducted from October 2000 to July 2006.

RESULTS

Older age, lower socioeconomic status, living with nonintact family, non-Caucasian race, anxiety, and disruptive disorders were associated with greater number of total negative life events. Specifically, increased independent, dependent, and uncertain negative life events were associated with lower socioeconomic status, nonintact family, and comorbid disruptive disorders. Increased independent negative life events were additionally associated with non-Caucasian race and comorbid anxiety disorders. Increased dependent and uncertain negative life events were also associated with older age. DEP-ANX youth reported a similar rate of negative life events as bipolar youth, and both groups had more negative life events than the healthy controls. Bipolar youth reported fewer total and dependent positive life events compared to DEP-ANX and healthy youths.

CONCLUSIONS

Similar to DEP-ANX youth, bipolar youth are exposed to excessive negative independent and dependent life events, which may have implications in the long-term outcome and negative consequences associated with this disorder.

Assessment and diagnostic issues in pediatric bipolar disorder

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

Anxiety symptoms and syndromes in bipolar children and adolescents

Anxiety disorders are relatively common in children and adolescents with bipolar disorder. Research to date indicates they may impact the onset, course, and treatment response of bipolar illness in children. Anxiety disorders often precede the onset of pediatric bipolar disorder. Family studies suggest first-degree relatives of bipolar patients are at increased risk for developing mood and anxiety disorders compared with relatives of individuals without mood disorders. Childhood adversity has been associated with higher rates of comorbid anxiety disorders and more severe illness course in bipolar patients. Preliminary study of the neurobiology of bipolar disorder with comorbid anxiety disorders suggests it may be neurophysiologically distinct from bipolar disorder without comorbid anxiety. Bipolar disorder with comorbid anxiety disorders has been associated with greater functional impairment and slower recovery. Prospective, longitudinal studies are needed to help us better understand the relationship between bipolar disorder and comorbid anxiety disorders so that opportunities for early intervention and effective treatment can be realized.

Phenomenology and diagnosis of bipolar disorder in children, adolescents, and adults: complexities and developmental issues

This review addresses the phenomenology of mania/bipolar disorder from a developmental psychopathology perspective and uses cases with longitudinal information to illustrate major points. Beginning with a summary of the phenomenology of bipolar illness as it occurs in adults, the authors identify diagnostic complexities unique to children and adolescents. These include the challenges of characterizing elation and grandiosity; differentiating mania from comorbid symptoms, rages, sequelae of maltreatment, and typical developmental phenomena; and the unique manifestations of psychosis. We conclude with the observation that a significant difference between early and later onset bipolar disorder is that, in the former, there appears to be a global delay or arrest in the development of appropriate affect regulation; whereas in adult-onset bipolar illness, emotion dysregulation generally presents as an intermittent phenomenon. At this juncture, the study of childhood bipolar illness would benefit from a developmental psychopathology perspective to move beyond the level of cross-sectional symptom description to begin to study individuals over time, focusing on developmental, environmental, genetic, and neurobiological influences on manifest behavior.

Early-onset bipolar disorder: a family treatment perspective

Mood disorder symptoms and their associated functional impairments are hypothesized to come about as the result of the conjoint, interactive influences of genetic, biological, and psychological vulnerabilities, family distress, and life stress at different points of development. We discuss a developmental psychopathology model that delineates pathways to high family conflict and mood exacerbation among early-onset bipolar patients. New data from a treatment development study indicate that adolescent bipolar patients in high expressed emotion families have more symptomatic courses of illness over 2 years than adolescents in low expressed emotion families. Chronic and episodic stressors are also correlated with lack of mood improvement while adolescents are in treatment. Family-focused treatment (FFT) given in conjunction with pharmacotherapy appears to ameliorate the course of bipolar disorder in adults. This treatment has recently been modified to address the developmental presentation of bipolar disorder among adolescents. We present data from an open trial of FFT and pharmacotherapy (N = 20) indicating that bipolar adolescents stabilize in mania, depression, and parent-rated problem behaviors over 2 years. Future research should focus on clarifying the developmental pathways to early-onset bipolar disorder and the role of protective factors and preventative psychosocial interventions in delaying the first onset of the disorder.

Psychosocial functioning of adolescents with and without paediatric bipolar disorder

BACKGROUND

While there has been a growing interest in the presentation of Bipolar Disorder (BD) in children and adolescents, few studies have investigated the psychosocial functioning of these individuals and its relationship to trauma and suicidal ideation.

METHODS

63 adolescents aged 13-17 participated: 39 controls and 24 with Bipolar Disorder (BD). Group allocation and histories of trauma and suicidal ideation were obtained using the K-SADS-PL and WASH-U-KSADS. Adolescents completed questionnaires covering negative life events, self-esteem, hopelessness, regulation of anger, locus of control and coping.

RESULTS

More traumatic events and negative life experiences were reported by the BD group with over 50% of the BD sample indicating a history of trauma compared with 10% of the controls. The BD group reported lower self-esteem, more hopelessness, more negative life events, a more external locus of control and greater difficulties regulating emotion in anger-provoking situations. They were also found to have poorer coping strategies than the controls. Histories of trauma did not differentiate those with and without psychosocial problems. Further, hopelessness was found to be the best predictor of those BD adolescents reporting suicidal ideation. Comorbidity could not account for the differences found.

LIMITATIONS

The sample was small and therefore disallowed comparisons among subtypes of BD. Cross-sectional design limited the ability to investigate causal relationships.

CONCLUSIONS

This is the first study to document the widespread psychosocial difficulties facing youth with BD, highlighting these issues as important ones to explore during assessment and treatment, particularly in management of affective storms and suicidal risk.